Perceptions Of Care Coordination Research Articles

Development and psychometric evaluation of a questionnaire to measure cancer patients\u2019 perception of care coordination

BackgroundAlthough the importance of care coordination (CC) is well-recognized, cancer patients often receive poorly coordinated care across varied care settings and different oncology providers. Efforts to improve cancer care are hampered by lack of adequate measures. In this two-part, mixed-method study, we describe the development, refinement, and validation of a new care coordination instrument (CCI) designed to assess cancer patients’ perception of CC.MethodsIn Study 1, an initial CCI was developed incorporating questions based on literature review. The items were then modified following four field tests conducted in a large academic hospital with oncology nurses (n = 20) and cancer patients (n = 120). This modified instrument was used to determine whether the CCI was able to distinguish CC between two practices (30 GI and 30 myeloma patients) within the same hospital setting. In Study 2, 68 patients receiving community-based care participated in seven focus groups. Based on these discussions, the CCI items were again refined, and psychometric evaluation was conducted to assess the quality of the instrument.ResultsBased on field tests, 3 domains of the CCI, Communication, Navigation, and Operational, were defined as critical components of CC. The Operational domain evaluates efficiency of care and is unique to this CCI. The field test demonstrated that GI patients reported significantly better CC Overall and for the Communication and Navigation domains (all p < .05). In Study 2, patients expressed concordance with the CCI items and their CC experiences, establishing validity of the CCI. Qualitative analysis of the focus group discussions indicated that the items with the highest frequencies of participants’ comments were related to the concepts of Navigator, Team, Survey, and Communication. Quantitative analysis identified items with a limited response range or high rates of “neutral” responses; accordingly, those items were removed. The final CCI survey is a 29 item, multiple-choice questionnaire with excellent reliability, Cronbach’s α = .922.ConclusionsWe developed a novel, patient-centered tool with excellent psychometric properties that can be utilized across varied practice settings to assess patients’ perception of cancer care coordination.Trial registrationNot required; retrospectively registered ClinicalTrials.gov NCT03594006 20 July 2018.

Validation of an oncology-specific instrument to measure cancer patients’ perception of care coordination.

6543 Background: According to the IOM, effective coordination of care (CC) is a critical component of high-quality cancer care; however, lack of a reliable and validated measure limits our current understanding of cancer care coordination. We examined psychometric properties and utility of a Care Coordination Instrument (CCI), a survey developed to assess cancer patients’ perceptions of care coordination. Methods: The 29-item CCI was administered to 200 patients receiving active treatment for cancer at private oncology practices and hospital-based facilities from Oct. 2018 to Jan. 2019. The CCI includes subscales that evaluate CC in 3 domains (Communication, Navigation, Operational) across 4 areas of CC (patient-physician; between health providers; during inpatient-to-ambulatory care transitions; during transitions across different phases of care). All items were rated on a 4-point Likert scale. Results: Psychometric analyses of the CCI demonstrated that it has good internal consistency reliability (α = .917) and the three-factor solution was an acceptable fit (CFI = .853, SRMR = .065). Overall, cancer types (leukemia, myeloma) and having an identified patient navigator significantly predicted higher patients’ ratings of CC ( p &lt; .05). Similar trends were found for Communication and Operation subscale scores ( p &lt; .05). Having an identified navigator predicted higher Navigation scores ( p &lt; .05). Marginally significant differences were found for practice setting, with patients receiving care in hospital-based facilities reporting better CC ( p = .085). Item-level analyses revealed significant differences in specific aspects of CC (e.g., physician-patient communication) across cancer type, presence/absence of a patient navigator, and practice setting. Conclusions: The results demonstrate that the CCI is a reliable and valid instrument for measuring cancer patients’ perceptions of care coordination. Perception of CC correlated with the presence of a navigator, underlying cancer type and (trending) practice setting. Use of this instrument may reveal important information about cancer care coordination and may identify areas of targets for improvement in patient-centered cancer care delivery.

Impact of Survivorship Care Plans and Planning on Breast, Colon, and Prostate Cancer Survivors in a Community Oncology Practice.

