Redesigning Supportive Cancer Care Delivery -- Aligning Goals

March 30, 2023

Yale Cancer Center Grand Rounds | March 28, 2023

Presentation by: Dr. Manali I. Patel

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00:00Started so I thank you all so
00:03much for being here today.
00:05I'd like you to join me in welcoming Dr.
00:09Manali Patel, who is an associate
00:11professor of medicine at Stanford
00:13Medicine and a staff oncologist with
00:16the VA Palo Alto healthcare system.
00:20She earned her medical degree and master's
00:22in public health at the University
00:24of North Carolina at Chapel Hill,
00:26followed by Internal Medicine residency.
00:29Key Monk Fellowship and
00:31several research fellowships.
00:32In addition to obtaining her masters in
00:35health services research at Stanford,
00:37doctor Patel directs a research program
00:40that focuses on improving equitable
00:42delivery of value based cancer care.
00:44She uses principles of community based
00:46participatory research in her work
00:48and is the principal investigator
00:50of multiple externally funded awards
00:53such as the California Initiative
00:55to advance Precision Medicine,
00:56the patient centered Outcomes
00:58Research Institute.
00:59And the National Institutes of Health.
01:01Her expertise lies in designing,
01:03implementing and evaluating new
01:04models of care delivery with academic,
01:07community and VA oncology practices aimed
01:10to improve patient experiences with care,
01:13clinical outcomes and reduce
01:15unwanted health disparities,
01:17unwanted healthcare utilization
01:19and health disparities.
01:20Doctor Patel also serves on
01:22several national committees
01:23focused on improving cancer care delivery
01:25and value based care.
01:26She is the past chair of the ASCO
01:29HealthEquity Committee and the
01:31current chair of the ASCO serving the
01:33Underserved Task Force.
01:34So Doctor Patel will be delivering
01:37the Iris Fisher Lectureship today.
01:40The Iris Fisher Lectureship was
01:42endowed by Doctor David Fisher in 1999.
01:45Doctor Fisher has been involved with Yale
01:47School of Medicine for nearly 60 years.
01:50He was the first medical oncologist in
01:52the New Haven community and remained
01:54in private practice for 30 years
01:56before joining Yale's Cancer Center in
01:581993 as a volunteer and full time in
02:011995 when Doctor Fisher's wife Iris
02:04was diagnosed with sarcoidosis and
02:06incurable disease of the heart and lungs.
02:09Treatment decisions were weighed and
02:11balanced against the impact that therapies
02:13would have on Iris's personal wellbeing.
02:16It was Doctor Fisher's hope that this
02:18lectureship would serve as a lasting
02:19memorial to Iris while providing an
02:22educational opportunity for physicians
02:23and staff for the benefit of patients.
02:25We are grateful to Doctor Fisher
02:27for his generous
02:28support and we are grateful
02:29for Doctor Patel for delivering
02:30this lectureship today. Please join
02:32me in welcoming Dr. Manali Patel.
02:39Thank you. I know Michaela from many
02:41eons ago and so it's nice to see so
02:43many familiar faces and also so many new
02:46faces that I've known more recently.
02:47And thank you all for joining in person.
02:50I really want this to be more interactive,
02:52so please ask questions, interrupt me,
02:55push it up against the the bar.
02:57I really want you to think outside
02:59the box and really push me in
03:01terms of what I'm presenting today.
03:03So I'm going to give a brief background.
03:05Of my work and why we started a lot
03:07of work and supportive cancer care
03:10delivery and then I'm going to focus on
03:12multilevel stakeholder engaged research,
03:14giving an example in supportive
03:16cancer care delivery,
03:17which are aspects of palliative
03:19care and then focus in on the why.
03:22For me, I love being first.
03:25How many of you all love being first?
03:28We're all competitive,
03:28so I know many of us want to be first.
03:31I actually don't like being first.
03:35In the amount that we're spending
03:37for healthcare.
03:38And why are we last in terms of
03:42our spending for social services?
03:46How many of you all saw this
03:49over the weekend? NPR. Yep.
03:51I see some folks saying yes.
03:54For all that money we are
03:57inputting into healthcare,
03:58why are we doing so poorly?
