Burden and trajectory of social needs after breast cancer diagnosis at a safety-net hospital.

PURPOSE: Unmet social needs pose barriers to cancer care, contributing to adverse outcomes and health inequities. A better understanding of how social needs change after cancer diagnosis can inform more effective, equity-focused interventions. METHODS: In this study, we examined self-reported social needs at 0, 3, and 6 months after a breast cancer diagnosis in a racially diverse, multilingual sample (n = 222) enrolled in patient navigation intervention at an urban safety-net hospital. At each timepoint, respondents completed surveys about social needs related to employment, disability benefits, housing and utilities, and personal and family stability. RESULTS: Over three-quarters (78%, n = 175) reported ≥ 1 social need, and 46% (n = 102) reported ≥ 3 social needs. The most frequently reported need was housing and utilities (64%, n = 142), followed by employment (40%, n = 90). Individuals from minoritized groups more frequently reported an increased number of social needs over time, compared with their White counterparts (p = 0.02). CONCLUSION: Our findings suggest that despite navigation, many cancer patients from historically underrepresented populations continue to experience social concerns over the first 6 months of treatment. Further research, conducted with historically underrepresented populations in research, is needed to better understand the social needs of breast cancer patients to inform effective and equitable interventions.

Patient navigation to address sociolegal barriers for patients with cancer: A comparative-effectiveness study.

BACKGROUND: Sociolegal barriers to cancer care are defined as health-related social needs like affordable healthy housing, stable utility service, and food security that may be remedied by public policy, law, regulation, or programming. Legal support has not been studied in cancer care. METHODS: The authors conducted a randomized controlled trial of patients who had newly diagnosed cancer at a safety-net medical center in Boston from 2014 through 2017, comparing standard patient navigation versus enhanced navigation partnered with legal advocates to identify and address sociolegal barriers. English-speaking, Spanish-speaking, or Haitian Creole-speaking patients with breast and lung cancer were eligible within 30 days of diagnosis. The primary outcome was timely treatment within 90 days of diagnosis. Secondary outcomes included patient-reported outcomes (distress, cancer-related needs, and satisfaction with navigation) at baseline and at 6 months. RESULTS: In total, 201 patients with breast cancer and 19 with lung cancer enrolled (response rate, 78%). The mean patient age was 55 years, 51% of patients were Black and 22% were Hispanic, 20% spoke Spanish and 8% spoke Haitian Creole, 73% had public health insurance, 77% reported 1 or more perceived sociolegal barrier, and the most common were barriers to housing and employment. Ninety-six percent of participants with breast cancer and 73% of those with lung cancer initiated treatment within 90 days. No significant effect of enhanced navigation was observed on the receipt of timely treatment among participants with breast cancer (odds ratio, 0.88; 95% CI, 0.17-4.52) or among those with lung cancer (odds ratio, 4.00; 95% CI, 0.35-45.4). No differences in patient-reported outcomes were observed between treatment groups. CONCLUSIONS: Navigation enhanced by access to legal consultation and support had no impact on timely treatment, patient distress, or patient needs. Although most patients reported sociolegal barriers, few required intensive legal services that could not be addressed by navigators. LAY SUMMARY: In patients with cancer, the experience of sociolegal barriers to care, such as unstable housing, utility services, or food insecurity, is discussed. Addressing these barriers through legal information and assistance may improve care. This study compares standard patient navigation versus enhanced navigation partnered with legal advocates for patients with breast and lung cancers. Almost all patients in both navigation groups received timely care and also reported the same levels of distress, needs, and satisfaction with navigation. Although 75% of patients in the study had at least 1 sociolegal barrier identified, few required legal advocacy beyond what a navigator who received legal information and coaching could provide.

Beyond Housing for Health: Using Flexible Funds to Improve Maternal and Child Health.