With a growing number of cancer survivors, survivorship care plans (SCPs) are recommended to communicate information about late effects of treatment and follow-up care. Community oncology practices follow 85% of adult cancer survivors but report more difficulty in providing SCPs compared to academic centers. Our objective was to evaluate the impact of delivering SCPs in a community oncology practice by examining awareness of SCP receipt as well as how provision affects survivors' perception of care quality and of their condition. Survivors who accepted a SCP as standard of care were recruited from a community oncology practice in the Midwest and completed surveys prior to SCP provision (baseline) and 4weeks later (follow-up). Within-survivor changes in knowledge of SCP receipt, satisfaction and perceived care coordination were assessed. Thirty cancer survivors (breast, colon, and prostate) completed the baseline survey, while 24 completed the follow-up survey (80% response rate). Participants reported receiving SCPs and treatment summaries more frequently at follow-up after receiving a SCP. At follow-up, there was a significant increase in survivor activation and involvement in care along with satisfaction of knowledge of care. Communication about and during SCP provision may need to be clearer: 34% of survivors could not correctly identify SCP receipt in this study. This may place these survivors at a disadvantage, if this leads to less awareness of important information regarding follow-up surveillance and management. Of those aware of SCP receipt, SCP provision had positive impacts in this small, short-term study.

Children with medical technology dependency living at home: perceptions of care coordination and family impact

Children with medical technology dependency living at home: perceptions of care coordination and family impact

"It's Really Overwhelming": Patient Perspectives on Care Coordination.

Failures of care coordination among health care providers are known to lead to poorer health outcomes for patients with complex medical needs. However, there has been limited research into the perspectives of patients who receive care from a variety of health care providers. This qualitative study sought to characterize the factors leading to emergency department (ED) patient satisfaction and dissatisfaction with their care coordination. Semistructured telephone interviews were conducted with 25 adult patients following ED visits about their experiences with their care coordination. All patients interviewed had 2 or more ED visits and hospitalizations in the past year and/or health providers in more than one health system. Interview transcripts were coded and analyzed following a modified grounded theory approach. Four broad categories of themes emerged from the patient interviews covering the following: (1) perceptions of care coordination between their providers, (2) the role of electronic health records, (3) challenges with information exchange between health systems, and (4) sources of support for care coordination activities, emphasizing the important role of the primary care provider. Patients with multiple health care providers identified significant barriers to communication among providers and inadequate support with care coordination activities. Expansion of team-based models of primary care and prioritizing interoperable technology for sharing patient health information between providers will be critical to improving the patient experience and the safety of transitions of care.

Variation in coordination of care reported by breast cancer patients according to health literacy.

Health literacy is the ability to perform basic reading and numerical tasks to function in the healthcare environment. The purpose of this study is to describe how health literacy is related to perceived coordination of care reported by breast cancer patients. Data were retrieved from the Patient-Centered Outcomes Research Institute-sponsored "Share Thoughts on Breast Cancer" Study including demographic factors, perceived care coordination and responsiveness of care, and self-reported health literacy obtained from a mailed survey completed by 62% of eligible breast cancer survivors (N = 1221). Multivariable analysis of variance was used to characterize the association between presence of a single healthcare professional that coordinated care ("care coordinator") and perceived care coordination, stratified by health literacy level. Health literacy was classified as low in 24% of patients, medium in 34%, and high in 42%. Women with high health literacy scores were more likely to report non-Hispanic white race/ethnicity, private insurance, higher education and income, and fewer comorbidities (all p < 0.001). The presence of a care coordinator was associated with 17.1% higher perceived care coordination scores among women with low health literacy when compared to those without a care coordinator, whereas a coordinator modestly improved perceived care coordination among breast cancer survivors with medium (6.9%) and high (6.2%) health literacy. The use of a single designated care coordinator may have a strong influence on care coordination in patients with lower levels of health literacy.

