Interdependent Care Research Articles

Chat windows and zoom bombers: virtual boundaries in mental health peer support

Mental health peer support is a form of care in which people with mental health conditions provide emotional support and education to fellow individuals in recovery, and it is often offered online. Yet little research has considered the social and ethical consequences of providing peer support virtually. Drawing on qualitative data on peer support at mental health agencies across Ohio, this paper argues that the move to online platforms like Zoom led to concerns around boundaries: the rules within personal relationships between people giving and receiving support. In particular, the shift to virtual delivery of peer support posed new questions around privacy and communication. I assert that understanding boundaries in virtual settings is critically important to the field of disability studies, as scholars, activists, and practitioners document and analyze the nature of interdependent care relationships that unfold across a variety of social contexts.

Family Health Equity in Chronic Disease Prevention and Management.

Efforts to improve chronic disease outcomes among US adults highlight families, particularly support from families, as a key aspect of disease prevention and management. To date, however, an overwhelming focus on individual-level outcomes and unidirectional support (eg, from a family caregiver to an identified care recipient) belies the existence of co-occurring health concerns and interdependent care. There are increasing calls for more sophisticated and intensive family health interventions that better integrate family-level factors, processes, and outcomes to provide comprehensive family support services in health care and community-based settings. This commentary provides key considerations for advancing this work while centering family health equity and families themselves in health initiatives. Several critical barriers are identified and discussed. For example, a narrow focus on family and inadequate measures of family-level disease burden make it challenging to understand how the disproportionate burden of chronic disease observed among individuals of lower socioeconomic status and certain racial and ethnic groups compounds and complicates family health experiences. In addition, limited attention to the interaction between individuals, families, and broader sociocultural factors that influence family resources and constraints, such as racism, hamper program design, implementation, and evaluation. To center families in efforts to reduce chronic disease disparities, it is necessary to move beyond superficial attention to the complexity of disease prevention and management within the family context. This commentary serves to enhance understanding of important drivers of family-level chronic disease outcomes, while providing important considerations for advancing research and practice.

Intervention to optimize guideline-recommended interdependent care delivery in breast and lung cancers with the 4R Oncology model.

34 Background: Team-based care improves quality, reduces fragmentation and lowers clinician burnout related to ad hoc care coordination. A key teamwork principle is managing timing and sequence of interdependent care (Vogel JOP 2016). The 4R Oncology model featured by the NCI ASCO Teams initiative fosters effective teamwork by facilitating systematic timing / sequence of interdependent care.1 4R is Right Info / Care / Patient / Time. Using a 4R intervention, a large health system created a high-functioning care team and conducted optimizations of guideline-based interdependent care in breast and lung cancers Oct 2020 - Dec 2021.2 We present results of these optimizations. Methods: We compared data from electronic health record on timing and sequence of care between historical control cohorts of patients who received care pre-4R (breast n=274, lung n=173) to the post-optimization 4R cohorts (breast n=211, lung n=140). Patient and tumor characteristics between control and 4R cohorts in both cancers were similar. Results: Timing and sequence of care for 6 of the 7 breast cancer metrics and all 7 lung cancer metrics was significantly improved between the control and 4R cohorts (Table). Despite significant increase, the rate of timely care for some metrics remained low, such as referrals based on distress screening in breast cancer and palliative care consult in lung cancer. Conclusions: The 4R Oncology model is effective in applying teamwork principles and improving timing and sequence of guideline-based care. Opportunities for further care optimizations exist to expand the 4R benefit to a higher number of patients. A learning system established in our institution will inform iterative optimizations. 1. Trosman JOP 2016. 2. Liu JCOOP 2022. [Table: see text]

Beyond the institution versus home care dichotomy: Lessons from a feeding‐tube medical home

