Financial burden among metastatic breast cancer patients: a qualitative inquiry of costs, financial assistance, health insurance, and financial coping behaviors

PURPOSE

Metastatic breast cancer (MBC) patients often face substantial financial burden due to prolonged and expensive therapy. However, in-depth experiences of financial burden among MBC patients are not well understood.

METHODS

Qualitative interviews were conducted to describe the experiences of financial burden for MBC patients, focusing on the drivers of financial burden, their experience using their health insurance, accessing financial assistance, and any resulting cost-coping behaviors. Interviews were transcribed and qualitatively analyzed using a descriptive phenomenological approach to thematic analysis.

RESULTS

A total of n = 11 MBC patients or caregiver representatives participated in the study. MBC patients were on average 50.2 years of age (range: 28-65) and 72.7% non-Hispanic White. MBC patients were diagnosed as metastatic an average of 3.1 years (range: 1-9) before participating in the study. Qualitative analysis resulted in four themes including (1) causes of financial burden, (2) financial assistance mechanisms, (3) health insurance and financial burden, and (4) cost-coping behaviors. Both medical and non-medical costs drove financial burden among participants. All participants reported challenges navigating their health insurance and applying for financial assistance. Regardless of gaining access to assistance, financial burden persisted for nearly all patients and resulted in cost-coping behaviors.

CONCLUSION

Our findings suggest that current systems for health insurance and financial assistance are complex and difficult to meet patient needs. Even when MBC patients accessed assistance, excess financial burden persisted necessitating use of financial coping-behaviors such as altering medication use, maintaining employment, and taking on debt.

Assessing the pre-implementation context for financial navigation in rural and non-rural oncology clinics

Background

Financial navigation (FN) is an evidence-based intervention designed to address financial toxicity for cancer patients. FN's success depends on organizations' readiness to implement and other factors that may hinder or support implementation. Tailored implementation strategies can support practice change but must be matched to the implementation context. We assessed perceptions of readiness and perceived barriers and facilitators to successful implementation among staff at nine cancer care organizations (5 rural, 4 non-rural) recruited to participate in the scale-up of a FN intervention. To understand differences in the pre-implementation context and inform modifications to implementation strategies, we compared findings between rural and non-rural organizations.

Methods

We conducted surveys (n = 78) and in-depth interviews (n = 73) with staff at each organization. We assessed perceptions of readiness using the Organizational Readiness for Implementing Change (ORIC) scale. In-depth interviews elicited perceived barriers and facilitators to implementing FN in each context. We used descriptive statistics to analyze ORIC results and deductive thematic analysis, employing a codebook guided by the Consolidated Framework for Implementation Research (CFIR), to synthesize themes in barriers and facilitators across sites, and by rurality.

Results

Results from the ORIC scale indicated strong perceptions of organizational readiness across all sites. Staff from rural areas reported greater confidence in their ability to manage the politics of change (87% rural, 76% non-rural) and in their organization's ability to support staff adjusting to the change (96% rural, 75% non-rural). Staff at both rural and non-rural sites highlighted factors reflective of the Intervention Characteristics (relative advantage) and Implementation Climate (compatibility and tension for change) domains as facilitators. Although few barriers to implementation were reported, differences arose between rural and non-rural sites in these perceived barriers, with non-rural staff more often raising concerns about resistance to change and compatibility with existing work processes and rural staff more often raising concerns about competing time demands and limited resources.

Conclusions

Staff across both rural and non-rural settings identified few, but different, barriers to implementing a novel FN intervention that they perceived as important and responsive to patients' needs. These findings can inform how strategies are tailored to support FN in diverse oncology practices.

Knowledge, Attitudes, and Resources of Frontline Oncology Support Personnel Regarding Financial Burden in Patients With Cancer

PURPOSE

Financial navigation services support patients with cancer and address the direct and indirect financial burden of cancer diagnosis and treatment. These services are commonly delivered through a variety of frontline oncology support personnel (FOSP) including navigators, social workers, supportive care providers, and other clinic staff, but the perspective of FOSPs is largely absent from current literature on financial burden in oncology. We surveyed a national sample of FOSPs to understand their perspectives on patient financial burden, resource availability, and barriers and facilitators to assisting patients with cancer-related financial burden.