Care Coordination and Continuity of Care in Oral Anticancer Treatment: The Patients' Perspective

Introduction: Patients receiving oral anticancer medications (OAMs) are at increased risk for fragmentation and lack of which can potentially significantly hinder their ability for self-management. Factors such as the complexity of the regimen, the need for special safety precautions, occurrence of side effects, and drug-drug interactions require close between the oncology and primary care and the alignment of treatment and follow-up plans (1-3). The multiplicity of and institutions challenges care coordination, and can impair of care (COC) and outcomes. This study aimed to asses: (1) Patient- reported COC for each type of health care provider involved in oral anticancer treatment (the oncology specialist (OS), the oncology nurse specialist (ONS), and the primary care physician (PCP)); (2) Care coordination as perceived by the patients, within the oncology team (between the OS and the ONS) or across specialty boundaries (between the PCP and the OS or the ONS). Methods: A prospective multicenter cohort study was conducted among cancer patients >18yrs, receiving a first prescription (in the prior 2 weeks) for one of the following OAMs: chemotherapy (Capecitabine, Vinorelbine), targeted therapy (Erlotinib, Sunitinib, Everolimus), or hormonal therapy (Abiraterone). Two-three months after OAMs initiation, a survey containing the Nijmegen Continuity Questionnaire (NCQ) was administered. The NCQ consists of continuity (8 items) and collaboration between providers (4 items) Likert-type subscales (1=strongly disagree to 5= strongly agree) (4). Results: 99 participants completed the NCQ-Hebrew version. Mean subscale score (MSS) for personal was significantly higher for the PCP, followed by the OS, and the ONS (MSS (SD)= 3.53(0.97); 3.27(1.00); 2.9(1.23), respectively; p Discussion: This study is the first to measure COC in a multi provider-multi setting context of OAM treatment.OAMs patients rated the COC with the PCP significantly higher than the COC with the OS or the ONS. Additionally, patients perceived care coordination between the oncology team and the PCP to be relatively low. Conclusions: The lack of COC between patients taking OAMs and their oncology as well as the low (patient) perceived coordination among OS and PCPs found in this study signifies major areas for much needed improvement in the quality of the cancer care trajectory. Lessons learned: The growing population of patients receiving OAM therapy requires better integration among specialist and primary care providers. Limitations: A relatively small sample and the lack of provider perspective on among providers. Suggestions for future research: Future studies should use larger samples, incorporate provider perspectives on their collaborative practices within and across professional boundaries, and examine the effects of and coordination in OAM therapy and patient outcomes.

Association between pancreatic cancer patients' perception of their care coordination and patient-reported and survival outcomes.

People with pancreatic cancer have poor survival, and management is challenging. Pancreatic cancer patients' perceptions of their care coordination and its association with their outcomes have not been well-studied. Our objective was to determine if perception of care coordination is associated with patient-reported outcomes or survival. People with pancreatic cancer who were 1-8 months postdiagnosis (52 with completed resection and 58 with no resection) completed a patient-reported questionnaire that assessed their perceptions of care coordination, quality of life, anxiety, and depression using validated instruments. Mean scores for 15 care-coordination items were calculated and then ranked from highest (best experience) to lowest (worst experience). Associations between care-coordination scores (including communication and navigation domains) and patient-reported outcomes and survival were investigated using general linear regression and Cox regression, respectively. All analyses were stratified by whether or not the tumor had been resected. In both groups, the highest-ranked care-coordination items were: knowing who was responsible for coordinating care, health professionals being informed about their history, and waiting times. The worst-ranked items related to: how often patients were asked about visits with other health professionals and how well they and their family were coping, knowing the symptoms they should monitor, having sufficient emotional help from staff, and access to additional specialist services. For people who had a resection, better communication and navigation scores were significantly associated with higher quality of life and less anxiety and depression. However, these associations were not statistically significant for those with no resection. Perception of cancer care coordination was not associated with survival in either group. Our results suggest that, while many core clinical aspects of care are perceived to be done well for pancreatic cancer patients, improvements in emotional support, referral to specialist services, and self-management education may improve patient-reported outcomes.

