1. Wolfgang, Kelly

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Results from a collaborative study from The Oncology Institute, Stanford University School of Medicine, and CareMore Health recently found that intervention by lay health workers in the last month of life had a positive impact on quality of care and financial burden for end-of-life cancer patients. Though the value-based care model had no impact on survival, the study found that utilizing additional members of the health care team had a positive impact on end-of-life care, including a reduction of inpatient admissions, emergency department visits, and total health care costs.

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Care Intervention

The study, which is ongoing and yet to be fully published, designed an end-of-life care intervention using lay health workers to increase the value of care being provided to patients with cancer.


"We found over time that there was a shift in the way health care was being provided to the value-based model and that there might be ways to improve the coordination of care, especially in respect to oncology care," noted Richy Agajanian, MD, Chief Medical Officer and Senior Regional Director at The Oncology Institute. "Having progressive partners tied it together and allowed us to go forward with the study."


To improve value-based care, the team designed an intervention using lay health workers who were trained to assess and refer patients based on their symptoms.


"A lay health worker is a non-physician involved in the health care team, such as a medical assistant or health care coach," Agajanian explained. "These individuals are not physicians but have training in health care and have a deep compassion for health care. Lay health workers are easier to come by than physicians in terms of resource utilization, and they are the primary population to help coordinate the study while patients are still being seen by medical physicians and mid-level providers.


"Following study and internal protocols, we sought lay health workers who were already involved in health care, very empathetic, had good communication skills, and were bilingual," he added. "Throughout the study, these individuals had direct supervision by myself, a physician extender, or other physicians in charge of the program."


Patient Assessment

The study enrolled newly diagnosed patients with solid and hematologic malignancies and compared outcomes to a control group of all patients diagnosed with cancer in the year prior to intervention. For patients who died within 12-months follow-up, the study compared risk of death using Cox models and generalized linear regression to compare health care use in the last month of life and total cost of care from diagnosis until death, the study noted. All models were adjusted for age, stage of cancer, comorbidities, diagnosis, and length of follow-up.


"When the study first started, we limited the patient population to senior patients on a Medicare Advantage Plan," Agajanian said. "With time, there have been different generations of the study focusing on higher-risk populations, such as advanced, pre-terminal patients. But regardless of the patient's demographic or medical history, they each received the same assessment and attention to care."


For patients enrolled in the study, lay health workers conducted a pre-determined assessment via email or phone for patients' physical and behavioral health and subsequently referred patients to additional health resources if necessary.


"Patients were evaluated for things like pain, fatigue, anxiety, appetite, shortness of breath, and other physical criteria on a regular basis," Agajanian stated. "Our additional patient health questionnaire had questions regarding interests, mood, energy, and concentration. The patient's scores would reflect into automatic mental health, physical health, pharmacy management, and social services evaluations. We used those scored systems to guide care coordination for whatever we thought the patient might need, including ancillary services from dietitians to social workers and copay assistance to travel coordination.


"We additionally used preset algorithms for symptoms such as shortness of breath, pain management, and nausea to coordinate follow-through with physicians and physician extenders to actively and quickly address any patient symptoms."


All referrals for palliative care or behavioral health in response to patient assessments were coordinated in collaboration with a community oncology group and a Medicare Advantage payer for patients with all stages of cancer.


Impact of Care

With enhanced care from lay health workers, the study found reductions in patient-reported symptoms, acute care use, and total costs of care. Though there was no difference in survival between the two groups, patients receiving value-based care experienced better quality end-of-life cancer care, with 40 percent lower inpatient admissions, 75 percent fewer emergency department visits in the last month of life, 40 percent fewer acute care facility deaths, 45 percent increased hospice use, and 25 percent lower median total health care costs from diagnosis until death.


"Lay health workers are part of our health care delivery system and provide essential supportive services that are needed toward the end of life," he commented. "Especially when looking at the population of physicians and physician shortages, we need these health care workers to be involved in the integration of health care through the cancer continuum for patients."


Agajanian noted that, based on the results of the study, it is evident that the value-based care model and lay health workers are a necessary part of providing quality, integrated, patient-centric cancer care. By utilizing these workers for patient assessments and coordinating care, physicians, physician extenders, and mid-level practitioners will have the opportunity to focus on patient care. For those requiring end-of-life care, additional quality health care from lay health workers resulting in fewer hospital stays and more time with family can make a valuable difference.


"Lay health workers are available, trainable, and exactly what patients need for end-of-life care coordination and satisfaction," Agajanian said. "This patient-centric oncology service is the future of cancer delivery."


Kelly Wolfgang is a contributing writer.