Upstreaming Housing for Health (UHfH) was a pilot program that aimed to improve housing stability and reduce health inequities among people experiencing high-risk pregnancies and their infants. It served 50 families from 2019 to 2020. One critical component of UHfH was an innovative flexible fund, which was originally designed to address housing stability (e.g., rent arrears) but expanded its scope to address material needs that promoted family stability within the context of their housing situation (e.g., housing safety or maternal-infant health while in shelter). Seventy-six percent of families accessed flexible funds for items such as rental assistance, cribs, and breast pumps, with average financial support of $1343 (standard deviation = $625). The flexible fund is an example of a cash transfer policy. Such policies have shown to positively impact family health and well-being in the USA and internationally. Similar funding should be considered as part of future programming to reduce housing instability and homelessness.

High touch, high trust: Using community health advocates and lawyers to address ED high utilizers.

BACKGROUND: Emergency department (ED) high utilizers are a costly group of patients due to their higher utilzation of acute care costs. At a safety-net hospital, we enrolled patients in a program which partnered with lawyers and community health advocates (CHAs) to navigate patients' social, medical and legal needs. Our aim was to decrease costs and utilization and address the patient's social determinants of heath (SDOH). METHODS: We enrolled patients with 4 or more ED visits in the prior 6 months and gave them SDOH and medical questionnaires. Patients were followed for 6 months on a weekly, then bi-monthly basis. All utilization and cost data were obtained through an internal data warehouse and evaluated using a pre-post analysis and broken down into quartiles. RESULTS: ED, admission, and total costs did not differ significantly between the 12 months pre-enrollment and the 12 months post-enrollment. Outpatient costs did increase ($2182 increase, p < 0.005). ED visits declined significantly in the post-enrollment period (IRR = 0.84, p = 0.048), with the highest impact on those with <7 ED visits. Total admissions did not decline (IRR 0.84, p = 0.059). But, among those with 4 or 5 ED visits, admission costs and visits decreased. On average, six SDOH issues were identified. Of these, approximately 30.3% were mitigated with up to 17% requiring legal help. CONCLUSION: While outpatient costs did increase, total costs did not decrease in this program. This type of non-clinical intervention may be best served for patients who are less clinically complex but significant social needs.

No Equity, No Triple Aim: Strategic Proposals to Advance Health Equity in a Volatile Policy Environment.

Health professionals, including social workers, community health workers, public health workers, and licensed health care providers, share common interests and responsibilities in promoting health equity and improving social determinants of health-the conditions in which people live, work, play, and learn. We summarize the underlying causes of health inequity and comparatively poor health outcomes in the United States. We describe barriers to realizing the hope embedded in the 2010 Patient Protection and Affordable Care Act, that moving away from fee-for-service payments will naturally drive care upstream as providers respond to greater financial risk by undertaking greater prevention efforts for the health of their patients. We assert that health equity should serve as the guiding framework for achieving the Triple Aim of health care reform and outline practical opportunities for improving care and promoting stronger efforts to address social determinants of health. These proposals include developing a dashboard of measures to assist providers committed to health equity and community-based prevention and to promote institutional accountability for addressing socioeconomic factors that influence health.

Burden of socio-legal concerns among vulnerable patients seeking cancer care services at an urban safety-net hospital: a cross-sectional survey.

BACKGROUND: Social and economic conditions that affect one's ability to satisfy life's most basic needs such as lack of affordable housing, restricted access to education and employment, or inadequate income are increasingly well-documented barriers to optimal health. The burden of these challenges among vulnerable patients accessing cancer care services is unknown. METHODS: We conducted a cross-sectional survey of patients presenting for ambulatory cancer care services (screening and treatment) at an urban safety-net hospital to assess socio-legal concerns (social problems related to meeting life's basic needs supported by public policy or programming and potentially remedied through legal advocacy/action). RESULTS: Among 104 respondents, 80 (77 %) reported concerns with one or more socio-legal needs in the past month, with a mean of 5.75 concerns per participant. The most common socio-legal concerns related to income supports, housing, and employment/education. CONCLUSION: Our findings support the need for innovations in cancer care delivery to address socio-legal concerns of a vulnerable patient population.

Social service barriers delay care among women with abnormal cancer screening.