Stakeholders' Perceptions of Care Coordination: A Participatory Process

ObjectiveChildren with special health care needs or chronic conditions are more likely to have unmet health needs than other children. The purpose of this study was to use a community engagement research strategy to assess the essential elements of care coordination that can serve as the foundation for a system-wide care coordination model for children with special health care needs. Study DesignAs part of a summit designed to review the status of pediatric care coordination within the state of Arizona and a call to action, a qualitative descriptive study was conducted to solicit anonymous feedback from 104 stakeholders (family, health care provider, or community entity) on the strengths and areas of improvement in the current system that provides care to Arizona children with special health care needs. Data were analyzed using inductive content analysis. ResultsFive essential categories crucial to building an effective and seamless care coordination model were extracted from the data: Communication, Insurance, Health Care Capacity, Provider Knowledge, and Family Education. ConclusionsThe results from this study can serve as the working foundation to build a system-wide model for pediatric care coordination throughout the state. Providing care coordination services involves many activities across a wide range of organizations and locations. Research that is inclusive of community stakeholders can determine essential components for building a foundation for care coordination.

Hematology and oncology patient perceptions of inpatient care coordination at an urban academic teaching center.

109 Background: Outpatient doctors increasingly defer inpatient care to hospital-based physicians. At academic medical centers, inpatient care coordination is further complicated by frequent handoffs between resident teams. Breaks in inpatient care continuity may disproportionately affect hematology and oncology patients, given their often complicated longitudinal histories and specialized problems. We sought to understand hematology and oncology patient perceptions of inpatient care coordination at Massachusetts General Hospital (MGH). Methods: Between July 2014 and June 2015, patients admitted to any MGH service were randomly selected to complete a survey about their perception of inpatient care coordination. In total, 1,783 patients responded. Of these, 158 were admitted to hematology or oncology. Hematology and oncology patient responses were compared to all MGH patient responses using chi-squared analysis, with p values less than or equal to 0.05 used as the threshold for statistical significance. Responses reflect the percentage of patients who chose the “top box” option. Results: Compared to all MGH patients, hematology and oncology patients were significantly more likely to recognize a clearly identified doctor responsible for their care while in the hospital (85% vs 74%, p = 0.003) and to perceive the presence of a responding clinician at all times (79% vs 66%, p = 0.001). Hematology/oncology patients were also much more likely to report seeing their longitudinal MGH doctors while admitted (77% vs 57%, p &lt; 0.001). However, despite more frequent in-person visits by outpatient physicians, significantly fewer hematology/oncology patients reported perceiving that their outpatient doctor receives discharge information (47% vs 64%, p = 0.005). Conclusions: MGH hematology and oncology patients reported stronger inpatient care coordination and higher frequency of outpatient physician visits than MGH patients overall. Nevertheless, patients perceived less frequent coordination of discharge information with outpatient physicians. More research is needed to understand whether patient perceptions of care coordination correlates with clinical and utilization outcomes.

Mental Health Services in NCAA Division I Athletics: A Survey of Head ATCs.

Background:There is a growing awareness of the importance of mental health care in National Collegiate Athletic Association (NCAA) student-athletes; however, there is a lack of literature on mental health resources in collegiate settings. Identifying current practices can set the stage to improve the delivery of care.Hypothesis:There is great variability in resources and current practices and no “standard of care” exists.Study Design:Observational, quantitative.Level of Evidence:Level 5.Methods:One hundred twenty-seven (36% response rate) head athletic trainers at Division I NCAA member colleges completed a web-based survey. Questions assessed several aspects of mental health clinicians, perception of care coordination, and screening.Results:Seventy-two percent of respondents noted that counseling took place in a counseling center, and 20.5% of respondents indicated that they had a mental health provider who worked in the athletic training room. Mental health clinician credentials included marriage and family therapist, psychologist, clinical social worker, and psychiatrist. The majority of athletic trainers (ATCs) noted that they are satisfied with the feedback from the mental health provider about the student-athletes’ mental health (57.3%) and believe that they would be able to provide better care to student-athletes if mental health services occurred onsite in the training room (46.4%). Fewer than half (43%) indicated that they use screening instruments to assess for mental health disorders.Conclusion:There is wide variability on how mental health services are provided to NCAA Division 1 student-athletes. Some mental health care providers are located offsite, while some provide care in the training room setting. Also, there are inconsistencies in the use of standardized screening tools for mental health evaluation. There is no standard collaborative or integrated care delivery model for student-athletes.Clinical Relevance:Opportunities exist for standardization through integrated care models and increased use of validated screening tools to deliver comprehensive care to student-athletes.

