Can Community Health Workers Increase Palliative Care Use for African American Patients? A Pilot Study

Tumor Is Not the Only Target: Ensuring Equitable Person-Centered Supportive Care in the Era of Precision Medicine

Communication in oncology has always been challenging. The new era of precision oncology creates prognostic uncertainty. Still, person-centered care requires attention to people and their care needs. Living with cancer portends an experience that is life-altering, no matter what the outcome. Supporting patients and families through this unique experience requires careful attention, honed skills, an understanding of process and balance measures of innovation, and recognizing that supportive care is a foundational element of cancer medicine, rather than an either-or approach, an and-with approach that emphasizes the regular integration of palliative care (PC), geriatric oncology, and skilled communication.

Palliative Care Across the Spectrum of Heart Failure

Persons with heart failure (HF) often suffer from poor symptom control, decreased quality of life, and poor communication with their health care providers. These needs are particularly acute in advanced HF, a leading cause of death in the United States. Palliative care, when offered alongside HF disease management, offers improved symptom control, quality of life, communication, and caregiver satisfaction as well as reduced caregiver anxiety. The dynamic nature of the clinical trajectory of HF presents distinct symptom patterns, changing functional status, and uncertainty, which requires an adaptive, dynamic model of palliative care delivery. Due to a limited specialty-trained palliative care workforce, patients and their caregivers often cannot access these benefits, especially in the community. To meet these needs, new models are required that are better informed by high-quality data, engage a range of health care providers in primary palliative care principles, and have clear triggers for specialty palliative care engagement, with specific palliative interventions tailored to patient's illness trajectory and changing needs.

Impact of training on knowledge, confidence and attitude amongst community health volunteers in the provision of community-based palliative care in rural Kenya

OBJECTIVES

Existing literature suggests multiple potential roles for community health volunteers (CHVs) in the provision of palliative care (PC) in low- and middle-income countries. In Kenya the role of CHV in the provision of PC has not been reported. The objective of this study was to assess knowledge, confidence, attitude, and clinical practice of community health volunteers after attending a novel palliative care (PC) training program.

METHODS

A total of 105 CHVs participated in a 3-day in person training followed by a 1-month in person and telephone observation period of the palliative care activities in the community. Structured questionnaires were used pre- and post-training to assess knowledge acquisition, impact on practice, and content delivery. A mixed method study design was conducted 12-month post training to assess impact on clinical practice.

RESULTS

Immediately after training, CHV provided positive ratings on relevance and content delivery. In the month following training, CHVs evaluated 1,443 patients, referred 154, and conducted 110 and 129 tele consults with the patients and PC providers respectively. The follow up survey at 12 months revealed improved knowledge and confidence in various domains of palliative care including symptom and spiritual assessment and provision of basic nursing and bereavement care. Focus group discussions revealed the CHVs ability to interpret symptoms, make referrals, improved communication/ interpersonal relationships, spiritual intervention, patient comfort measures and health care practices as newly learned and practiced skills.

CONCLUSIONS

We noted improved knowledge, new skills and change in practice after CHVs participation in a novel training curriculum. CHVs can make important contributions to the PC work force and be first line PC providers in the community as part of larger hub and spoke care model.

The Promise of Cancer Health Justice: How Stakeholders and the Community Can Build a Sustained and Equitable System of Cancer Care Through the Lens of Colorectal Cancer Interventions

ABSTRACT

Disparities in outcomes and persistent barriers to adequate care in colorectal cancer are reflective of a system that has failed to achieve the ideals of health equity and health justice. In this review, we discuss that although much research has been done to improve upon gaps in screening, treatment, and supportive care in colorectal cancer, a concerted effort across multiple research, regulatory, and funding stakeholders with community-level organizations is essential in building a self-sustained system that effectively achieves health equity outcomes. We also highlight several examples of novel community-based interventions along the continuum of cancer care that demonstrate the potential of what can be accomplished when we invest in scaling up small-scale solutions to the state and national levels and offer ways in which stakeholders and the community may mutually benefit through a system of incentives, self-assessment tools, and attainable metrics.