BACKGROUND: Inequity in cancer outcomes for minorities and vulnerable populations has been linked to delays in cancer care that arise from barriers to accessing care. Social service barriers represent those obstacles related to meeting life's most basic needs, like housing and income, which are often supported by public policy, regulation and services. OBJECTIVE: To examine the association between social service barriers and timely diagnostic resolution after a cancer screening abnormality. DESIGN: Secondary analysis of the intervention arm of Boston Patient Navigation Research Program (2007-2008) conducted across six urban community health centers. Subjects with no barriers, other barriers, and social service barriers were compared on their time to diagnostic resolution. SUBJECTS: Women ≥ 18 years of age with a breast or cervical cancer screening abnormality. MAIN MEASURES: Social service barriers included: income supports, housing and utilities, education and employment, and personal/family stability and safety. Time to event analyses compared across five groups: those with no barriers, one barrier (other), one barrier (social service), two or more barriers (all other), and two or more barriers (at least one social service). KEY RESULTS: 1,481 navigated women; 31 % Hispanic, 27 % Black, 32 % White; 37 % non-English speakers and 28 % had private health insurance. Eighty-eight women (6 %) had social service barriers. Compared to those without social service barriers, those with were more likely to be Hispanic, younger, have public/no health insurance, and have multiple barriers. Those with two or more barriers (at least one social service barrier), had the longest time to resolution compared to the other four groups (aHR resolution < 60 days = 0.27, ≥ 60 days = 0.37). CONCLUSION: Vulnerable women with multiple barriers, when at least one is a social service barrier, have delays in care despite navigation. The impact of patient navigation may never be fully realized if social service barriers persist without being identified or addressed.

Sustaining and scaling a clinic-based approach to address health-related social needs.

Objective: Scaling evidence-based interventions (EBIs) from pilot phase remains a pressing challenge in efforts to address health-related social needs (HRSN) and improve population health. This study describes an innovative approach to sustaining and further spreading DULCE (Developmental Understanding and Legal Collaboration for Everyone), a universal EBI that supports pediatric clinics to implement the American Academy of Pediatrics' Bright Futures™ guidelines for infants' well-child visits (WCVs) and introduces a new quality measure of families' HRSN resource use. Methods: Between August 2018 and December 2019, seven teams in four communities in three states implemented DULCE: four teams that had been implementing DULCE since 2016 and three new teams. Teams received monthly data reports and individualized continuous quality improvement (CQI) coaching for six months, followed by lighter-touch support via quarterly group calls (peer-to-peer learning and coaching). Run charts were used to study outcome (percent of infants that received all WCVs on time) and process measures (percent of families screened for HRSN and connected to resources). Results: Integrating three new sites was associated with an initial regression of outcome: 41% of infants received all WCVs on time, followed by improvement to 48%. Process performance was sustained or improved: among 989 participating families, 84% (831) received 1-month WCVs on time; 96% (946) were screened for seven HRSN, 54% (508) had HRSN, and 87% (444) used HRSN resources. Conclusion: An innovative, lighter-touch CQI approach to a second phase of scale-up resulted in sustainment or improvements in most processes and outcomes. Outcomes-oriented CQI measures (family receipt of resources) are an important addition to more traditional process-oriented indicators.

Cross-Sector Approach Expands Screening and Addresses Health-Related Social Needs in Primary Care.

