Abstract

Social determinants of health (SDH), such as financial hardship, have been associated with higher mortality among patients with cancer [1Ramsey S.D. Bansal A. Fedorenko C.R. et al.Financial insolvency as a risk factor for early mortality among patients with cancer.J Clin Oncol. 2016; 34: 980-986Crossref PubMed Scopus (649) Google Scholar]. Additionally, research has indicated a correlation between populations (eg, individuals residing in low-income areas) experiencing unfavorable oncological outcomes (eg, higher rates of recurrence and mortality) and a higher prevalence of financial hardship [2Jagsi R. Pottow J.A. Griffith K.A. et al.Long-term financial burden of breast cancer: experiences of a diverse cohort of survivors identified through population-based registries.J Clin Oncol. 2014; 32: 1269-1276Crossref PubMed Scopus (219) Google Scholar]. For example, compared with White women, Black women present with more advanced-stage and aggressive breast cancer subtypes, which necessitates costly multimodal treatments, thereby elevating the risk of encountering financial hardship [3Giaquinto A.N. Sung H. Miller K.D. et al.Breast Cancer Statistics, 2022.CA Cancer J Clin. 2022; 72: 524-541Crossref PubMed Scopus (905) Google Scholar]. Furthermore, studies suggest Black women and individuals living in low-income neighborhoods are more likely to file for bankruptcy, which is an extreme manifestation of financial hardship [4Obeng-Gyasi S. Timsina L.R. Bhattacharyya O. et al.Bankruptcy among insured surgical patients with breast cancer: who is at risk?.Cancer. 2021; 127: 2083-2090Crossref Scopus (4) Google Scholar]. Nevertheless, despite this established association between financial hardship and poor oncologic outcomes, screening for financial hardship in patients with cancer remains inconsistently implemented across health care systems in the United States. To this end and to gain a deeper insight into how SDH impact patients with cancer, we initiated a screening process for all new and returning patients who sought care for breast, lung, and hematologic malignancies at our National Cancer Institute–designated comprehensive cancer center. The screening focused on three key SDH domains: financial hardship, housing, and transportation. We report on the implementation process of this screening initiative to identify SDH. Before initiating the screening process, all stakeholders (eg, clinicians, nurse, social workers, patient navigators, and financial counselors) met to discuss and outline the screening process in each oncology clinic. We assessed current barriers and facilitators to integration of SDH screening. This approach allowed stakeholder buy-in and increased awareness about implementing this new process. Based on this initial assessment, we modified the clinic intake process as an initial implementation step. We also established frequent meetings to discuss the screening process and identify continued barriers to adoption in clinic. Nurse managers acted as champions of the process in each clinic. In its first iteration, the workflow involved three steps: (1) an intake nurse asked existing SDH questions in the electronic medical record (EMR) and recorded the response in the EMR; (2) if a patient reported financial hardship, issues with transportation, or food insecurity, they were referred to a social worker for a needs assessment; and (3) based on the needs assessment, the social worker referred the patient to the appropriate resource (eg, financial counselor). Early assessment of implementation measured the reach of the intervention. The primary issue identified during needs assessment was the lack of awareness about the location of the SDH questions in the EMR. Although the questions were accessible in the EMR before the start of this study, they were not being used in any of the clinics, and there had been no training to ensure consistency in asking these questions. Furthermore, there were concerns that adding the responsibility of asking these questions would unfairly increase the workload of the intake nurse. To complicate the issue further, this study occurred during the great resignation, which resulted in frequent staff changes across clinics [5Amanor-Boadu V. Empirical evidence for the "Great Resignation." Monthly Labor Review, U.S. Bureau of Labor Statistics.https://www.bls.gov/opub/mlr/2022/article/empirical-evidence-for-the-great-resignation.htmDate: 2022Date accessed: November 3, 2023Google Scholar]. We also faced logistical issues once a patient-reported financial hardship or responded "yes" to any other SDH screening questions. These issues included the following: (1) Who would place the referral to social work? (2) How should the referral be placed (eg, consult order, telephone call, e-mail, or secure message through EMR)? (3) Once the referral was placed, who was responsible for ensuring the patient had been seen by social work? (4) What was the acceptable time frame for follow-up? By obtaining stakeholder buy-in before design and initiation of the process, health care workers in the clinics were amenable to the process and eager to participate. Furthermore, as this study occurred during the COVID-19 pandemic, there was greater awareness about the SDH and their implications for patients with cancer. The cornerstone of our implementation strategy was quarterly stakeholder meetings to review EMR data on implementing the questions into the clinic workflow. This strategy allowed the research team to (1) re-examine the project's logistics, (2) assess uptake of the new process in each clinic, and (3) troubleshoot issues as they arose. Furthermore, maintaining all records in the EMR enabled the nurse managers to be precise about gaps in their clinic based on data entry or lack thereof. Based on the identified barriers and facilitations, including ongoing quarterly meetings with the implementation champions, we adapted the clinic intake process as follows. Apart from placing the consultation order in the EMR, each clinic verified the consultation with the social work department through telephone or e-mail. To ensure all patients reporting SDH concerns were addressed, the IT department sent a weekly list of patients who responded "yes" to the EMR questions to the study