Engagement of Patients With Advanced Cancer (EPAC)

The Engagement of Patients with Advanced Cancer is an intervention that utilizes well-trained lay health coaches to engage patients and their families in goals of care and shared decision-making after a diagnosis of advanced cancer. Although lay health workers have never been tested in this role, we hypothesize that lay health workers can feasibly improve goals of care documentation and help to reduce unwanted healthcare utilization at the end of life for Veterans diagnosed with new advanced stages of cancer and those diagnosed with recurrent disease.

VAPAHCS proposes to implement and evaluate several critical elements to be in alignment with the VHA's Strategic Goal and priority areas for FY2013. The Engagement of Patients with Advanced Cancer project is an innovative program that will strengthen provider-patient relationship and facilitate whole person care about matters important to Veterans with cancer and important to support network and family. The project is intended to help establish Goals of Care Plan with appropriate documentation, develop, deploy, and evaluate a model of care for persons with cancer that is intended to improve clinical outcomes and experience of care for individuals with advanced cancer who have advanced cancer (stages III, IV or recurrent disease). The intervention provides patients with lay health coaches who assist patients and their families in discussing goals of care and engage in shared-decision making. The goal of the project is to demonstrate that there is improved patient experiences, outcomes, and that the program helps to reduce utilization of health care resources at the end of life.

End of Life, Advanced Cancer, Lung Neoplasm, Gastric Cancer, Colon Cancer, Glioblastoma Multiforme, Head and Neck Neoplasms, Rectum Cancer, Melanoma, Kidney Cancer, Prostate Cancer, Testicular Neoplasms, Liver Cancer, Cancer of Unknown Origin

All participants randomized to Arm A will receive the EPAC intervention as well as usual oncologic care.

Each patient will receive a lay health worker who will engage and educate patients on goals of care documentation and will continue to address goals of care for at least 6 months with patients after enrollment in the study.

Number of Participants With Completed Goals of Care Documentation. We Will Evaluate if 75% of Patients in the Intervention Arm Have a Documented Goals of Care Titled Medical Note Within 6 Months of Patient Enrollment in the Study.

Feasibility is defined as at least 75% of patients in the intervention arm with a documented Goals of Care titled medical note within 6 months of patient enrollment in the study.

Emergency Department Use for each patient will be abstracted by electronic medical record chart review for each patient at 6 months after enrollment.

Emergency Department Use for each patient will be abstracted by electronic medical record chart review for each patient at 15 months after enrollment.

Hospitalization use for each patient will be abstracted by electronic medical record chart review for each patient at 6 months after enrollment.

Hospitalization use for each patient will be abstracted by electronic medical record chart review for each patient at 15 months after enrollment.

Hospice referral for each patient will be abstracted by electronic medical record chart review for each patient at 6 months after enrollment.

Palliative Care Referral for each patient will be abstracted by electronic medical record chart review for each patient at 6 months after enrollment.

Palliative Care Referral for each patient will be abstracted by electronic medical record chart review for each patient at 15 months after enrollment.

Change in Patient Satisfaction With Care Using the Consumer Assessment of Health Care Providers and Systems -General Survey

Each patient will receive a satisfaction with care survey (The Consumer Assessment of Health Care Providers and Systems - General (CAHPS)) at baseline and 6 months. We will measure the change in satisfaction from baseline to 6 months. Scores for satisfaction were assessed using the Consumer Assessment of Healthcare Providers and Systems-General survey question #18 which measured rating of health provider, on which scores range from 0 to 10, with higher ratings correspond to higher patient satisfaction. Scores for each group are averaged at baseline and at 6 months.

Each patient will receive a validated satisfaction with decision-making survey (The Satisfaction with Decision Survey) at 6 months after study enrollment.Satisfaction with Decision was assessed with the use of the 6-question Satisfaction with Decision Scale, on which scores range from 0 to 5, with higher scores indicating better satisfaction with decision-making. Scores for each group are averaged at 6 months after study enrollment.

Inclusion Criteria: Newly diagnosed stage III or IV cancer Recurrent disease (any stage) Ability to consent to study Exclusion Criteria: Patients who are unable to consent to study procedures

Patel MI, Sundaram V, Desai M, Periyakoil VS, Kahn JS, Bhattacharya J, Asch SM, Milstein A, Bundorf MK. Effect of a Lay Health Worker Intervention on Goals-of-Care Documentation and on Health Care Use, Costs, and Satisfaction Among Patients With Cancer: A Randomized Clinical Trial. JAMA Oncol. 2018 Oct 1;4(10):1359-1366. doi: 10.1001/jamaoncol.2018.2446.