OBJECTIVES: During infancy, the American Academy of Pediatrics Bright Futures fourth edition health supervision guidelines recommend frequent well-child visits (WCVs) in which providers are expected to screen for and address maternal depression, intimate partner violence (IPV), and health-related social needs (HRSN). We spread an evidence-based approach that implements these recommendations (Developmental Understanding and Legal Collaboration for Everyone; DULCE) with 3 aims for 6-month-old infants and their families: 75% receive all WCVs on time, 95% are screened for 7 HRSNs, and 90% of families with concrete supports needs and 75% of families with maternal depression or IPV receive support. METHODS: Between January 2017 and July 2018, five DULCE teams (including a community health worker, early childhood system representative, legal partner, clinic administrator, pediatric and behavioral health clinicians) from 3 communities in 2 states participated in a learning collaborative. Teams adapted DULCE using Plan-Do-Study-Act cycles, reported data, and shared learning monthly. Run charts were used to study measures. The main outcome was the percent of infants that received all WCVs on time. RESULTS: The percentage of families who completed all WCVs on time increased from 46% to 65%. More than 95% of families were screened for HRSNs, 70% had ≥1 positive screen, and 86% and 71% of those received resource information for concrete supports and maternal depression and IPV, respectively. CONCLUSIONS: Quality improvement-supported DULCE expansion increased by 50% the proportion of infants receiving all WCVs on time and reliably identified and addressed families' HRSNs, via integration of existing resources.

Health Literacy, Language, and Cancer-Related Needs in the First 6 Months After a Breast Cancer Diagnosis.

PURPOSE: Low health literacy (HL) and language negatively affect cancer screening and prevention behaviors; less is known about how they affect the patient's experience during cancer treatment. This study explores associations among HL, spoken language, and dimensions of cancer-related needs within 6 months of receiving a breast cancer diagnosis. METHODS: Women speaking English, Spanish, or Haitian Creole, enrolled in a patient navigation study at diagnosis, completed a survey in their primary spoken language at baseline and 6 months to characterize their cancer-related needs. HL was measured using the Brief Health Literacy Screening Tool. Outcomes included the Cancer Needs Distress Inventory (CaNDI; n = 38 items) and the Communication and Attitudinal Self-Efficacy scale (CASE-Cancer) for cancer (n = 12 items). Linear regressions measured the impact of HL and language on total CaNDI and CASE-Cancer scale for cancer scores and subscales, adjusted for demographics. RESULTS: At baseline, 262 women participated and 228 (87%) followed up at 6 months. Of these, 38% had adequate HL, 33% had marginal HL, and 29% had inadequate HL. Women with inadequate or marginal HL had higher median baseline CaNDI scores (P = .02) and lower self-efficacy scores (P = .008), relative to those with adequate HL. Haitian-Creole speakers had significantly lower CANDI scores at baseline (P = .03). Adjusting for demographics, differences in CaNDI scores at baseline remained significant for those with lower HL and Haitian-Creole speakers. At 6 months, differences in self-efficacy persisted for Haitian-Creole speakers. CONCLUSION: Findings suggest that interventions oriented to mitigating HL and language barriers might reduce distress at the time of diagnosis and improve self-efficacy over the course of treatment.

Growth-and Documentation-Deficits: Where To Start in Helping Families.

CASE: Pedro is a 2-year 7-month-old boy who was presented for the first time after a visit to a local emergency room (ER) for diarrhea. At the time of his birth, his undocumented mother, Clara, was 20 years old, uninsured, and with limited English proficiency living approximately 400 miles south of our practice in a different state. Although she had been brought to the United States as a child, she had never finished high school. Pedro was born what mother thought was full-term at his parent's home, where a lay midwife assisted during the delivery. Pedro was not brought to a medical facility at birth; therefore, neither medical nor legal documentation of his birth in the United States, or elsewhere, existed.After enduring 4 years of ongoing verbal and physical abuse, Clara fled to her maternal aunt in our community. The child's initial exposure to medical care was during the emergency visit, which ended up in referral to us. The ED physician suggested that the child visit a primary care physician, but establishment of pediatric care was not made until months later. The child received his first vaccines and immediately was referred to the Growth and Nutrition clinic due to mild wasting and stunting based on Waterlow criteria.Pedro speaks both English and Spanish and has no 2-word combinations and a 50-word combined vocabulary in English and Spanish. In addition, a complete blood count was consistent with iron deficiency anemia, but both sickle cell and G6PD screening are negative.The nutritionist from the specialty clinic obtained a detailed history including overall appetite, feeding skills, meal plans, and eating environment noting that the child was a competent finger feeder. The family's meals were distributed throughout the day as a meal at home and a shared fast food meal while accompanying mother, as she worked as a hair stylist 6 days per week. In addition, the diet is supplemented by ricewater mixed with sugar and ground carrots throughout the day.Where would you head next?REFERENCE1. Waterlow JC. Classification and definition of protein-calorie malnutrition. Br Med J. 1972;3:566-569.