AbstractDecades of rights‐based advocacy for people with disabilities have transitioned long‐term care in the United States from institutional settings to home‐based care provided by interdependent care networks. This paper argues that policies and practices within these home‐based care systems unintentionally produce and often perpetuate unrecognized structural violence on the recipients of care and the caregivers. Understanding the caregivers' experiences through a case study of a Facebook feeding tube family support group exposes the geographic realities and ableist underpinnings of the home‐based care model that undergird this violence. Further, I illustrate the contradictions of “home is best” ideology by focusing on three interwoven themes: structural dependency on unpaid mother‐experts, spatio‐temporal erasure through decentralization, and invasive surveillance structures. This research attends to how home‐based care, as a practice and a place, reflects broader patriarchal, gendered, and neoliberal concepts of autonomy and individual rights as expressed through policies like “person‐centered” care and the medical home model. While this analysis has theoretical, methodological, and policy implications, more important is the contextualization of family experiences that sometimes impacts life and death.

The impact of the 4R Oncology model of team-based care delivery on timing and sequence of guideline recommended interdependent care in breast and lung cancers.

1523 Background: Team-based care improves quality, reduces fragmentation and lowers clinician burnout related to ad hoc care coordination. A key principle of teamwork is managing timing and sequence of interdependent care (Vogel JOP 2016). The 4R Oncology model featured by the NCI ASCO Teams project fosters effective teamwork by facilitating systematic timing / sequence of interdependent care (Trosman JOP 2016). 4R is Right Info / Care / Patient / Time. Using 4R, a large health system created a high-functioning care team and conducted optimizations of interdependent care in breast and lung cancers Oct 2020 - Dec 2021 (Liu JCOOP 2022). Optimizations focused on guideline-based care with suboptimal timing / sequencing in respective cancers. We present results of these optimizations. Methods: We compared data from electronic health record on timing and sequence of care between historical control cohorts of patients who received care pre-4R (breast n=270, lung n=173) to the post-optimization 4R cohorts (breast n=208, lung n=139). Patient and tumor characteristics between control and 4R cohorts in both breast and lung cancers were similar. Results: Timing and sequence of care for 5 of the 6 breast cancer metrics and all 6 lung cancer metrics was significantly improved between the control and 4R cohorts. Despite significant increase, the rate of timely care for some metrics remained low, such as referrals based on distress screening in breast cancer and palliative care in lung cancer. Conclusions: The 4R Oncology model is effective in applying teamwork principles and improving timing and sequence of guideline-based care. Opportunities for further improvement exist to expand the benefit of 4R to a higher number of patients. A learning system being established in our institution will inform iterative care optimizations.[Table: see text]

Fostering a High-Functioning Team in Cancer Care Using the 4R Oncology Model: Assessment in a Large Health System and a Blueprint for Other Institutions.

Delivering cancer care by high-functioning multidisciplinary teams promises to address care fragmentation, which threatens care quality, affects patient outcomes, and strains the oncology workforce. We assessed whether the 4R Oncology model for team-based interdependent care delivery and patient self-management affected team functioning in a large community-based health system. 4R was deployed at four locations in breast and lung cancers and assessed along four characteristics of high-functioning teams: recognition as a team internally and externally; commitment to an explicit shared goal; enablement of interdependent work to achieve the goal; and engagement in regular reflection to adapt objectives and processes. We formed an internally and externally recognized team of 24 specialties committed to a shared goal of delivering multidisciplinary care at the optimal time and sequence from a patient-centric viewpoint. The team conducted 40 optimizations of interdependent care (22 for breast, seven for lung, and 11 for both cancers) at four points in the care continuum and established an ongoing teamwork adaptation process. Half of the optimizations entailed low effort, while 30% required high level of effort; 78% resulted in improved process efficiency. 4R facilitated development of a large high-functioning team and enabled 40 optimizations of interdependent care along the cancer care continuum in a feasible way. 4R may be an effective approach for fostering high-functioning teams, which could contribute to improving viability of the oncology workforce. Our intervention and taxonomy of results serve as a blueprint for other institutions motivated to strengthen teamwork to improve patient-centered care.