patient navigator to ensure no patients were overlooked. Furthermore, a predefined template or dot phrase was generated within the EMR to assist the IT team in identifying and retrieving data in social work and patient navigator notes. The final implemented intervention included the following steps:1.An intake nurse would inquire about SDH questions and document the responses in the EMR.2.If a patient reported experiencing financial hardship, they would be referred to a social worker for a needs assessment.3.A designated team member (eg, nurse, advanced practice provider, physician) would place the consult order and notify social work by telephone or e-mail.4.The designated team member would follow up with the patient and review the EMR's predefined template provided by social work or patient navigation.5.The IT department would furnish a weekly report of patients reporting financial hardship. During the study period (November 1, 2020, to November 30, 2021), we screened 4,543 patients. Approximately 480 (10.6%) patients reported financial hardship. Of the patients reporting financial hardship, the breakdown by cancer site was 56% hematologic, 24% lung, and 19% breast malignancies. Overall, patients reporting financial hardship were more likely to be Black, insured by Medicaid, and live in neighborhoods with the highest deprivation based on the social deprivation index (Table 1) [6Butler D.C. Petterson S. Phillips R.L. Bazemore A.W. Measures of social deprivation that predict health care access and need within a rational area of primary care service delivery.Health Serv Res. 2013; 48: 539-559Crossref PubMed Scopus (362) Google Scholar].Table 1Comparison of patients reporting financial hardship vs no financial hardshipStudy VariablesFinancial Hardship (n = 480)No Financial Hardship (n = 4,063)P ValueAge, mean (SD)61.28 (12.20)63.13 (12.24).0017Race, n (%)<.001 White339 (8.7)3,572 (91.3) Black117 (25.5)341 (74.5) Asian8 (9.4)77 (90.6) Other13 (17.8)60 (82.2)Insurance, n (%)<.001 Private121 (6.3)1,814 (93.7) Medicaid90 (27.8)234 (72.2) Medicare238 (11.2)1,887 (88.8) Other21 (19.3)89 (81.7)Neighborhood deprivation, n (%)<.001 Quintile 1 (least)41 (4.7)839 (95.3) Quintile 273 (8.1)833 (91.9) Quintile 373 (8.9)748 (91.1) Quintile 4119 (12.3)849 (87.7) Quintile 5 (most)155 (20.4)605 (79.6) Open table in a new tab Incorporating financial hardship screening questions into a large, comprehensive academic medical center highlighted procedural and logistical barriers in the implementation process. Specifically, despite receiving strong support and commitment from all stakeholders, the oversight of crucial details, such as the responsible party for initiating the consultation order with social work or the absence of well-defined steps for postconsultation follow-up, resulted in implementation challenges. Our study had the following limitations. The intervention was implemented in a comprehensive cancer center, which may have more resources and institutional support to implement SDH screening and may not be generalizable in other clinic settings. We did not assess the cost nor the sustainability of the intervention. Due to the early phase of intervention implementation, we were unable to assess the impact of identification of SDH at intake and any relief from financial burden, transportation, or housing needs. CMS have required mandatory screening for SDH for all hospitalized patients starting in 2024 [7Schoenbaum A.E. Stephenson L. Evans J. Addressing social determinants of health (SDOH) in healthcare part 2.HIMSS. Published 2023; (Available at:)https://www.himss.org/resources/addressing-social-determinants-health-sdoh-healthcare-part-2Date accessed: December 7, 2023Google Scholar]. Furthermore, the Joint Commission has updated its accreditation standards to include an element of performance focused on collection of SDH [7Schoenbaum A.E. Stephenson L. Evans J. Addressing social determinants of health (SDOH) in healthcare part 2.HIMSS. Published 2023; (Available at:)https://www.himss.org/resources/addressing-social-determinants-health-sdoh-healthcare-part-2Date accessed: December 7, 2023Google Scholar]. Consequently, our experiences offer valuable insights into the potential challenges and opportunities that health care facilities may encounter when striving to adhere to this recent mandate and accreditation standard. To enhance the implementation of these new regulations, our recommendations consist of involving stakeholders in the planning phase, developing methods for ongoing data assessment to pinpoint deficiencies, and establishing well-defined roles within the clinic team (Table 2).Table 2Summary of strategies to integrate SDH questions into clinic workflowStakeholders (eg, hospital leadership, nurse managers, nurses) buy-in before project initiation and their involvement during project implementationData review from EMR frequently (eg, quarterly)Establishment of process for who and how referral should be placedDetermination of who is responsible to follow up on the referral once placedGeneration of weekly reports of patients who reported financial hardship for review by social work or patient navigationCreation of tools to increase retrievability of data (eg, SDH dot phrase)EMR = electronic medical record; SDH = social determinants of health. Open table in a new tab EMR = electronic medical record; SDH = social determinants of health. Declaration of generative artificial intelligence (AI) and AI-assisted technologies in the writing process: During the preparation of this work, the author(s) used ChatGPT to improve language and readability. After using this tool or service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication. This project is funded by a Financial Hardship Supplement to grant, P30CA016048 from the National Cancer Institute, National Institutes of Health. Samilia Obeng-Gyasi, MD, MPH, is funded by the Paul Calabresi Career Development Award (K12 CA133250), Conquer Cancer Breast Cancer Research Foundation Advanced Clinical Research Award for Diversity and Inclusion in Breast Cancer Research, The Society of University Surgeons, and The American Cancer Society (RSG-22-106-01-CSCT). Carolyn J. Presley, MD, MHS is supported by the National Institute on Aging K76AG074923-01.