04:04And many will say, well,
04:04it's our COVID-19 policies.
04:06I'm sorry, the trend was
04:09beginning long before COVID-19.
04:12And so could it be this longterm
04:15shortchanging of social services?
04:20And then you look at cancer,
04:22which is all of our areas of expertise,
04:26this is completely unsustainable.
04:30How many of you all drive on the highways?
04:35When there's a pothole that comes out
04:39of the same bucket of congressional
04:41funding as paying for healthcare.
04:44So if utilizing most of the gross domestic
04:47product on healthcare expenditures,
04:49we have limited for other
04:52social care expenditures,
04:55limited funding to fix our roads,
04:57limited funding through K through
05:0012 education. You name it,
05:05and despite all this money,
05:07we are investing into cancer care,
05:10especially at the end of life.
05:12We see really horrible care.
05:15How many of you all have had a patient
05:19that was unaware of their prognosis
05:22when they were nearing their death?
05:28Many of our patients are
05:30experiencing undertreated symptoms.
05:32We also see this large shift
05:33and I've heard about it.
05:35What you all are building here in this
05:37network is actually quite different.
05:39But out in the the real world
05:42outside of Connecticut,
05:43we see this huge shift of care from
05:47community based settings into these
05:49large hospital conglomerates and then
05:52we also see tacked on facility charges.
05:55So not only is care then centralized.
05:59And away from people in their communities.
06:02But then it's also more expensive
06:06for the same product. Fascinating.
06:11Then my own area of expertise is disparities.
06:14We see persistent disparities
06:17by socioeconomic status, race,
06:19ethnicity,
06:20demographic characteristics that
06:21are largely due to the lack of
06:25expenditure for social care services.
06:27That continue across the continuum.
06:31How many of you all have seen this graph?
06:34Robin Yaborov, good friend of ours,
06:37the American Cancer Society,
06:39I love this U-shaped curve because
06:42it shows you and I know when I walk
06:44away they're not going to be able
06:45to hear me on zoom, is that right?
06:48But what's wonderful about it is it
06:50shows you this peri diagnostic phase.
06:53There's this huge uptick and uprise.
06:56That coincides with when patients have
06:59the worst experiences with their care.
07:02So not only when they're becoming
07:04diagnosed and going through the flurry of
07:07activity during diagnosis with treatments,
07:11but then also at the end of life,
07:13you see this sharp uprise and it doesn't
07:15matter how long your survival is,
07:17you see this same pattern.
07:20And I think she revised this most recently.
07:23So the only thing that's changed essentially,
07:24is the Y axis. It's much more expensive now.
07:28How many of you all know of Don Berwick?
07:32He challenged us in 2008 and said
07:35he was a medpac commissioner and
07:38thought about these disruptive
07:39innovations in in, in healthcare.
07:41Why is it that in every other sector,
07:45when a new technology is developed,
07:47the cost come down, you think about
07:51the first iPhone first CT scanner.
07:55But in medicine, it tends to be the opposite.
07:57We're we don't have very many interventions
08:01that achieve this whole triple aim
08:03of improving population health,
08:05bettering patient experiences
08:07and reducing total cost of care.
08:10You may see some interventions
08:12that may do 2 out of the three,
08:15but not interventions that
08:18can achieve all three.
08:20And he challenged us as a nation and
08:22said if we really want to ensure.
08:25That our population is better overall and
08:29that we have some GDP left for social cares.
08:32We really have to tackle this
08:35cost problem in healthcare,
08:37but also think about our interventions such
08:39that we're not decreasing the quality.
08:45I know Makayla knows this,
08:46but community based participatory research?
08:50Raise hands if you know this about it, okay?
08:53I learned a very critical lesson,
08:56so I went into medical school at UNC and I'd
09:00really hoped to be a global practitioner.
09:03And I went into the traditional medical
09:05school training and it was right across the
09:07street from the School of Public Health.
09:10But there was little interplay.
09:12I love UNC.
09:12I'm a Tar hill born, Tar hill bred.
09:14When I die, I'm a tar hill dead.
09:17But what I hated about medical
09:19school and what led me to think.