How to Deal with a Bully: Debility, Non-Production, and Radical Care

This article examines how resistance toward capitalism's temporal bullying is performed in contemporary art and activism. It addresses the relationship between creativity, institutions, and empowerment. Building on the conceptual work of Croatian artist Mladen Stilinović (1947–2016), the article explores several aesthetic presentations of resistive temporalities we identify as non-production. The case studies of non-production herein marshaled affirm a performance of resistance that centers discussion of radicality in self-consciously interdependent care networks, ostensibly available to all disabled and nondisabled individuals. This care ethic claps back at the idea of self-optimization and fiduciary endurance amidst economic regimes of exploitation as virtuous. In the place of 'wellness,' this article affirms new directions in care and mutual aid, as premised on queer, crip, and feminist portrayals of disability praxis and pedagogy.

Nursing care as a systemic and entrepreneurial phenomenon.

The objective is to produce a critical-reflexivity analysis of nursing care, from the perspective of complexity thinking and social entrepreneurship. Theoretical-reflective study, supported by the framework of complexity thinking and social entrepreneurship. The main characteristics that lead and support nursing care are analyzed from a systemic-entrepreneurial perspective. A parallel is conceived between vertical care, design from a hierarchical structure and nursing care in the systemic-entrepreneurial perspective, which leads to singularity, originality, circularity, complementarity and interactivity. The centrality of nursing care is reaffirmed as a tangible social good or not. Theoretical reflection on nursing care as a systemic and entrepreneurial phenomenon raises a unique and multidimensional perception of the human being/user, health, the nursing work process, in order to achieve an increasingly agile, dynamic, circular, complementary and interdependent care.

Nursing care as a systemic and entrepreneurial phenomenon

The objective is to produce a critical-reflexivity analysis of nursing care, from the perspective of complexity thinking and social entrepreneurship. Theoretical-reflective study, supported by the framework of complexity thinking and social entrepreneurship. The main characteristics that lead and support nursing care are analyzed from a systemic-entrepreneurial perspective. A parallel is conceived between vertical care, design from a hierarchical structure and nursing care in the systemic-entrepreneurial perspective, which leads to singularity, originality, circularity, complementarity and interactivity. The centrality of nursing care is reaffirmed as a tangible social good or not. Theoretical reflection on nursing care as a systemic and entrepreneurial phenomenon raises a unique and multidimensional perception of the human being/user, health, the nursing work process, in order to achieve an increasingly agile, dynamic, circular, complementary and interdependent care.

Evaluation of the Novel 4R Oncology Care Planning Model in Breast Cancer: Impact on Patient Self-Management and Care Delivery in Safety-Net and Non–Safety-Net Centers

Optimal cancer care requires patient self-management and coordinated timing and sequence of interdependent care. These are challenging, especially in safety-net settings treating underserved populations. We evaluated the 4R Oncology model (4R) of patient-facing care planning for impact on self-management and delivery of interdependent care at safety-net and non-safety-net institutions. Ten institutions (five safety-net and five non-safety-net) evaluated the 4R intervention from 2017 to 2020 with patients with stage 0-III breast cancer. Data on self-management and care delivery were collected via surveys and compared between the intervention cohort and the historical cohort (diagnosed before 4R launch). 4R usefulness was assessed within the intervention cohort. Survey response rate was 63% (422/670) in intervention and 47% (466/992) in historical cohort. 4R usefulness was reported by 79.9% of patients receiving 4R and was higher for patients in safety-net than in non-safety-net centers (87.6%, 74.2%, P = .001). The intervention cohort measured significantly higher than historical cohort in five of seven self-management metrics, including clarity of care timing and sequence (71.3%, 55%, P < .001) and ability to manage care (78.9%, 72.1%, P = .02). Referrals to interdependent care were significantly higher in the intervention than in the historical cohort along all six metrics, including primary care consult (33.9%, 27.7%, P = .045) and flu vaccination (38.6%, 27.9%, P = .001). Referral completions were significantly higher in four of six metrics. For safety-net patients, improvements in most self-management and care delivery metrics were similar or higher than for non-safety-net patients, even after controlling for all other variables. 4R Oncology was useful to patients and significantly improved self-management and delivery of interdependent care, but gaps remain. Model enhancements and further evaluations are needed for broad adoption. Patients in safety-net settings benefited from 4R at similar or higher rates than non-safety-net patients, indicating that 4R may reduce care disparities.

