Care coordination for complex cancer survivors in an integrated safety-net system

 描述(申请人提供)：近70%的癌症患者是患有多种慢性病的复杂患者，他们不仅要应对癌症的影响，还要应对糖尿病、抑郁症、高血压或心脏病等持续性疾病。贫困、保险不足和未参保的个人在多种慢性病方面的负担最重，癌症幸存者也是如此。在达拉斯县综合安全网系统Parkland，72%的癌症患者是少数族裔，70%没有保险，超过60%的人患有三种或三种以上的慢性疾病，需要协调管理才能获得最佳结果。然而，幸存者往往在初级保健和肿瘤科护理之间的过渡中迷失，导致零散和低质量的护理。例如，我们的初步数据显示，在Parkland患有糖尿病的结直肠癌幸存者中，只有43%的人在癌症复发和糖尿病护理方面得到了适当的随访。在最初的癌症诊断后，当务之急是接受癌症治疗。但是，在治疗完成后，患者需要对他们所有的慢性病进行协调治疗，现在包括癌症。护理协调战略被证明在改善初级保健中常见疾病的结果方面是有效的，包括：患者向专科护理和从专科护理系统过渡；强化病例管理；以及以团队为基础的综合护理方法。尽管医学研究所的一份报告建议将这些策略作为改善癌症幸存者护理的潜在方法，但它们的实施尚未对癌症幸存者进行评估。为了解决这一知识差距，我们将：(目标1)在Parkland为1000名复杂的癌症幸存者实施系统级EMR驱动的干预，结合三种循证护理协调战略；(1)EMR驱动的登记，以促进患者在初级保健和肿瘤学护理之间的过渡，(2)在复杂的护理团队中共同安置一名接受过护理协调培训的护士，以及(3)通过教练和技术援助加强团队合作；(2)使用严格的准实验设计，通过实施前后测量结果来测试战略对系统和患者水平结果的有效性；(目的3)阐明促进或阻碍实施的系统和患者因素，以及导致复杂的癌症患者和非癌症患者之间护理协调体验的差异。我们将在整个过程中收集定量(EMR数据、患者调查)和定性(结构化观察、患者和提供者访谈、EMR审计)数据。Parkland领导人不仅致力于改善对弱势患者的护理，而且还致力于与研究人员合作，学习保持和传播最佳做法的方法，以提供高质量的护理。我们与Parkland合作开展研究的长期记录将使我们能够成功实现我们的目标，并促进向寻求改善复杂癌症幸存者护理协调的其他安全网系统传播经过测试的工具和战略。

 DESCRIPTION (provided by applicant): Nearly 70% of people living with cancer are "complex patients" with multiple chronic conditions who must deal not only with effects of their cancer but also continuing diseases such as diabetes, depression, hypertension, or heart disease. Poor, under- and un-insured individuals have highest burdens of multiple chronic conditions and this is also true for cancer survivors. At Parkland the Dallas county integrated safety- net system, 72% of cancer patients are racial/ethnic minorities, 70% are uninsured, and more than 60% have three or more chronic conditions that require coordinated management for optimal outcomes. However, survivors are often lost in transition between primary care and oncology care, resulting in fragmented and poor quality care. For example, our preliminary data show only 43% of colorectal cancer survivors with diabetes at Parkland were appropriately followed up for both cancer recurrence and diabetes care. Upon initial cancer diagnosis, the immediate concern is receipt of cancer treatment. But, upon treatment completion, patients need coordinated care for all their chronic conditions, which now include cancer. Care coordination strategies shown to be effective in improving outcomes for common medical conditions seen in primary care include: systematic transitions for patients to and from specialty care; intensive case management; and a team- based approach to comprehensive care. Despite an Institute of Medicine report suggesting these strategies as potential ways to improve care for cancer survivors, their implementation has not yet been evaluated for cancer survivors. To address this gap in knowledge, we will: (Aim 1) Implement a system-level EMR-driven intervention for 1000 complex cancer survivors at Parkland, combining three evidence-based care coordination strategies; (1) EMR-driven registry to facilitate patient transitions between primary care and oncology care, (2) co-locate a nurse practitioner trained in care coordination within a complex care team, and (3) enhance teamwork through coaching and technical assistance; (Aim 2) Test effectiveness of the strategies on system- and patient-level outcomes using a rigorous, quasi-experimental design with outcomes measured before and after implementation; (Aim 3) Elucidate system and patient factors that facilitate or hinder implementation and result in differences in experiences of care coordination between complex patients with and without cancer. We will collect quantitative (EMR data, patient surveys) and qualitative (structured observations, patient and provider interviews, EMR audits) data throughout. Parkland leaders are committed not only to improving care for vulnerable patients but also to collaborating with researchers to learn ways of sustaining and disseminating best practices to provide high quality care. Our longstanding track record of conducting research in partnership with Parkland will enable us to successfully accomplish our aims and to foster dissemination of tested tools and strategies to other safety-net systems seeking to improve care coordination for complex cancer survivors.