Addressing multimorbidity to improve healthcare and economic sustainability.

Patients with multimorbidity are responsible for more than half of all healthcare utilization, challenging the healthcare budgets of all European nations. Although the European Union is showing signs of a fragile economic recovery, achieving sustainable growth will depend on delivering a combination of fiscal responsibility, structural reforms, and improved efficiency. Addressing the challenges of multimorbidity and providing more effective, affordable, and sustainable care, has climbed the political agenda at a global, European, and national level. Current healthcare systems are poorly adapted to cope with the challenges of patients with multimorbidity. Little is known about the epidemiology and natural history of multimorbidity; the evidence base is weak; clinical guidelines are not always relevant to this population; and financing and delivery systems have not evolved to adequately measure and reward quality and performance. Pockets of innovation are, however, beginning to emerge. In Spain, for example, the ongoing economic crisis has forced regional governments to deliver substantial efficiency savings and, with this in mind, integrated care programmes have been introduced across the country for people with chronic disease and multimorbidity. Early results suggest that formalized integrated care for patients with multimorbidity improves their perceptions of care coordination, reduces hospital and emergency admissions and readmissions, and reduces average costs per capita. Such innovations require meaningful investments at a national level – something that is now supported within the framework of the European Union’s Stability and Growth Pact.

Continuity in Visiting Nurse Personnel Has Important Implications for the Patient Experience

Continuity in health care personnel is an important component of high-quality care delivery. This study examines the extent to which continuity in nursing personnel is associated with Home Health Care Consumer Assessment of Healthcare Providers and Systems survey patient experience ratings. We examined the survey responses and administrative records of 7,196 patients served by a large home health agency between 2009 and 2014. Multivariate models were used to estimate associations between nursing continuity, measured with the Bice-Boxerman index, and five domains of patient experience ratings. Results indicated that patients’ overall ratings of care, willingness to recommend the agency to family/friends, perceived care coordination, and levels of communication with providers were positively associated with nursing continuity. No relationship was observed between continuity in nursing personnel and patients’ perceptions of safety, comfort, and education.

Building integrated care systems: a case study of Bidasoa Integrated Health Organisation.

This paper analyses the implementation of integrated care policies in the Basque Country through the deployment of an Integrated Health Organisation in Bidasoa area during the period 2011-2014. Structural, functional and clinical integration policies have been employed with the aim to deliver integrated and person-centred care for patients, especially for those living with chronic conditions. This organisational case study used multiple data sources and methods in a pragmatic and reflexive manner to build a picture of the organisational development over a 4-year period. In order to measure the progress of integration three concepts have been measured: (i) readiness for chronicity measured with Assessment of Readiness for Chronicity in Healthcare Organisations tool; (ii) collaboration between clinicians from different care levels measured with the D'Amour Questionnaire, and (iii) overall impact of integration through several indicators based on the Triple Aim Framework. The measurement of organisational readiness for chronicity showed improvements in five of the six areas under evaluation. Similarly the collaboration between professionals of different care levels showed a steady improvement in each of the 10 items. Furthermore, the Triple Aim-based indicators showed a better experience of care in terms of patients' perceptions of care coordination; a reduction in hospital utilisation, particularly for patients with complex chronic conditions; and cost-containment in terms of per capita expenditure. There is a significant amount of data that shows that Bidasoa Integrated Health Organisation has progressed in terms of delivering integrated care for chronic conditions with a positive impact on several Triple Aim outcomes.