Reclaiming Location in Education: a Response to the COVID Pandemic

The school shutdowns necessitated by the 2020 COVID pandemic have highlighted the importance of “located” education. A located education is not determined by medium or physical proximity. Instead, a located education acknowledges the limits of human understanding and sustains mutually beneficial relationships. Recent neoliberal reform efforts have sought to dis-locate education – to strip it of both spatial limitation and the obligations of interdependent care. However, the COVID-related shutdowns have highlight the brokenness of a dis-located education. Drawing from the work of activist Wendell Berry and philosopher Nel Noddings, this article makes the case for located education – an education that recognizes the importance of both place and people.

A Care Ethical Justification for an Interest Theory of Human Rights

ABSTRACT Care ethics is often criticized for being incapable of outlining what responsibilities we have to persons beyond our personal relations, especially toward distant others. This criticism centres on care theorists’ claim that the concerns of morality emerge between people, generated through our relations of interdependent care: it is difficult to see how moral duties can be applied to those with whom we do not forge a relationship. In this article, I respond to this criticism by outlining a care ethical justification for an interest theory of human rights. This theory will argue that the demands of global justice include various positive actions that aim toward ensuring the conditions for good caring relations to flourish, which in turn protect and promote the vital interests of all persons. In doing so, I aim to concurrently advance the sparse work on human rights within the care literature, systematizing the ideas of care theorists such as Daniel Engster, Virginia Held, and Fiona Robinson.

787. Improving ED Sepsis Care

BackgroundSepsis is a severe, life-threatening illness in response to an infection from the body’s immune system. Sepsis can progress rapidly, causing hypotension, organ failure, and death. Mortality from severe forms of sepsis and septic shock range between 20% to 50%, but with appropriate and timely treatment, mortality decreases to 5%-10%. Before completing the Improving ED Sepsis Care project, there was only 18% and 12% compliance with the CMS 3 and 6-hour core measure bundles, respectively, within the Ochsner Main Campus Emergency Department.MethodsA multi-disciplinary team followed Lean methodology for process improvement. The failure to identify sepsis patients as high acuity in triage was a key root causes identified. There was also a need to simplify the process and workflow to facilitate antibiotic administration and resuscitation. A triage tool called “Code Sepsis” was created to allow for early identification of severe forms of sepsis, to ensure an appropriate ESI score, and to dedicate immediate attention from staff. A provider order set was created that included the necessary lab work standardized antibiotics.Results3-hour bundle compliance increased from 18% to 90% following the intervention. Improvements were noted in time to antibiotic administration, volume resuscitation, and appropriate initiation of vasopressors. The addition of the “Code Sepsis” triage tool decreased the median time to antibiotic administration from 1 hour 53 minutes to 33 minutes. Improvements were also noted in the elements of the 6-hour “perfect care” bundle; however, compliance rates were lower than goal.ConclusionEarly identification and appropriate treatment of sepsis is key to improving survival. Despite widespread knowledge early treatment, many EDs struggle to meet the CMS sepsis care bundles. Utilizing the Lean framework allowed the improvement team to breakdown a multi-siloed, interdependent care process. Disclosures All authors: No reported disclosures.

Does the innovative 4R Care Delivery Model improve timing and sequencing of guideline recommended breast cancer care in safety net and non-safety net centers?

