Integrating outpatient palliative care into a metastatic breast oncology clinic.

Abstract

154 Background: The Advanced Breast Cancer (ABC) program at UCSF aims to improve metastatic breast cancer outcomes through early integration of palliative and oncologic care. Oncologists now routinely refer stage 4 patients to a palliative care physician and social worker. Thus this initiative translates ASCO policy recommendations into clinical practice. We report early results from our development, implementation, and evaluation of this novel program. Methods: To evaluate ABC, we used the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation and Maintenance), and Rogers’ Diffusion of Innovations theory. Results: Reach: From 10/2014 to 6/2015, 43 women participated out of 64 invited. Decliners’ main reason for refusal was to avoid additional appointments. Effectiveness: 36 patients reported improvements in 13 of 15 quality criteria, including care coordination, emotional support, and propensity to recommend the program. 34 patients responded to ESAS, QUAL-E and Steinhauser Spiritualty Screen questionnaires, with improvement in 10 out of 14 outcomes at 1-2 month follow-up. Improvements included reduction of anxiety, improved quality of life, and decreased nausea. Adoption: Early integration of palliative care is complex and requires additional coordination among busy clinicians. To address this, we embedded a palliative care physician in the oncology clinic two half-days per week; relied on an oncology fellow to facilitate ongoing cross-disciplinary collaboration; and leveraged the program coordinator’s capacity for following up on both project and patient issues. We also instituted a monthly team meeting to review patient cases. Implementation: Overall, our program design succeeded. Challenges included how to best communicate about patient prognosis and reason for referral. We also struggled to determine what patient eligibility criteria should trigger a referral. Maintenance: The program is currently sustained by grants and intramural cancer center funding. We are seeking continued investment. Conclusions: The ABC program demonstrates that early integration of palliative and oncologic care is feasible and associated with the psychosocial benefits previously found in efficacy studies.