09:21Whether medicine was really in it for me,
09:23is this the right career,
09:25was that there was this
09:27lack of focus on prevention,
09:29but this huge focus on treatment,
09:31and I'm going to talk a little bit
09:33later about why potentially that
09:34may be in this consumerist society.
09:36And so I did my master's in public health.
09:38I took a year off, year off, right.
09:40It was actually a very difficult
09:43year in the public health degree
09:45space and did my practicum.
09:46So as part of your thesis,
09:48you have to write up a practicum.
09:50And I decided to go back to a
09:52community that had worked in as
09:54an undergrad and in Honduras.
09:55And as one of the key principles
09:58of community based participatory
10:00research is this understanding
10:02that communities know the problem
10:04and they also know the solutions.
10:07And so as researchers and as
10:10budding medical physicians,
10:11we always like to do what
10:14I call global tourism.
10:16Where we go in, we take our ideas,
10:18hey, we have this great idea.
10:20We're going to input it in your system
10:21and not really knowing if that's
10:23really what the community needs.
10:25And so I thought I would really
10:28focus on diabetes, food insecurity,
10:30housing and security in this community.
10:32But instead I heard from the community
10:35Members what the main problem was,
10:37was cervical cancer,
10:39women dying from cervical cancer.
10:41Now,
10:42this was long before the connection
10:44with HPV had been made.
10:46And what they said was we have lots and
10:50lots of women dying from cervical cancer.
10:54Makes sense.
10:54Now,
10:55this was a migrant farm working population.
10:57They were coming to areas of North Carolina,
10:59going back and transmitting HPB.
11:02And thus lots of women were
11:04dying and there was no screening.
11:07So I came back to the United States and I
11:08said, Oh my gosh, what did I get myself into?
11:10Right?
11:10I know nothing about cervical cancer.
11:12I'm an internist, right,
11:14budding internist.
11:15So I came back and asked 2 budding
11:18OB gine Med students if they would
11:21help me and we went back and we heard
11:24from the community members and they
11:27said how do you screen for cervical cancer?
11:31Why can we not provide the screening?
11:35How ingenious?
11:38What differentiates me as a medical student
11:41from community members in the community?
11:43How can we?
11:44You know,
11:44the question came up.
11:45Well,
11:46we don't have the infrastructure.
11:48We've got sticks.
11:50So we made wooden stirrups.
11:53We have headlamps.
11:55And just as easily as we were trained in
11:58medical school to conduct PAP smears,
12:00so can community members in
12:02their own community be trained.
12:05But who's going to pay for it?
12:07So the other principle of public
12:09health is the number needed to screen
12:12and the number needed to treat.
12:14And it was a very eye opening experience for
12:17me to think about following the dollars.
12:20If you're really going to make an
12:23intervention sustainable, that's great.
12:25As a UNC practicum,
12:26I've got a small bucket of funding.
12:28I can come here, do some pap smears, go back.
12:31What's going to happen when
12:32that funding is gone?
12:34The program ends.
12:38So to create a sustainable model,
12:40you have to engage other
12:41people in the community.
12:43Where were people going when they
12:45were diagnosed with cervical cancer?
12:47Well, they weren't diagnosed.
12:48They were actually going to the
12:50local Planned Parenthood and dying
12:52in that facility from symptoms,
12:54from other disease burden, from bleeding.
12:59And all of that cost was being
13:01borne by this facility.
13:03Guess what?
13:03I bet they would pay
13:07for the number needed to screen
13:09to do all of the samples.
13:11Evaluate all the.
13:12Coposcopies and also conduct
13:15the Coposcopies now,
13:16over 20 years later.
13:19Guess who's teaching UNC students
13:21in the summer how to do Pap smears?
13:26Sustainable model not dependent on us,
13:29and the Community knew the solution.
13:33Had I gone in with my own idea,
13:35it would have turned into a very
13:36different project that may have
13:38been completely meaningless.
13:41I went to Stanford.
13:42I'm looking at Pam because,
13:43you know, Stanford is a silicon.
13:44How many of you all have been to California?
13:46Silicon Valley.
13:48It's like community based
13:50participatory research with A twist.
13:52Is this design school?
13:53So many of you have an iPhone, right?
13:56What was ingenious about Stanford, right?