What is care coordination about: towards a theoretical framework for the study of care coordination

Purpose: Strategies to improve care coordination between primary and hospital care do not always have the desired result partly due to incomplete understanding of key concepts of care coordination. The aim of this study is to explore key concepts of care coordination and the relationships between them. Methods: We performed an in-depth analysis of existing theoretical frameworks, interviewed twenty-two patients and organised six focus groups with healthcare professionals. Findings: Fourteen key concepts were identified in existing theoretical frameworks. Two new concepts revealed in patient perceived care coordination. Preliminary results confirm the 16 previously identified key concepts in healthcare professionals perceived care coordination. Core key concept of care coordination include defining and knowing each other “roles”, the “quality of relationships” promoting mutual respect and collaboration, “information exchange” between healthcare professionals and defining and sharing common “goals”. These core key concepts are influenced by “external factors”, “task characteristics”, “cultural factors”, “knowledge and technology”, “need for coordination”, “administrative operational processes” and “patient characteristics” leading to a certain outcome. Discussion: It is important to improve “roles”, “quality of relationships” between healthcare professionals and with the patient, “information exchange” and “goals” to ensure care coordination between primary and hospital care certainly when unexpected events occur.

Disseminating team training across an academic cancer center and community-based satellites.

188 Background: Dana-Farber Cancer Institute is the first cancer center to implement Team Training (TT). This program illustrates critical lessons about disseminating a quality improvement initiative across an academic center and its regional community-based satellites. Methods: We adapted TT principles to the needs of our satellite centers. This required recognizing different work flows and communication patterns, identifying hazards in routine communications, integrating satellite-main campus communication, and facilitating situational awareness when practicing at multiple sites. Key components included: support from executive leadership and Board of Trustees; previous success at the main campus; use of data and actual near-miss scenarios; development of workflows for critical communications; and workflows for shared care of patients at different sites. Results: Staff surveys demonstrated safer, more efficient, and more respectful practice environments. Higher scores were seen across most categories in comparison to main campus. We observed an increase in the number of chemotherapy orders without issues (81.7% to 91.9%) and a decrease in the number of missing (7.0% to 3.4%) or noncommunicated order changes (3.1% to 1.0%) when the patient arrived for treatment pre TT vs. post TT. Patient perception of teamwork, measured by Press-Ganey, showed a statistically significant increase at both the main and satellite campuses. Conclusions: TT improved communication, task coordination, perceptions of efficiency, quality, safety, and patient perception of care coordination, at both the academic main campus and our community-based satellite practices. [Table: see text]

Patient experiences after hospitalizations for elective surgery

BackgroundLittle is known from patients' perspective about the quality of postdischarge care and the causes of rehospitalization after elective surgery. MethodsA prospective observational cohort study was conducted. ResultsOf 400 patient participants, 374 completed the 30-day follow-up questionnaire (completion rate, 94%). Half of all unplanned rehospitalizations (experienced by 13% of patients) and nonrehospitalization emergency department visits (experienced by 6%) occurred within 10 days of discharge. Patients used emergency departments and were rehospitalized at facilities near their homes (mean distance traveled, 12.1 mi). The most common primary reason for rehospitalization was postoperative complications, according to patient report, clinical records, and administrative data. Poor perceived care coordination was associated with higher readmission risk. ConclusionsPatients perceive surgical complications as dominating the reasons for rehospitalizations after elective surgery. Strategies to improve care quality around elective surgery at referral centers should target the discharge process and the coordinated management of postoperative complications through care received at regional hospitals.

Implementation of team training in outpatient breast oncology.

83 Background: Team Training (TT) principles, used in high-risk industries to reduce errors and improve communication and task coordination, have been applied in several areas of medicine, but not in outpatient oncology. We piloted a TT program in a large, academic, clinical breast cancer program. Methods: Observations, interviews, and anonymous adverse event reporting systems were used to identify areas of vulnerability for intervention: Communication of changes in same-day chemotherapy orders (“change orders”); Missing treatment orders on days patients were not also scheduled with physician (“unlinked” visits); Follow-up and communication to other team members on important patient issues (e.g., pending test results or changes in patient status); Conflict resolution between providers and staff. Agreements about roles, responsibilities, and behaviors were made to address vulnerabilities. Using a train-the-trainer model, clinical leaders trained all providers and staff in TT principles, behavioral agreements, and the tools to support them. Results: The program was assessed six months after implementation. There was insufficient power to detect a significant difference in communication of change orders because of infrequency of events (&lt; 2% pre- and post-training). However, 100% of providers reported it was easier to communicate change orders and 87% of infusion nurses reported a decrease in non-communicated changes. The incidence of missing orders for unlinked visits decreased from 38%to 2%. Press-Ganey patient satisfaction scores highlighted improvements in perception of care coordination. Providers, infusion nurses, and support staff all reported strongly positive perceptions of improvement in the efficiency (75%, 86%, 90%), quality (82%, 93%, 93%) and safety (92%, 92%, 90%) of patient care. Similarly, all groups reported improved relationships and more respectful behavior among team members (91%, 85%, 93%). Conclusions: Team Training improved communication, task coordination and perceptions of efficiency, quality, safety, and interactions among team members and patients’ perceptions of care coordination. Widespread implementation of TT across the entire Adult Service is ongoing at our institution.