36 Background: Under the NCI ASCO Teams Project, we proposed a 4R Model which enables patient (pt) and care team to manage timing and sequencing of interdependent care with a novel multimodality 4R Care Project Plan (Trosman JOP ’16). 4R (Right Info/Care/Patient/Time) was previously piloted at 3 Chicago centers (Weldon ASCO ‘18). Methods: A new study tested impact of 4R on timing and sequencing of guideline recommended care at 4 safety net and 3 non safety net US centers. 4R Plans were provided to stage 0-III breast cancer pts Jan - Nov’18, 4R cohort. Clinical and pt reported data analyses compared 4R cohort (N = 105) to a historical control cohort of pts who received care pre-4R, Jan - Dec ’17 (N = 190). Results: We significantly improved 3 referral metrics and 4 referral completion metrics - receipt of care by pts who were referred (Table). After referrals, safety net pts had a significant increase in 4R vs control cohort in receiving genetic consult (72%, 21/29 vs. 42%, 18/43, p = .02) and dental visit (100%, 6/6 vs. 20%, 1/5, p = .02). They had lower increases in flu shot referrals (41%, 24/58, vs 36%, 37/104, NS) and dental referrals (10%, 6/58, vs 5%, 5/104, NS) than non safety net pts who had significant increases. Other metrics improved at a similar rate for safety net and non safety net pts. Conclusions: 4R markedly improved referral and receipt of interdependent guideline recommended breast cancer care. For most metrics safety net pts benefited from 4R at a similar or higher rate than non safety net pts, indicating that 4R may reduce care disparities. Low increases in referrals for safety net pts and in trial referral/enrollment for all pts must be addressed. An expansion of 4R across the US continues this work. [Table: see text]

Contextual determinants of CHILDREN\u2019S health care and policy in Europe

BackgroundThe main objective of this study was to explore the contextual determinants of child health policies.MethodsThe Horizon 2020 Models of Child Health Appraised (MOCHA) project has one Country Agent (CA) in all 30 EU and EEA countries. A questionnaire designed by MOCHA researchers as a semi-structured survey instrument asked CAs to identify and report the predominating public and professional discussions related to child health services within the last 5 years in their country and the various factors which may have influenced these. The survey was issued to CAs following validation by an independent Expert Advisory Board. The data were collected between July and December 2016.The data was qualitatively analysed using software Nvivo11 for data coding and categorization and constructing the scheme for identified processes or elements.ResultsContextual determinants of children’s health care and policy were grouped into four categories. 1) Socio-cultural determinants: societal activation, awareness, communication, trust, freedom, contextual change, lifestyle, tolerance and religion, and history. 2) Structural determinants which were divided into: a) external determinants related to elements indirectly correlated with health care and b) internal determinants comprising interdependent health care and policy processes. 3) International determinants such as cross-nationality of child health policy issues. 4) The specific situational determinants: events which contributed to intensification of debates which were reflected by behavioural, procedural, institutional and global factors.ConclusionsThe influence of context across European countries, in the process of children’s health policy development is clearly evident from our research. A number of key categories of determinants which influence child health policy have been identified and can be used to describe this context. Child health policy is often initiated in reaction to public discontentment. The multiple voices of society resulted, amongst others, in the introduction of new procedures, action plans and guidelines; raising levels of awareness, intensifying public scrutiny, increasing access and availability of services and provoking introduction of structural changes or withdrawing unfavourable changes.

Does the innovative 4R Care Delivery Model improve timing and sequencing of guideline recommended breast cancer care in safety net and non-safety net centers?