13:58They are always trying to
14:00create ways to make money.
14:01So this huge startup culture,
14:03they created the school then that would
14:05teach people about how to make companies
14:07that would get more market share.
14:09So you involve the consumers, right?
14:11If you have a product like an iPhone,
14:14maybe go out and codesign it with the people
14:18that would potentially buy the iPhone,
14:20such as then you're going to
14:22design A product that's going to
14:23be more applicable to other people,
14:25like the people that you designed it with.
14:28But if you think about what they do,
14:29it's actually the same concept of
14:31listening to consumers and building this
14:34out now if you think about supportive
14:37cancer care and trying to achieve.
14:39Actually,
14:40not even supportive cancer care,
14:41but just care in general
14:44and healthcare in general.
14:45There has to be an alignment of
14:49goals and also financial payment
14:53models across each of these groups.
14:57But where we're lacking in Healthcare is
14:59that there's always this misalignment.
15:01And so I'm going to walk you through
15:03one example where we focused in on that.
15:06Uptick of EU shaped curve,
15:08the right side of EU shaped curve
15:10because at the end of life many patients
15:14are experiencing unwanted acute care use,
15:16unwanted healthcare expenditures
15:18at a very high cost.
15:20So that's low yield if we want to
15:23try to achieve the triple aim.
15:25So we started off with this combined
15:28Amalga rhythm of the design school
15:31and the community based participatory
15:34research methods.
15:35So we asked patients and caregivers,
15:37which is clearly what you would do
15:39with community members and CBPR,
15:41what were the barriers and the
15:43challenges and what would some
15:45solutions look like if you were
15:47to create a system focused on end
15:50of life cancer care delivery that
15:52looked very different than the
15:53one that you're currently in.
15:55We also did the same with clinicians
15:58and then we included a critical piece
16:00that we learned from the design school,
16:02which was this idea of payers.
16:05As well as policymakers.
16:10And surprising to me is a wideeyed,
16:12bushytailed fellow who was
16:13kind of in my little realm,
16:15really not thinking about
16:17the financial misalignment.
16:19What I heard from clinicians
16:21and from healthcare systems was
16:23this is the right thing to do,
16:25but if we were to reduce emergency
16:28department visits and hospitalizations
16:29like what Hospice and palliative
16:31care are meant to help with?
16:33Local concordant care,
16:34usually patients will choose not to be in
16:37a hospital setting at the end of life.
16:40There goes our bottom line.
16:43And I was shocked, but it made sense.
16:49And so we heard from communities that they
16:52wanted to be a part of the the, the product.
16:54They want to codesign the product.
16:56They are often not involved in
16:58palliative care efforts and we heard
17:00from patients that it was easier.
17:03To talk to people in the waiting
17:05room about their prognosis and their
17:07questions about end of life, cancer care,
17:12what questions they should ask.
17:13They were getting activated in the waiting
17:15room by other people in the waiting room,
17:18peers, and they felt less comfortable talking
17:21about these issues with their clinicians.
17:25And then the clinicians of course said lack
17:27of time and also some considerations that
17:30palliative care and Hospice weren't quite.
17:33Read they weren't quite ready, right?
17:34Patients may not quite be ready
17:36for some of these services.
17:39And so we have the same players,
17:40same stakeholders.
17:42Create a model where we long
17:46before the A/C A in 2012.
17:48We had them design an ideal approach
17:52that would align their goals and also
17:54would be aligned by financial values.
17:56And what they landed on was
17:59training a community health worker.
18:01For a peer support navigator to help
18:04them understand concepts of values,
18:06goals, preferences outside of our 15 to
18:0930 minute visit in the oncology clinic,
18:14they also had wanted someone to call them.
18:16And again this was long before E pros right?
18:18E pros have not been up and
18:20running at this point 2009,
18:222010 by the time we published this
18:24right it was many years later,
18:26but they wanted people to
18:28call them and ask them.
18:30About their symptoms rather than
18:32reactively calling us when their
18:35symptoms were too far advanced.
18:37And then again,
18:38before the COVID pandemic,
18:40we heard that and had talked with
18:43individuals in Australia and the UK who
18:46were receiving chemotherapy on mobile vans.