Social disparities in perceived coordination of care and use of chemotherapy among patients with stage III colorectal cancer.

24 Background: Our prior work demonstrated low uptake of chemotherapy among advanced stage rectal cancer patients and significantly lower uptake among minorities. Underuse of chemotherapy is associated with decreased survival. In this analysis, we hypothesized that health system factors such as inadequate coordination of care contribute to under-use of chemotherapy among minority and low socioeconomic status (SES) patients. Methods: We performed a population-based survey of all stage III colorectal cancer patients diagnosed in the State of Georgia and Metropolitan Detroit SEER catchment areas. Our outcomes of interest were perceived care coordination and self-reported use of chemotherapy. Independent variables included clinical and demographic factors. We used chi square analyses to assess associations between patient characteristics, coordination of care, and use of chemotherapy. Multiple linear regression examined relationships between SES, coordination of care, and use of chemotherapy after adjusting for age, sex, and comorbidity. Results: In preliminary analyses, 215 patients have completed the survey (initial response rate of 60%). To date, most participants have reported good-to-excellent coordination of care (mean=4.3 on scale of 1-5), and care coordination did not differ by clinical or demographic factors. Those who perceived better care coordination were more likely to receive chemotherapy (p&lt;0.001). Respondents with high school education or less had significantly lower uptake of chemotherapy relative to their counterparts (71% vs. 89%, p=0.005), and this difference was significant even when adjusting for coordination of care. Conclusions: SES, in particular education level, was associated with both coordination of care and with receipt of chemotherapy. If these findings are confirmed in our larger sample, we will be able to identify targets for health system intervention and improvement.

Implementation of a team training program in the treatment of breast cancer patients.

e16515 Background: Team Training (TT) principles, used in high-risk industries to reduce errors and improve communication and task coordination, have been applied in other areas of medicine, but never in an outpatient subspecialty setting. We piloted a TT program in a large, academic breast cancer program. Methods: Observations, interviews and anonymous adverse event reporting systems were used to identify areas of vulnerability warranting intervention: 1) communication of changes in chemotherapy orders on the day of treatment ("change orders") 2) missing orders on treatment days that patients were not also scheduled to see their physician (“unlinked” visits) 3) follow-up and communication to other team members on important patient issues (e.g. pending test results or changes in patient status) 4) conflict resolution between providers and staff. For each area, agreements about roles, responsibilities and behaviors were made. Using a train-the-trainer model, clinical leaders trained all providers and staff in TT principles, the agreements, and the tools to support them. Results: The program was evaluated six months after implementation. There was insufficient power to detect a significant difference in communication of change orders because of the infrequency of events (&lt; 2% pre and post-training). However, 100% of providers reported it was easier to communicate change orders and 87% of infusion nurses reported a decrease in non-communicated changes. The incidence of missing orders for unlinked visits decreased from 30% to 2%. Press-Ganey patient satisfaction scores suggested improvement in patient perception of care coordination. Providers, infusion nurses and support staff reported strongly positive perceptions of improvement in efficiency (75%, 86%, 90%), quality (82%, 93%, 93%) and safety (92%, 92%, 90%) of patient care. Similarly, all groups reported improved relationships and more respectful behavior among team members (91%, 85%, 93%). Conclusions: Team Training improved communication, task coordination and perceptions of efficiency, quality, safety and interactions among team members as well as patient perception of care coordination. Widespread implementation of this strategy is ongoing at our institution.