Minority and low-income populations have less involvement in their cancer care, experience worse health-related quality of life, and register more acute care visits and higher total costs of care than their affluent and white counterparts.

However, incorporation of a community-based intervention into health care delivery for these underserved populations may yield significant improvement in these measures, according to a study presented at ASCO Annual Meeting.

The intervention, LEAPS, uses community health workers trained to facilitate patients/clinician discussions of cancer care, particularly regarding advance care planning and symptom burden. These community health workers also play an important role in connecting patients with community-based resources to overcome social determinants of health.

“What’s exciting about this plan is that these community health advocates are actually embedded into the clinics and work very closely with patients to navigate their cancer treatment,” Manali I. Patel, MD, MPH, MS, assistant professor of medicine in the oncology division at Stanford University School of Medicine, said in an interview with Healio. “This is a very unique collaboration.”

Patel spoke with Healio about the barriers to quality health care among this population, the promising results of her study, and the potential future use of community health advocates in the cancer space.

Healio: How did you develop this intervention?

Patel: We created a multilevel intervention with an employer union health plan, which is essentially a situation where the labor union, Unite Here, has a health plan associated with it. Unite Here Health provides benefits to individuals who would otherwise not have benefits in their jobs and occupations. These are mostly hourly-wage workers who work for hotels, casinos or restaurants. The union has a trust fund that sets up health benefits for these individuals. So, the health plan has a vested interest in improving value-based care for its members.

This collaboration has been going on for 10 years. In these clinics, they have nurses, nurse practitioners, pharmacists and clinicians. However, as part of the care team, they were employing community health advocates. These advocates were assisting with various aspects of care delivery, but mostly in the chronic disease space — diabetes, heart failure, blood pressure management and primary care. There was nothing in the cancer space.

I first encountered them after I gave a presentation about utilizing community health workers to assist patients with advance care planning and symptom assessments. At the time, I had no data on cost of care, but the impact on patients’ experiences was part of the reason they reached out to me. They wanted to investigate what we could do in the cancer space for their health plan members.

Healio: How did you conduct the study?

Patel: Along with United Here Health, we conducted a randomized, controlled trial of LEAPS in Atlantic City, New Jersey, and Chicago. We randomly assigned 160 union members enrolled in the employer-union health plan and newly diagnosed with hematologic and solid tumor cancers to either usual care or the 6-month LEAPS intervention. Those in the intervention group were assigned to a community health advocate who had been trained by my team in advance care planning and symptom management. In addition, they received screenings for any barriers they may have faced from a social or economic standpoint. In addition, as part of usual care, we really wanted individuals to seek out clinicians who provided the best care, even if it wasn’t the least costly. We knew there were some providers in Atlantic City who seemed to do better than others, so we would waive copays for those who sought care at these facilities.

The only thing that the control group did not get was the advance care planning and symptom management.

Healio: What did you find?

Patel: Over time, as compared with the control group, the intervention group tended to have better health-related quality of life at 4 months, and then again at 12 months. There was more activation and engagement in their care. That was part of the intervention — we trained these community health advocates to help patients be more activated, engaged and confident in taking ownership of their health care. They also helped patients have more confidence in engaging and following through with their clinicians regarding their treatment plans.

We found greater activation in the intervention group and significant reductions in hospitalizations. The number of ED visits was lower, but the difference was not statistically significant. However, that translated to an almost 50% reduction in hospitalization among the intervention group. In the intervention group, the overall cost at 12 months was about $70,000 vs. about $150,000 in the control group. It shows that perhaps what is leading those differences is that patient activation is associated with reductions in unnecessary health care use.

Another benefit is in symptom assessment. Most studies we’ve done in my group have shown that if you identify and address patient symptoms after they are diagnosed with cancer, you can potentially not only improve their health-related quality of life, but also reduce the need to come into the hospital for symptoms that are uncontrolled.

This intervention is also proactive. We’re not waiting until patients need these services. They are getting them before they need them. That requires time and money, and the fact that Unite Here Health is invested in this is exciting. They invested in this long before we knew there would be a cost reduction. Now, we’ve shown that the return on investment is beyond paying for itself.

Healio: What are your plans for future research in this area?

Patel: We’re engaging in training Unite Here Health advocates across the United States. In July, we’re planning a training for most of the health advocates to engage these individuals. Then we’re planning to replicate a larger study with this group. My group will also be doing a 24-clinic cluster randomized study.

Healio: Is there anything else you would like to mention?

Patel: I never expected to see these kinds of results, and I don’t think United Here Health did, either. I can’t be more thankful to have been involved in this community-based approach — United Here Health was involved in designing this intervention, as well as the community advisory board members. I think that community involvement leads to an effective approach, because the community itself knows where best to focus these efforts. They were critical in terms of telling me what they wanted us to design for them. So, we started with a bit of a half-baked idea of what we thought we could do, and then together, we really worked through the process. Did it take a decade? Yes, but so many patients benefited from the work we put in. I think you have to make some sort of upfront investment of doing the hard work at the beginning, so you can reap benefits at the end.

For more information:

Manali I. Patel, MD, MPH, MS, can be reached at Stanford University, 875 Blake Wilbur Drive, Palo Alto, CA 94304; email: manalip@stanford.edu.

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