A pilot study of participatory and rapid implementation approaches to increase depression screening in primary care

Background Most individuals with depression go unidentified and untreated. In 2016 the US Preventive Services Task Force released guidelines recommending universal screening in primary care to identify patients with depression and to link them to treatment. Feasible, acceptable, and effective strategies to implement these guidelines are needed. Methods This three-phased study employed rapid participatory methods to design and test strategies to increase depression screening at Penn Medicine, a large health system with 90 primary care practices. First, researchers solicited ideas and barriers from stakeholders to increase screening using an innovation tournament—a crowdsourcing method that invites stakeholders to submit ideas to address a workplace challenge. Second, a panel of stakeholders and scientists deliberated over and ranked the tournament ideas. An instant runoff election was held to select the winning idea. Third, the research team piloted the winning idea in a primary care practice using rapid prototyping, an approach that quickly refines and iterates strategy designs. Results The innovation tournament yielded 31 ideas and 32 barriers from diverse stakeholders (12 primary care physicians, 10 medical assistants, 4 nurse practitioners, 2 practice managers, and 4 patient support assistants). A panel of 6 stakeholders and scientists deliberated on the ideas and voted for patient self-report (i.e., through tablet computers, text message, or an online patient portal) as the winning idea. The research team rapid prototyped tablets in one primary care practice with one physician over 5 five-hour shifts to examine the feasibility, acceptability, and effectiveness of the strategy. Most patients, the physician, and medical assistants found the tablets acceptable and feasible. However, patient support assistants struggled to incorporate them in their workflow and expressed concerns about scaling up the process. Depression screening rates were higher using tablets compared to usual care; follow-up was comparable between tablets and usual care. Conclusions Rapid participatory methods engaged and amplified the voices of diverse stakeholders in primary care. These methods helped design an acceptable and feasible implementation strategy that showed promise for increasing depression screening in a primary care setting. The next step is to evaluate the strategy in a randomized controlled trial across primary care practices.

Improving Delays in Obtaining Lenalidomide at a Large Safety Net Hospital

Introduction: Lenalidomide is an immunomodulatory agent used primarily in the management of multiple myeloma and non-Hodgkin's lymphomas. Owing to the risks of birth defects and fetal death, lenalidomide is only available under a restricted program through Celgene called Revlimid Risk Evaluation and Mitigation Strategy (REMS). The Revlimid REMS program includes various requirements for patients and providers aimed to avoid embryo-fetal exposure from lenalidomide. Prescribers and patients are required to complete periodic mandatory surveys attesting that the patient is aware of the risks. Once the surveys are completed, a unique and time-limited authorization number is generated by Celgene, which must be included on the prescription. Each prescription is restricted to a 4-week supply with no automatic refills and must be sent to certified specialty pharmacy. In addition, the patient may require insurance authorization or may need to enroll in financial assistance program. Given this multi-step process, patients from our safety net hospital, LAC+USC Medical Center, experience delays in receiving their lenalidomide prescriptions. Such delays may lead to interruptions in cancer treatment and additional clinic visits. Our aim was to assess the effectiveness of the following interventions: creation of a standardized process flowchart, training of clinic staff, and additional patient support from Celgene to reduce delays in the dispensing of lenalidomide prescriptions. Methods: This is a retrospective study of patients prescribed lenalidomide through the hematology clinic at LAC+USC Medical Center, Los Angeles, CA from June 1, 2020 to December 31, 2020. Patients were identified through the Celgene REMS database. The electronic medical record was reviewed for: patient demographics, insurance, and specialty pharmacy dispensing of lenalidomide. Each prescription was reviewed for the authorization number, days from prescription submission to dispensing, and days between each prescription dispensing. A delay was defined as > 2 weeks from the time from prescription submission to pharmacy dispensing. The medical chart was reviewed to identify the reason for the delay. A standardized process was created between July 2020 and August 2020. This included the creation of a workflow flowchart and training of the clinic staff. Additionally, a patient access specialist from Celgene was assigned to support patients and providers through the multi-step process for each prescription. The percentage of pre-intervention delays (before Sept 2020) and post-intervention delays (after Sept 2020) was compared. Results: A total of 196 lenalidomide prescriptions were reviewed. Prior to the intervention, the median time from prescription sent to date of dispensing was 3 days (range: 0-27 days), with a mean time of 5.9 days. 14 of 128 prescriptions (10.9%) had a delay of > 2 weeks. Causes for delay included: awaiting completion of patient survey, insurance issues (need for prior authorization, insurance changes), clinic visit missed or not in correct timeframe to submit new prescription, hospitalization, and medication hold due to toxicity. Following the intervention, 3 of 68 prescriptions (4.4%) were delayed. Median time from prescription sent to date dispensed was 2.5 days (range: 0-29 days) with a mean time of 4.2 days. One prescription was not sent to the correct specialty pharmacy and one was on hold in setting of disease progression. Conclusion: Given the multi-step process, on-time dispensing of the specialty drug lenalidomide is a challenge at our safety net hospital. We identified several delays in the dispensing of lenalidomide prescriptions, including the timeliness of patient survey completion, drug coverage/insurance issues, and coordination of clinic visits with the time that the patient was due for the refill. Formalizing the workflow, training the clinic staff, and having a Celgene patient support specialist led to an improvement in prescription dispensing delays. With the continual addition of specialty medications into hematology/oncology clinics, establishing a standardized workflow with engagement of the clinic staff and specialty pharmacies/drug companies may help reduce delays in the dispensing of specialty drugs. Figure 1 Figure 1. Disclosures Piatek: Rigel: Consultancy, Research Funding; Alexion: Consultancy, Research Funding; Apellis: Research Funding; Dova: Consultancy, Speakers Bureau.

Psychosocial and Patient Support Services in Comprehensive Cancer Centers

Patient support and psychosocial services are an important aspect of cancer care. Comprehensive cancer centers need to provide a spectrum of these services to provide high-quality and holistic care to cancer patients. Provision of these services begins from the time of diagnosis, continues through cancer treatment, and then subsequently transitions to survivorship or end-of-life phase. Examples of these services include psychological assessment and management, patient navigation, care coordination, genetic counseling, and complementary medicine. Survivorship care is an important aspect of patients’ experience during their cancer journey and beyond. This chapter discusses key psychosocial and supportive care services that are recommended for cancer centers that strive to provide comprehensive cancer care to their patients.