METHODS

We used Qualtrics online survey software and recruited participants using multiple professional society and interest group mailing lists. Categorical responses were described using frequencies, distributions of numeric survey responses were described using the median and IQR, and two open-ended survey questions were categorized thematically using a priori themes, allowing additional emergent themes.

RESULTS

Two hundred fourteen FOSPs completed this national survey. Respondents reported a high awareness of patient financial burden and felt comfortable speaking to patients about financial concerns. Patient assistance resources were commonly available, but only 15% described resources as sufficient for the observed needs. A substantial portion of respondents reported moral distress related to this lack of resources.

CONCLUSION

FOSPs, who already have requisite knowledge and comfort in discussing patient financial needs, are a critical resource for mitigating cancer-related financial burden. Interventions should leverage this resource but prioritize transparency and efficiency to reduce the administrative and emotional toll on the FOSP workforce and reduce the risk of burnout.

Adaptation of a financial toxicity intervention for scale-up to diverse contexts: Core functions of Lessening the Impact of Financial Toxicity (LIFT)

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Background: Rural and non-English speaking populations experience a disproportionate burden of financial toxicity and access to services for their cancer care. Lessening the Impact of Financial Toxicity (LIFT) is an intervention designed to address financial toxicity (FT) through financial navigation (FN). FN identifies patients at risk for FT, assesses eligibility for financial support, clarifies costs, and develops strategies to cope with costs. LIFT was successful in reducing financial toxicity in preliminary studies among English-speaking patients with high levels of FT in a single large academic cancer center. To benefit diverse patients with FT in cancer programs across the US, there is a need to adapt LIFT. Adapting LIFT requires distinguishing between its core functions— the components of LIFT key to its effectiveness and implementation, and its forms— the activities that comprise LIFT, facilitate its implementation, and may be adapted to accommodate new populations and contexts. We completed the first stage of adaptation, identifying LIFT core functions. Methods: We conducted interviews with individuals responsible for LIFT’s design and implementation. Interview questions were based on Kirk’s methods for identifying core functions and were recorded and transcribed verbatim. Using a codebook based on the Model for Adaptation Design and Impact, we coded interview transcripts and identified themes related to how LIFT engaged cancer program staff in FN (implementation core functions) and decreased FT (intervention core functions). Results: Eight interview participants filled various roles in designing and implementing LIFT (e.g., P.I.s; FNs). LIFT intervention core functions include a systematic way of cataloging knowledge, resources, and tracking patient information; using patient-specific needs to guide access to resources; ongoing, dynamic assistance and strong one-on-one relationships between navigators and patients; and removing common barriers to accessing resources. Conclusions: We identified core functions key to LIFT’s effectiveness and implementation. Next steps include identifying systematic differences between LIFT’s original context and population and new ones. Successfully adapting LIFT has the potential to extend its benefits to diverse patients in cancer programs throughout the US, such as Spanish-speaking patients served by rural community cancer programs.

Financial Assistance Processes and Mechanisms in Rural and Nonrural Oncology Care Settings

PURPOSE

Patients with cancer are at heightened risk of experiencing financial hardship. Financial navigation (FN) is an evidence-based approach for identifying and addressing patient and caregiver financial needs. In preparation for the implementation of a multisite FN intervention, we describe existing processes (ie, events and actions) and mechanisms (ie, how events work together) connecting patients to financial assistance, comparing rural and nonrural practices.

METHODS

We conducted in-depth, semistructured interviews with stakeholders (ie, administrators, providers, and staff) at each of the 10 oncology care sites across a single state (five rural and five nonrural practices). We developed process maps for each site and analyzed stakeholder perspectives using thematic analysis. After reporting findings back to stakeholders, we synthesized themes and process maps across rural and nonrural sites separately.