562 Background: Under the NCI ASCO Teams Project, we proposed a 4R Model which enables patient (pt) and care team to manage timing and sequencing of interdependent care with a novel multimodality 4R Care Project Plan (Trosman JOP ’16). 4R (Right Info/Care/Patient/Time) was previously piloted at 3 Chicago centers (Weldon ASCO ‘18). Methods: A new study tested impact of 4R on timing and sequencing of guideline recommended care at 4 safety net and 3 non safety net US centers. 4R Plans were provided to stage 0-III breast cancer pts Jan-Nov’18, 4R cohort. Clinical and pt reported data analyses compared 4R cohort (N=105) to a historical control cohort of pts who received care pre-4R, Jan - Dec ’17 (N=190). Results: We significantly improved 3 referral metrics and 4 referral completion metrics - receipt of care by pts who were referred (Table). After referrals, safety net pts had a significant increase in 4R vs control cohort in receiving genetic consult (72%, 21/29 vs. 42%, 18/43, p=.02) and dental visit (100%, 6/6 vs. 20%, 1/5, p=.02). They had lower increases in flu shot referrals (41%, 24/58, vs 36%, 37/104, NS) and dental referrals (10%, 6/58, vs 5%, 5/104, NS) than non safety net pts who had significant increases. Other metrics improved at a similar rate for safety net and non safety net pts. Conclusions: 4R markedly improved referral and receipt of interdependent guideline recommended breast cancer care. For most metrics safety net pts benefited from 4R at a similar or higher rate than non safety net pts, indicating that 4R may reduce care disparities. Low increases in referrals for safety net pts and in trial referral/enrollment for all pts must be addressed. An expansion of 4R across the US continues this work. [Table: see text]

Results from a pilot of an innovative 4R Cancer Care Delivery Model: Impact on patient self-management.

224 Background: Under the “NCI ASCO Teams” Project, we proposed a 4R Model of teamwork and patient self-management (pSM) (Trosman JOP ’16). 4R is Right Info / Care / Patient / Time. It enables patient (pt) and care team to manage interdependent care along the care continuum with an innovative multimodality personalized 4R Care Project Plan. We piloted 4R at 3 centers (academic, community, safety net) and assessed its impact on pSM. Methods: 4R Plans were administered to breast cancer pts stage 0-III Sep ’16 – Aug ’17 (4R cohort). We surveyed the 4R cohort and a comparable historical cohort of pts who received care pre-4R, Jun ’15 – May ’16 (control). We used simple frequencies and Fisher’s exact test in analyses. Results: Survey response rates: 68%, 185/271 (4R cohort); 47%, 241/410 (control). 75% of 4R respondents reported 4R Plans very useful / useful in overall understanding and organizing their care; 68% found 4R’s novel “project” component, very useful / useful in managing timing &amp; sequencing of interdependent care. Care complexity impacted 4R usefulness: 67% of pts who received &gt; 6 care services found 4R very useful / useful vs. 47% of pts who received &lt; = 6 services, p = .01. Pts with lower care complexity suggested how to make 4R more useful to them, eg focus on endocrine therapy. Table compares pSM metrics in the 4R and control cohort. Care complexity was a significant factor of feeling overwhelmed for pts in the control cohort (51% of pts receiving &gt; 6 care services felt overwhelmed vs. 31% of pts receiving &lt; = 6 services, p = .02), but not a significant factor for pts in the 4R cohort (30% vs. 28%, p = .9). Conclusions: The 4R model significantly improved pt self-management in early breast cancer and reduced the impact of care complexity on pts, but provider factors of pSM need improvement. A 4R pilot at additional 12 cancer centers across the U.S. is in progress.[Table: see text]

Results from a pilot of an innovative 4R Cancer Care Delivery Model in early breast cancer: Impact on timing and sequencing of guideline recommended care.