Dissemination and Implementation of a Community Health Worker Intervention for Disparities in Palliative Care (DeCIDE PC): a study protocol for a hybrid type 1 randomized controlled trial

BACKGROUND

There are persistent racial and ethnic health disparities in end-of-life health outcomes in the United States. African American patients are less likely than White patients to access palliative care, enroll in hospice care, have documented goals of care discussions with their healthcare providers, receive adequate symptom control, or die at home. We developed Community Health Worker Intervention for Disparities in Palliative Care (DeCIDE PC) to address these disparities. DeCIDE PC is an integrated community health worker (CHW) palliative care intervention that uses community health workers (CHWs) as care team members to enhance the receipt of palliative care for African Americans with advanced cancer. The overall objectives of this study are to (1) assess the effectiveness of the DeCIDE PC intervention in improving palliative care outcomes amongst African American patients with advanced solid organ malignancy and their informal caregivers, and (2) develop generalizable knowledge on how contextual factors influence implementation to facilitate dissemination, uptake, and sustainability of the intervention.

METHODS

We will conduct a multicenter, randomized, assessor-blind, parallel-group, pragmatic, hybrid type 1 effectiveness-implementation trial at three cancer centers across the United States. The DeCIDE PC intervention will be delivered over 6 months with CHW support tailored to the individual needs of the patient and caregiver. The primary outcome will be advance care planning. The treatment effect will be modeled using logistic regression. The secondary outcomes are quality of life, quality of communication, hospice care utilization, and patient symptoms.

DISCUSSION

We expect the DeCIDE PC intervention to improve integration of palliative care, reduce multilevel barriers to care, enhance clinic and patient linkage to resources, and ultimately improve palliative care outcomes for African American patients with advanced cancer. If found to be effective, the DeCIDE PC intervention may be a transformative model with the potential to guide large-scale adoption of promising strategies to improve palliative care use and decrease disparities in end-of-life care for African American patients with advanced cancer in the United States.

TRIAL REGISTRATION

Registered on ClinicalTrials.gov (NCT05407844). First posted on June 7, 2022.

Palliative Care Curriculum and Training Plan for community health workers

African American patients are less likely than White patients to access palliative care. Community health workers (CHWs) are non-clinical public health workers who may address this gap. We developed a Palliative Care Curriculum and Training Plan for CHWs as part of an ongoing randomised controlled trial evaluating the effectiveness of a CHW palliative care intervention for African American patients with advanced cancer. This study aimed to determine whether the Palliative Care Curriculum and Training Plan leads to gains in knowledge, perceived competence on CHW study-based tasks, and satisfaction among CHWs. The curriculum was delivered over 3 months using synchronous, asynchronous and experiential training components. CHWs were assessed through survey questionnaires and semistructured interviews. We trained a total of three CHWs, one from each of our enrolment sites: Johns Hopkins Hospital, TidalHealth Peninsula Regional and University of Alabama at Birmingham Hospital. CHWs demonstrated an increase in knowledge, with a mean pre-training test score of 85% (SD 10.49) and post-training test score of 96% (SD 4.17). The training led to increases in perceived competence among CHWs. Areas for future training were identified. This curriculum serves as a template for CHW training focused on palliative care, oncology and health disparities.

"We've Got to Bring Information to Where People Are Comfortable": Community-Based Advance Care Planning with the Black Community

BACKGROUND

People identifying as Black/African American are less likely to engage in advance care planning (ACP) compared to their White peers, despite the association of ACP with improved patient and caregiver outcomes.

OBJECTIVES

Assess facilitators/barriers to ACP in the San Francisco (SF) Black community and co-design/implement/test community-based ACP pilot events.

DESIGN

Community-based participatory research, including qualitative research, intervention development, and implementation.