Medical-Legal Strategies to Improve Infant Health Care: A Randomized Trial.

BACKGROUND: Changes in health care delivery create opportunities to improve systems to better meet the needs of low-income families while achieving quality benchmarks. METHODS: Families of healthy newborns receiving primary care at a single large urban safety-net hospital participated. Intervention families were randomly assigned a family specialist who provided support until the 6-month routine health care visit. The Developmental Understanding and Legal Collaboration for Everyone (DULCE) intervention is based on the Strengthening Families approach and incorporated components of the Healthy Steps and Medical-Legal Partnership models. Medical record reviews determined use of preventive and emergency care. Surveys conducted at baseline, postintervention (6 months), and follow-up (12 months) were used to determine hardship and attainment of concrete supports. RESULTS: Three hundred thirty families participated in the study. At baseline, 73% of families reported economic hardships. Intervention parents had an average of 14 contacts with the family specialist, and 5 hours of total contact time. Intervention infants were more likely to have completed their 6-month immunization schedule by age 7 months (77% vs 63%, P < .005) and by 8 months (88% vs 77%, P < .01). Intervention infants were more likely to have 5 or more routine preventive care visits by age 1 year (78% vs 67%, P < .01) and were less likely to have visited the emergency department by age 6 months (37% vs 49.7%, P < .03). The DULCE intervention accelerated access to concrete resources (P = .029). CONCLUSIONS: Assignment to the Project DULCE intervention led to improvements in preventive health care delivery and utilization and accelerated access to concrete supports among low-income families.

Growth--and documentation-deficits: where to start in helping families.

REFERENCE: Pedro is a 2-year 7-month-old boy who was presented for the first time after a visit to a local emergency room (ER) for diarrhea. At the time of his birth, his undocumented mother, Clara, was 20 years old, uninsured, and with limited English proficiency living approximately 400 miles south of our practice in a different state. Although she had been brought to the United States as a child, she had never finished high school. Pedro was born what mother thought was full-term at his parent's home, where a lay midwife assisted during the delivery. Pedro was not brought to a medical facility at birth; therefore, neither medical nor legal documentation of his birth in the United States, or elsewhere, existed.After enduring 4 years of ongoing verbal and physical abuse, Clara fled to her maternal aunt in our community. The child's initial exposure to medical care was during the emergency visit, which ended up in referral to us. The ED physician suggested that the child visit a primary care physician, but establishment of pediatric care was not made until months later. The child received his first vaccines and immediately was referred to the Growth and Nutrition clinic due to mild wasting and stunting based on Waterlow criteria.Pedro speaks both English and Spanish and has no 2-word combinations and a 50-word combined vocabulary in English and Spanish. In addition, a complete blood count was consistent with iron deficiency anemia, but both sickle cell and G6PD screening are negative.The nutritionist from the specialty clinic obtained a detailed history including overall appetite, feeding skills, meal plans, and eating environment noting that the child was a competent finger feeder. The family's meals were distributed throughout the day as a meal at home and a shared fast food meal while accompanying mother, as she worked as a hair stylist 6 days per week. In addition, the diet is supplemented by rice water mixed with sugar and ground carrots throughout the day.Where would you head next?

Medical-legal partnerships: transforming primary care by addressing the legal needs of vulnerable populations.

Health care is undermined when patients don't receive the benefit of laws intended to address social determinants of health, such as housing and food. Medical-legal partnerships, which now exist in more than 200 clinical sites in the United States, integrate lawyers into health care to address legal problems that create and perpetuate poor health. This paper describes how such medical-legal partnerships can change clinical systems--for example, by adding legal form letters to electronic health records to help low-income patients rectify substandard housing conditions. We recommend the integration of medical-legal partnerships into federal health care programs.