18:48Yet what we're doing in the United States
18:50is we're centralizing care and actually
18:52removing sites that may potentially
18:54be more convenient for patients.
18:56You could leverage telemedicine and deliver.
18:59Low risk chemotherapeutics in
19:03essentially rooms that are half the size,
19:05quarter of the size,
19:06which is what was also being done
19:09in parts of Nebraska in the VA with
19:11a telemedicine oncologist that was
19:13leveraged in to ensure no complications
19:16and now that makes less disruptive.
19:18But at the time this was really a no go.
19:21Many people thought that the third
19:23model was really not very idealist,
19:25it was a little bit too idealistic.
19:28And so we decided to test this.
19:30What we heard from clinicians was
19:31we need to see a randomized control
19:34trial before we're willing to engage
19:36in any of this work.
19:37And so this was essentially our
19:39framework was if you were to remove
19:41many of the barriers in the yellow,
19:43potentially you could get to
19:46improving patients,
19:47understanding about advanced care planning.
19:50You could also improve symptom management
19:52by proactively reaching out to patients.
19:55And then hopefully ultimately
19:56improve goal concordant care,
19:58which many of you know is hard to measure.
20:00Many in the palliative care space,
20:01there's a lot of debate about
20:03measurements of goal concordant care
20:05and how one would do that given the
20:07fact that goals change so often and
20:10you certainly can't measure it once
20:11patients have already passed away.
20:12And the surrogates may be able to help you,
20:15but it's really unclear so that
20:17this idea of being
20:19able to achieve goal concordant
20:21care is really addressing something
20:23that may be hard to measure.
20:25And so we tried again as a fellow,
20:27I thought, let's test all three together.
20:29But I already told you,
20:30most people said no way to the last one.
20:32Like telemedicine.
20:33What, on a mobile van?
20:35No way. Right?
20:37We're not giving chemotherapy in places
20:39that are not in our infusion center.
20:41But shockingly,
20:42I also heard from places that we are
20:44not going to have a lay health worker,
20:46community health worker talk to our patient
20:48about what a surrogate decision maker is.
20:51We don't want anyone to talk to our
20:53patient about advanced care planning.
20:55You're going to remove hope.
20:57And so we also got a lot of pushback on
21:00even testing the Community health worker
21:02advanced care planning intervention.
21:04So I thought, well,
21:05let's split up the model.
21:07We'll test each one individually and we'll
21:09go to a place that's more integrated.
21:11So the VAI was a clinic clinical
21:14fellow there and really never thought
21:16about having a fulltime VA job.
21:19But what I was really shocked
21:20by is many of the innovations
21:22happen in the VA telemedicine.
21:23We've been using it for decades in the VA.
21:26Many of our packed models of utilizing
21:29peer support were developed at
21:32the VA and you can get innovations
21:34if you pair with operations,
21:36you can really jumpstart these
21:39out-of-the-box clinical ideas and
21:40get them into practice very quickly.
21:43And there's also this alignment of
21:46finances because they serve as a pair.
21:49So there was a desire by the VA.
21:53To improve not only veteran experiences,
21:55to improve their health outcomes,
21:57but also to lower costs.
21:59So there was a clear alignment
22:01and they said yes, let's do it.
22:03So we trained this lay health worker to
22:05conduct a series of segments either by
22:08telephone or in person with patients.
22:11And so the first segment was really
22:13just discussing and developing rapport.
22:15The next few segments over time it was
22:17a six month intervention would be about.
22:19Tailored messaging about goals and
22:21values and preferences and giving people
22:24the time they need to make these decisions.
22:26So that means starting way upfront
22:28from when people were actually
22:30having conversations about this at
22:33a point which made some oncologists
22:35very uncomfortable.
22:36So we would start at diagnosis
22:38if not before diagnosis,
22:39before the 1st oncologist visit.
22:42Discussing this is part of usual care
22:46and the last was helping patients.
22:48With advanced directive completion.
22:50Completion of documents like
22:51the Stanford letter project,
22:53which wasn't in existence at the time,
22:55developed by BJ Perry Acoyle
22:57using sudor Rebecca Sudor's work,
23:00but really ending up really completing
23:02those documents but also getting
23:04the tailored support they needed.