PARTICIPANTS

In partnership with the SF Palliative Care Workgroup (which includes health system, city, and community-based organizations), we formed an African American Advisory Committee (n = 13). We conducted 6 focus groups with Black older adults (age ≥ 55), caregivers, and community leaders (n = 29). The Advisory Committee then selected 5 community-based organizations through a widespread request for proposal. These community-based organizations designed and implemented community-based pilot events to support ACP engagement.

MAIN MEASURES

Two authors analyzed recorded focus group transcripts using thematic analysis. We assessed pre- vs post-event readiness to engage in ACP (validated ACP Engagement Survey; 1-4 scale, 4 = most ready) using Wilcoxon signed rank tests and assessed event acceptability with open-ended questions.

KEY RESULTS

Themes included the importance of ACP to the Black community (sub-themes: strengthens families; preserves dignity, particularly for sexual/gender minorities; is tied to financial planning) and facilitators for increasing ACP engagement (sub-themes: culturally relevant materials; events in trusted community spaces including Black-owned businesses). A total of 114 participants attended 5 events; 74% identified as Black, and 16% as sexual/gender minorities. Readiness to engage in ACP was similar pre- vs post-events; 98% would recommend the events to others.

CONCLUSIONS

Community-based ACP events designed and led by and for the Black community are highly acceptable. Novel insights underscored the importance of financial planning as part of ACP and the role of Black-owned businesses as trusted spaces for ACP-related discussions.

The 2023-2026 Hospice and Palliative Nurses Association Research Agenda

The Hospice and Palliative Nursing Association established the triannual research agenda to ( a ) provide focus for researchers to conduct meaningful scientific and quality improvement initiatives and inform evidence-based practice, ( b ) guide organizational funding, and ( c ) illustrate to other stakeholders the importance of nursing research foci. HPNA Research Agendas are developed to give direction for future research to continue advancing expert care in serious illness and ensure equitable delivery of hospice and palliative care.

Advance Care Planning With Black Women with Breast Cancer: A Community Health Worker Model

BACKGROUND

Despite the importance of advance care planning (ACP), a process that optimizes future medical treatment and end-of-life care, for at-risk populations, rates of patient-provider ACP conversations are extremely low among Black women with breast cancer. Community health workers (CHWs) are well-positioned to support patients in engaging in ACP conversations with their providers; yet research on integrating CHWs to promote ACP is scant. The current study examined multilevel facilitators and barriers to successful ACP conversations among Black women from the perspective of providers and CHWs who serve this community.

METHODS

Providers and CHWs were recruited from an academic medical center in a large urban city. Retrospective qualitative data on barriers and facilitators to ACP conversations, as well as CHWs' training needs, were collected from two focus groups (N = 5 providers, N = 5 CHWs) and one individual interview (N = 1 provider), and transcribed and coded for themes.

RESULTS

All providers reported working primarily with Black patients, and identified stigma and time constraints as major barriers to ACP discussions; they also identified the structural barriers and injustices that their patients face during medical care. CHWs reported having a trusted relationship with their patients and flexibility in their care that would allow for ongoing ACP conversations, discussing their ability to serve as a bridge between the patient and provider. However, CHWs discussed that they lacked the tools and skills to have ACP conversations, largely because existing formal trainings in ACP are cost prohibitive.

DISCUSSION

Competing priorities of the provider to discuss/treat the patient's disease and medical mistrust were major barriers to successful ACP conversations among Black women with breast cancer, leading to ACP completion occurring late in treatment. CHWs are uniquely qualified to overcome multilevel barriers to ACP and establish trusting relationships with patients in order to facilitate earlier and ongoing communication between patients and providers.

The current status of survivorship care provision at the state level: a Wisconsin-based assessment

PURPOSE

As the number of cancer survivors grows, the responsibility for addressing their unique physical and emotional needs also increases. Survivorship care services vary by geography, health system, and insurance coverage. We aimed to understand the state of survivorship care services in Wisconsin's cancer facilities.