RESULTS

Eighty-three stakeholders were interviewed. We identified six core elements of existing financial assistance processes across all sites: distress screening (including financial concerns), referrals, resource connection points, and pharmaceutical, insurance, and community/foundation resources. Processes differed by rurality; however, facilitators and barriers to identifying and addressing patient financial needs were consistent. Open communication between staff, providers, patients, and caregivers was a primary facilitator. Barriers included insufficient staff resources, challenges in routinely identifying needs, inadequate preparation of patients for anticipated medical costs, and limited tracking of resource availability and eligibility.

CONCLUSION

This study identified a clear need for systematic implementation of oncology FN to equitably address patient and caregiver financial hardship. Results have informed our current efforts to implement a multisite FN intervention, which involves comprehensive financial toxicity screening and systematization of intake and referrals.

Core functions of a financial navigation intervention: An in-depth assessment of the Lessening the Impact of Financial Toxicity (LIFT) intervention to inform adaptation and scale-up in diverse oncology care settings

Background

Lessening the Impact of Financial Toxicity (LIFT) is an intervention designed to address financial toxicity (FT) and improve cancer care access and outcomes through financial navigation (FN). FN identifies patients at risk for FT, assesses eligibility for financial support, and develops strategies to cope with those costs. LIFT successfully reduced FT and improved care access in a preliminary study among patients with high levels of FT in a single large academic cancer center. Adapting LIFT requires distinguishing between core functions (components that are key to its implementation and effectiveness) and forms (specific activities that carry out core functions). Our objective was to complete the first stage of adaptation, identifying LIFT core functions.

Methods

We reviewed LIFT's protocol and internal standard-operating procedures. We then conducted 45-90 min in-depth interviews, using Kirk's method of identifying core functions, with key LIFT staff (N = 8), including the principal investigators. Interviews focused on participant roles and intervention implementation. Recorded interviews were transcribed verbatim. Using ATLAS.ti and a codebook based on the Model for Adaptation Design and Impact, we coded interview transcripts. Through thematic analysis, we then identified themes related to LIFT's intervention and implementation core functions. Two report back sessions with interview participants were incorporated to further refine themes.

Results

Six intervention core functions (i.e., what makes LIFT effective) and five implementation core functions (i.e., what facilitated LIFT's implementation) were identified to be sufficient to reduce FT. Intervention core functions included systematically cataloging knowledge and tracking patient-specific information related to eligibility criteria for FT relief. Repeat contacts between the financial navigator and participant created an ongoing relationship, removing common barriers to accessing resources. Implementation core functions included having engaged sites with the resources and willingness necessary to implement FN. Developing navigators' capabilities to implement LIFT-through training, an established case management system, and connections to peer navigators-were also identified as implementation core functions.

Conclusion

This study adds to the growing evidence on FN by characterizing intervention and implementation core functions, a critical step toward promoting LIFT's implementation and effectiveness.

Reducing Cancer-related Financial Toxicity through Financial Navigation: Results from a Pilot Intervention

Our purpose was to pilot a novel patient-centered financial navigation (FN) intervention to decrease the burden of financial toxicity (FT) among uninsured and underinsured patients with cancer treated at the North Carolina Cancer Hospital (NCCH). Methods: Participants were recruited by cancer clinic nurses and social workers at the NCCH. Eligible patients scored less than 22 points (indicating significant FT) on the COmprehensive Score for financial Toxicity (COST) instrument. Fifty patients were enrolled in the intervention, which included an intake assessment of financial needs and vulnerability, initial one-on-one consultation with a trained financial navigator (i.e., financial counselor or social worker), triage to financial support services matching patients' needs, and multiple follow-up appointments. Navigator recommendations were based upon a detailed review of patients' financial status, billing information, insurance, and other indicators used to refer patients to appropriate financial and social services resources offered by the hospital, government, nonprofits and private corporations. Following the initial appointment, patients were given a checklist of resources they were eligible for and the required paperwork to complete applications. During follow-up appointments, application status was reviewed, and practical assistance was provided. Patients were re-contacted at 2-week intervals to assess progress toward financial assistance goals. Outcome data collection included pre/post-intervention COST scores, patient satisfaction with the intervention, and intervention fidelity and retention. Results: The first fifty patients approached all screened positive for FT (COST < 22). Baseline COST scores ranged from 0–19. Results indicated a significant improvement in COST scores following the FN intervention (average increase = 6.86, 95% CI = 4.30–9.42), P < 0.0001). Post-intervention questionnaires indicated excellent patient satisfaction and retention with the FN intervention, and navigator logs indicated high fidelity to the intervention protocol. Conclusions: A novel FN intervention was feasible, acceptable, and effective in reducing FT among uninsured and underinsured oncology patients.

