OPTIMISE: A Shared Care Approach for Improving Comprehensive Care of Cancer Patients with Comorbidities in A Safety-Net System

项目摘要。癌症幸存者有独特的医疗保健需求，包括严重晚期效应的风险， 持续监测、改变生活方式以降低第二次癌症风险以及心理社会支持。近 70%的人被认为是“复杂的癌症幸存者”，因为他们至少有一种合并的慢性疾病， 除了癌症。共病对提供高质量的癌症护理构成了重大挑战，因为它们 对癌症治疗产生不利影响并受其影响。医疗服务不足的患者负担最重 在癌症治疗期间和之后，多种慢性疾病的风险增加，结果不佳。作为 医疗服务不足的复杂癌症患者可能缺乏健康护理知识和获得支持性护理的途径， 通过加强沟通和协作， 他们的肿瘤学家和初级保健提供者（PCP）之间。这项研究测试和评估了一本小说分享 复杂癌症幸存者的护理模式，称为OPTIMISE（肿瘤学-初级保健合作伙伴关系，以改善 综合生存护理）在最大的安全网医疗保健系统在休斯敦，得克萨斯州。三百 正在接受根治性治疗的新诊断乳腺癌、GI癌和血液癌患者， 在癌症治疗期间需要持续管理的合并症患者将完成基线调查 并随机分配至OPTIMISE或Mental Medical Care（UMC）组。接受UMC的患者将接受 癌症治疗，由他们的肿瘤学家指导，在积极治疗结束时的生存护理计划（SCP）， 并根据国家指导方针与他们的肿瘤学家进行监测访问。OPTIMISE中的患者将1） 肿瘤科护士导航员在诊断时被分配到他们的护理团队，以促进肿瘤学家与PCP的沟通 和护理的连续性; 2）在整个癌症期间接受肿瘤科医生和PCP之间的协调护理 通过结构化的沟通和转诊程序促进治疗和监测; 3）接受 治疗结束时的生存护理计划（SCP），包括合并症管理; 4）接受 治疗后监测的风险分层共享护理模式，其中一名或多名常规肿瘤学家遵循- 由PCP访视取代了up访视。目的1评价OPTIMISE对患者慢性疾病自我的影响， 管理（主要结局）和生活质量（次要结局）。目标2探索了OPTIMISE的效果 积极癌症治疗期间和之后的医疗保健使用和患者未满足的需求。目标3考察了 对肿瘤科医生和PCP的态度和护理协调的优化。目的4旨在阐明患者和 可能影响执行结果的系统一级因素。优化改变了思考的时间， 生存到诊断点，并寻求发展临床基础设施，以支持从 通过治疗后存活率进行癌症诊断。如果发现有效，OPTIMISE可以扩展到其他 癌症，点燃了一个潜在的丰富的研究领域。这也可能对其他领域产生重大的下游影响。 通过加强从专科到初级保健的护理过渡，改善医疗环境。

PROJECT SUMMARY. Cancer survivors have unique healthcare needs including risk for serious late effects, ongoing surveillance, lifestyle modifications to reduce second cancer risk, and psychosocial support. Nearly 70% are considered “complex cancer survivors” because they have at least one comorbid chronic condition in addition to cancer. Comorbidities pose significant challenges to the delivery of quality cancer care because they adversely affect and are affected by cancer treatment. Medically underserved patients have the highest burden of multiple chronic conditions and are at increased risk for poor outcomes during and after cancer treatment. As medically underserved complex cancer patients may lack healthcare knowledge and access to supportive care, their health outcomes and care transitions might be improved by enhancing communication and collaboration between their oncologists and primary care providers (PCPs). This study tests and evaluates a novel shared care model for complex cancer survivors called OPTIMISE (Oncology-Primary Care Partnership to Improve Comprehensive Survivorship Care) in the largest safety-net healthcare system in Houston, TX. Three-hundred newly diagnosed breast, GI, and hematological cancer patients who are being treated with curative intent and who have comorbidities requiring ongoing management during cancer treatment will complete baseline surveys and be randomized to either OPTIMISE or Usual Medical Care (UMC). Patients receiving UMC will receive their cancer treatment, as directed by their oncologist, a survivorship care plan (SCP) at the end of active treatment, and surveillance visits with their oncologist based on national guidelines. Patients in OPTIMISE will 1) have an oncology nurse navigator assigned to their care team at diagnosis to facilitate oncologist-PCP communication and continuity of care; 2) receive coordinated care between their oncologist and PCP throughout cancer treatment and surveillance facilitated by a structured communication and referral process; 3) receive a survivorship care plan (SCP) at the end of treatment that incorporates comorbidity management; and, 4) receive a risk-stratified shared care model of post-treatment surveillance where one or more routine oncologist follow- up visits is replaced by a PCP visit. AIM 1 evaluates the impact of OPTIMISE on patient chronic disease self- management (primary outcome) and quality of life (secondary outcome). Aim 2 explores the effects of OPTIMISE on healthcare use and patient unmet needs during and after active cancer treatment. Aim 3 examines the effects of OPTIMISE on oncologist and PCP attitudes and coordination of care. Aim 4 seeks to elucidate patient- and system-level factors that may influence implementation outcomes. OPTIMISE shifts the timing of thinking about survivorship to point of diagnosis and seeks to develop a clinical infrastructure to support continuity of care from cancer diagnosis through post-treatment survivorship. If found effective, OPTIMISE could be expanded to other cancers, igniting a potentially rich area of research. It may also have significant downstream impact in other medical settings by enhancing care transitions from specialty to primary care.