METHODS

The selection of cancer treatment facilities sought to provide a geographically representative sample. An adapted Patient-Centered Survivorship Care Index was comprised of questions regarding different aspects of survivorship practices. Areas of interest included disciplines incorporated, services provided, standards of care, and discussion of late-term effects, among others.

RESULTS

Out of 90 sites invited, 40 responded (44.4%). Oncologists, physician assistants, and nurse practitioners were the most common follow-up care disciplines. Risk reduction services, dietary services, access to physical activity, and behavioral health specialist referral were described as standards of care in less than half of sites. All sites reported working with community partners, 92.5% of which worked with YMCA-related programs. Discussion of long-term effects was a standard of care for all sites. Effects such as emotional distress and health practice changes were frequently discussed with almost all patients, while sexual functioning and fertility were not.

CONCLUSIONS

Services and specialties related to behavioral health, fertility/sexual health, and rehabilitation and physical activity varied between sites. Such services may be offered less often due to variable insurance coverage.

IMPLICATIONS FOR CANCER SURVIVORS

Policy solutions should be explored to increase insurance coverage and provision rates of necessary survivorship services to keep up with the projected increase in demand. Given imperfect and evolving measurement tools to assess needs for cancer survivorship care services, cancer survivors should feel empowered to voice when they have unmet needs and request referrals.

Factors Influencing Palliative Care Access and Delivery for Great Plains American Indians

CONTEXT

Despite the known importance of culturally tailored palliative care (PC), American Indian people (AIs) in the Great Plains lack access to such services. While clinicians caring for AIs in the Great Plains have long acknowledged major barriers to serious illness care, there is a paucity of literature describing specific factors influencing PC access and delivery for AI patients living on reservation land.

OBJECTIVES

This study aimed to explore factors influencing PC access and delivery on reservation land in the Great Plains to inform the development culturally tailored PC services for AIs.

METHODS

Three authors recorded and transcribed interviews with 21 specialty and 17 primary clinicians. A data analysis team of seven authors analyzed transcripts using conventional content analysis. The analysis team met over Zoom to engage in code negotiation, classify codes, and develop themes.

RESULTS

Qualitative analysis of interview data revealed four themes encompassing factors influencing palliative care delivery and access for Great Plains American Indians: health care system operations (e.g., hospice and home health availability, fragmented services), geography (e.g., weather, travel distances), workforce elements (e.g., care continuity, inadequate staffing, cultural familiarity), and historical trauma and racism.

CONCLUSION

Our findings emphasize the importance of addressing the time and cost of travel for seriously ill patients, increasing home health and hospice availability on reservations, and improving trust in the medical system. Strengthening the AI medical workforce, increasing funding for the Indian Health Service, and transitioning the governance of reservation health care to Tribal entities may improve the trustworthiness of the medical system.

Patient Navigator and Community Health Worker Attitudes Toward End-of-Life Care

Background: There are racial/ethnic disparities in hospice use and end-of-life (EOL) care outcomes in the United States. Although the use of community health workers (CHWs) and patient navigators (PNs) has been suggested as a means of reducing them, CHW/PNs' attitudes toward a palliative care philosophy remain unknown. The purpose of this study was to examine how personal attributes affect a CHW/PN's attitude toward EOL care. Methods: CHWs/PNs were recruited from two state-wide organizations and invited to complete an online survey. We collected information on demographics, attitudes toward the palliative care philosophy, and comfort with caring for patients at the EOL. Results: Of the 70 CHWs/PNs who responded to the survey, 82.5% identified as female, 56.4% identified as black, and 56.2% had a four-year college degree or higher. The mean score on a validated scale to assess attitudes toward EOL care was 33.5 (SD = 4.9; possible range, 8-40). Eighty percent strongly agreed or agreed with being open to discussing death with a dying patient. Higher self-efficacy scores were associated with more favorable attitudes toward hospice (r = 0.306, p = 0.016). Conclusions: CHWs/PNs have an overall favorable attitude toward the palliative care philosophy and may be inclined to providing EOL care.