¿Ahora qué?: Cultural Adaptation of a Cancer Survivorship Intervention for Latino/a Cancer Survivors

OBJECTIVE

With a steadily increasing number of Latino/a cancer survivors, there is a need for supportive care programs for this underserved survivor subgroup.

METHODS

In this study, the authors culturally adapted an evidence-based survivorship program, Cancer Transitions: Moving Beyond Treatment (CT) for this population. Guided by Barrera and Castro's heuristic model for cultural adaptation of interventions, we conducted five focus groups (FG) among Latino/a cancer survivors (n = 54) in several US sites to inform the preliminary adaptation of program materials. We conducted four additional FGs (n = 38) to obtain feedback on adapted materials.

RESULTS

Common themes from initial FGs were related to program delivery and logistics, and general recommendations for CT modification. Program adaptations addressed information needs, including health care system navigation, employment concerns, and sexuality. Other adaptations included an emphasis on family, spirituality, culturally appropriate translation and features, and role plays. Participants in the second round of FGs confirmed adaptations incorporated earlier findings and suggested additional refinements.

CONCLUSION

This project helps guide the cultural adaptation of survivorship programs for Latino/a cancer survivors.

Using Telehealth to Train Providers of a Cancer Support Intervention

BACKGROUND

Group interventions are effective for addressing the transition from cancer treatment to survivorship but are not widely available outside of urban areas. In addition, minimal training is available for group facilitators outside of the mental healthcare discipline. Telehealth as a medium can facilitate conversation and interactive learning and make learning accessible to individuals in areas that lack resources for traditional classroom teaching. Little is known, however, regarding the feasibility and acceptability of a telehealth training program for group leaders. This project aimed to investigate the utility of a telehealth training program for the delivery of a copyrighted, manualized psychosocial group intervention, Cancer Transitions: Moving Beyond Treatment.

MATERIALS AND METHODS

Nine group leaders attended one in-person orientation, four telehealth training classes, and four telehealth supervision sessions, completing self-report measures of content knowledge, quality satisfaction, and self-confidence. Following the completion of their last Cancer Transitions facilitation, group leaders participated in a focus group to provide qualitative feedback regarding their experiences in training for and leading the respective groups in eight urban and rural North Carolina communities.

RESULTS

Group leaders rated the training program highly across the domains of content knowledge, quality satisfaction, and self-confidence. Satisfaction with the technology itself was equivocal.

CONCLUSIONS

Telehealth represents a feasible avenue for training and supporting leaders of psychosocial interventions. In addition, telehealth is particularly well suited to the need for training group leaders in areas outside urban centers or academic communities.

Implementing a one-on-one peer support program for cancer survivors using a motivational interviewing approach: results and lessons learned

Peer Connect matches cancer survivors and caregivers (guides) with those currently experiencing cancer-related issues seeking support (partners). Motivational interviewing (MI)-based communication skills are taught to provide patient-centered support. There is little guidance about MI-based applications with cancer survivors who may have multiple coping needs. This paper addresses the results and lessons learned from implementing Peer Connect. Thirteen cancer survivors and two caregivers received a 2-day MI, DVD-based training along with six supplemental sessions. Nineteen partners were matched with guides and received telephone support. Evaluation included guide skill assessment (Motivational Interviewing Treatment Integrity Code) and 6-month follow-up surveys with guides and partners. Guides demonstrated MI proficiency and perceived their training as effective. Guides provided on average of five calls to each partner. Conversation topics included cancer fears, family support needs, coping and care issues, and cancer-related decisions. Partners reported that guides provided a listening ear, were supportive, and nonjudgmental. Limited time availability of some guides was a challenge. MI can provide support for cancer survivors and caregivers without specific behavioral concerns (e.g., weight and smoking). An MI support model was both feasible and effective and can provide additional support outside of the medical system.

