Training community health workers to increase advanced care planning in African American women with breast cancer.

Abstract

e18549 Background: Black women are more likely to be diagnosed with more aggressive subtypes of breast cancer, at more advanced stages, and have worse outcomes than white women. Rates of advanced care planning (ACP) discussions are lower among black patients with advanced cancer, and they are less likely to receive care concordant with their wishes at end of life. Community health workers (CHW) play a versatile role in bridging social barriers to care and offer a unique mechanism to improve ACP discussions in this population. The aim of our study was to use a mixed methods approach to examine current practices and strategies to facilitate integration of CHW in ACP with black women with breast cancer. Methods: Participants completed a 22-item questionnaire to assess prior training in ACP and experience serving cancer patients. Focus groups were conducted with CHW (N = 5) and providers (i.e., oncologists, radiation oncologists, and palliative medicine physicians; N = 6) to discuss knowledge of ACP, barriers to ACP discussions, strategies to integrate CHW into ACP, and components of an effective ACP training curriculum for CHW. Focus groups were transcribed and two independent coders analyzed the data using the Framework method to extract themes and components of an ACP training curriculum for CHW. Results: Approximately 60% of CHW reported having received prior training in ACP. All providers reported primarily serving Black patients, and 66% self-reported low rates of ACP documentation (10-25%) among their patients. In the focus groups, CHW and providers described elements of effective ACP discussions as patient value-focused, multidisciplinary, timely, and empowering. Common barriers to ACP discussions identified by CHW included inexperience with ACP, unclear responsibility to initiate the discussion, and patient factors such as reluctance and complex social dynamics; providers identified issues of mistrust, historic injustice and power dynamics with their patients. Both CHW and providers viewed the role of CHW in ACP as a longitudinal process to empower, educate and reinforce patients’ values via a non-judgmental member of the community. For both groups, an ideal training curriculum teaches about key oncologic concepts, assesses patient readiness, and increases familiarity with ACP documentation. Conclusions: CHW serve a vital role in bridging care gaps for vulnerable patients and provide an opportunity to improve rates of ACP discussions in Black women with breast cancer. A training curriculum designed to help CHW assess a patient’s understanding of ACP and reinforce a longitudinal conversation is feasible, straightforward and can be incorporated into CHW workflow. One such training curriculum could expose CHW to different ACP documents, provide simulated patient encounters, and educate CHW on verbal and non-verbal cues from providers that may signal an ACP discussion is needed.