281 Background: Under the “NCI ASCO Teams” Project, we proposed a 4R Model of teamwork and patient self-management (Trosman JOP ’16). 4R = Right Info / Care / Patient / Time. It enables patient and care team to manage timing / sequencing of interdependent care with an innovative multimodality personalized 4R Care Project Plan. We piloted 4R at 3 centers (academic, community, safety net) and assessed impact on timing / sequencing of guideline based care. Methods: 4R Plans were administered to breast cancer patients stage 0-III Sept ’17 – Aug ’17. Clinical data for 185 patients who received 4R (4R cohort) were compared with a historical control cohort of comparable patients who received care pre-4R, Jun ’16 – May ’17. We used simple frequencies and Fisher’s exact test in analyses. Results: We improved timing / sequencing of 7 guideline recommended metrics (Table). Significant improvements were shown for care lacking in the control cohort. 4R improved rate of patients receiving genetic test results and fertility in a timely manner. Neoadjuvant therapy rate doubled, but low sample size precluded statistical conclusions. However, timing / sequencing of care needed prior to neoadjuvant therapy (eg fertility, flu shot) were significantly improved. Conclusions: The 4R model significantly improved timing / sequencing of guideline recommended care in early breast cancer. An ongoing 4R pilot at 12 additional cancer centers across the U.S. is continuing to accrue patients and focusing on other guideline-recommended metrics. [Table: see text]

How well is interdependent care managed across specialties in breast cancer? Metrics and pre-implementation data from the 4R in Oncology Project.

e12067 Background: The “NCI ASCO Teams” Project emphasized management of interdependent cancer care across specialties as crucial to teamwork, yet a considerable challenge (Taplin JOP 2015). Interdependent care requires well-managed timing and sequencing of events across specialties. We developed the 4R model (Right Information / Care / Patient / Time) to manage interdependent care and facilitate teamwork (Trosman JOP 2016). 4R is being implemented at 3 centers: academic, community and safety net. Pre-implementation, we identified guideline recommended interdependent care whose timing / sequencing is challenging, developed relevant adherence metrics and gathered current state data. Methods: Interviews with 42 clinicians across breast cancer (BC) specialties at the 3 sites, using theme analysis to identify challenging interdependent care. Guidelines and literature were used to define adherence metrics. Clinical data were reviewed for 216 Stage I-III patients at 3 sites to measure adherence. Results: We identified 7 BC interdependent care events for which timing / sequencing is a challenge - Table. Adherence ranged from 0% to 100%, and was &lt; 50% for 5 of the 7 care events. Preoperative BRCA 1/2 results and neoadjuvant consult showed highest adherence, yet were most frequently noted as a challenge: interviewees reported substantial ad-hoc efforts applied to managing timeliness of these events. Conclusions: Identified challenges and adherence gaps support the need for the 4R implementation for systematic, consistent and timely delivery of interdependent care. Established metrics will allow pre / post 4R implementation comparison and may inform broader adoption of the 4R model. [Table: see text]

How well is interdependent care managed across specialties in breast cancer? Metrics and pre-implementation data from the 4R in Oncology Project.

171 Background: The “NCI ASCO Teams” Project emphasized management of interdependent cancer care across specialties as crucial to teamwork, yet a considerable challenge (Taplin JOP 2015). Interdependent care requires well-managed timing and sequencing of events across specialties. We developed the 4R model (Right Information / Care / Patient / Time) to manage interdependent care and facilitate teamwork (Trosman JOP 2016). 4R is being implemented at 3 centers: academic, community and safety net. Pre-implementation, we identified guideline recommended interdependent care whose timing / sequencing is challenging, developed relevant adherence metrics and gathered current state data. Methods: Interviews with 42 clinicians across breast cancer (BC) specialties at the 3 sites, using theme analysis to identify challenging interdependent care. Guidelines and literature were used to define adherence metrics. Clinical data were reviewed for 162 Stage I-III patients at 3 sites to measure adherence. Results: We identified 7 interdependent BC care events for which timing / sequencing is a challenge - Table. Adherence ranged from 0% to 100%, and was &lt; = 50% for 6 of the 7 care events. Preoperative BRCA 1/2 results and neoadjuvant consult showed highest adherence, yet were most frequently noted as a challenge: interviewees reported substantial ad-hoc efforts applied to managing timeliness of these events. Conclusions: Identified challenges and adherence gaps support the need for the 4R implementation for systematic, consistent and timely delivery of interdependent care. Established metrics will allow pre / post 4R implementation comparison and may inform broader adoption of the 4R model. [Table: see text]