Process of diffusing cancer survivorship care into oncology practice

The LIVESTRONG Centers of Excellence were funded to increase the effectiveness of survivorship care in oncology practice. This study describes the ongoing process of adopting and implementing survivorship care using the framework of the diffusion of innovation theory of change. Primary data collection included telephone interviews with 39 members from the eight centers and site visits. Organizational characteristics, overall progress, and challenges for implementation were collected from proposals and annual reports. Creating an awareness of cancer survivorship care was a major accomplishment (relative advantage). Adoption depended on the fit within the cancer center (compatibility), and changed over time based on trial and error (trialability). Implementing survivorship care within the existing culture of oncology and breaking down resistance to change was a lengthy process (complexity). Survivorship care became sustainable as it became reimbursed, and more new patients were seen (observability). Innovators and early adopters were crucial to success. Diffusion of innovation theory can provide a strategy to evaluate adoption and implementation of cancer survivorship programs into clinical practice.

The use of motivational interviewing to promote peer-to-peer support for cancer survivors

Motivational interviewing (MI) as a counseling approach has gained empirical support for its use in a number of settings and for a variety of behaviors. However, the majority of practitioners trained to use MI have been professionals rather than laypeople. This article presents the rationale, design, and evaluation of an MI-based training for cancer survivors and caregivers to deliver peer support. The training and evaluation of the peers ("guides") to encourage practice and increase research knowledge for using MI-based peer support models for cancer care are discussed. Thirteen cancer survivors and two caregivers received two-day DVD-based MI training, as well as supplemental monthly sessions for six months. The guides demonstrated MI proficiency as assessed by the MI Treatment Integrity scale and other process evaluation assessments. MI can be adapted to train laypeople to provide support for groups such as cancer survivors.

Adult cancer survivorship care: experiences from the LIVESTRONG centers of excellence network

BACKGROUND

The objectives of this study were to characterize survivorship models of care across eight LIVESTRONG Survivorship Center of Excellence (COE) Network sites and to identify barriers and facilitators influencing survivorship care.

METHODS

Using the framework of the Chronic Care Model (CCM), quantitative and qualitative methods of inquiry were conducted with the COEs. Methods included document reviews, key informant telephone interviews with 39 participants, online Assessment of Chronic Illness Care (ACIC) surveys with 40 participants, and three site visits.

RESULTS

Several overarching themes emerged in qualitative interviews and were substantiated by quantitative methods. Health system factors supporting survivorship care include organization and leadership commitment and program champions at various levels of the health care team. System barriers include reimbursement issues, lack of space, and the need for leadership commitment to support changes in clinical practices as well as having program "champions" among clinical staff. Multiple models of care include separate survivorship clinics and integrated models as well as consultative models. COEs' scores on the ACIC survey showed overall "reasonable support" for survivorship care; however, the clinical information system domain was least developed. Although the ACIC findings indicated "reasonable support" for self-management, the qualitative analysis revealed that self-management support was largely limited to health promotion provided in clinic-based education and counseling sessions, with few COEs providing patients with self-management tools and interventions.

CONCLUSIONS

The CCM framework captured experiences and challenges of these COEs and provided insight into the current state of survivorship care in the context of National Cancer Institute-designated comprehensive cancer centers. Findings showed that cancer patients and providers could benefit from clinical information systems that would better identify candidates for survivorship care and provide timely information. In addition, a crucial area for development is self-management support outside of clinical care.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer survivors may benefit from learning about the experience and challenges faced by the eight LIVESTRONG Centers of Excellence in developing programs and models for cancer survivorship care, and these findings may inform patient and caregiver efforts to seek, evaluate, and advocate for quality survivorship programs designed to meet their needs.

Pet therapy for the homebound elderly

The Visiting Nurses Association-Community Services, Inc., responding to community interest and support, developed a pet therapy program for homebound clients. Early reports indicate that the program has improved the physiological as well as psychosocial wellbeing of participants.