23:06And it's easier.
23:07If you just hear this, let me see.
23:11Not sure how the video will work?
23:14Let me see if I can.
23:24Let's see,
23:42let's see.
23:50Is there anyone that can help? Do you
23:54think anyone can help me with the video?
24:08What was that?
24:11This one? The right
24:17one? More.
24:20Let's see.
24:23Is your primary
24:24goal to fight parts to
24:25make sure it's out of yours?
24:28Really, it's
24:30your primary goal to fight
24:31parts to make sure it's out of.
24:35I
24:37don't want to die. Bloomberg meets
24:39regularly with healthier checks.
24:43I'm sharing. I'm sharing the sharing,
24:51if not shared one. That's that's sharing and
24:57there on the last one.
25:01Just click that. OK.
25:08Thank you. You gotta get
25:11it again. It came on.
25:16No, that's fine. That's fine.
25:18Just go to share screen. Sure sense.
25:23Now you can select the then you
25:27go share. Yeah.
25:37Is your primary goal
25:38to fight this?
25:39To make sure it's out of your system?
25:42I don't want to die.
25:42I got lots of things to do.
25:45Blumberg meets regularly with healthcare.
25:47Coach Laviba share a
25:49compassionate ear shares role,
25:51is to provide the big picture
25:53to help patients think
25:55about how cancer treatment.
25:56Will fit in with the way they want
25:58to spend the rest of their lives.
26:01Can I learn a little bit more about
26:02what it is that you want to do? Well,
26:05I wanna do some more traveling.
26:08I wanna spend time with my kids getting a
26:13little emotional. What are they
26:16getting from you that they don't
26:19get from anyone else? Well, they
26:21get someone who's
26:22actually helping them through their care.
26:24With me they're actually discussing things.
26:26What they're feeling, what they're
26:27going through, what they want to do,
26:32what they what they understand
26:34is their prognosis.
26:35I just decided not to go through
26:37the treatment patients like
26:3947 year old Raphael Arias,
26:42a former army police officer.
26:44Arias is suffering from a recurrent sarcoma
26:47and has already lost a leg to cancer.
26:50Right now we just.
26:52I'm trying to do take advantage of
26:54the fact that I'm still here and
26:57trying to do something so all I can.
27:01Why have you decided not to have?
27:02Chemotherapy made me sick and
27:07within a week we had to stop it.
27:10So as difficult as it was,
27:12I just decided not to go through with it.
27:17You want to have the highest quality
27:19of life for as long as you have life,
27:21correct?
27:21With a little bit of time that I have left,
27:26my wife and I have plans of maybe
27:28doing some things before my departure
27:34is your primary goal.
27:35And that was essentially a
27:387 minute flip. So Al Jazeera America
27:40had heard what we were doing and
27:42before we had any results back,
27:44they thought it was so fascinating that
27:46someone who is not trained medically.
27:48Was having what would otherwise be considered
27:51a medicalized conversation with patients.
27:52Why do we medicalize these conversations?
27:55Patients really do need the time
27:57to be able to engage in this work.
27:59And while I've had clinical equipoise
28:00as to whether or not it would work,
28:03we certainly knew that there were
28:04facets like these stories where she
28:06had spent so much time with patients
28:08who would have otherwise in my clinic,
28:10had received chemotherapy and
28:12gone through with it.
28:13What patients then said was
28:15we didn't want to disappoint.
28:17Doctor, so and so
28:20it's very multi,
28:22it's very complex and so we decided
28:24to test this in a randomized trial.
28:26We heard from oncologists that we
28:29were potentially causing harm and
28:31that we would potentially buy this
28:33intervention cause people to die faster.
28:34So we had to dispel that myth.
28:36We also wanted to see if it was feasible,
28:38can we improve goals of care conversation.
28:41So we randomized patients stage three
28:43and stage four disease also with
28:45recurrence of cancer agnostic to
28:47disease into this intervention that
28:49you just saw clips of versus usual
28:51care and we measured goals of care
28:54documentation as well as patient
28:56experiences and total cost of care.
28:59We randomized 213 patients
29:00in this consort diagram.
29:02You see 100 and 805 respectively in
29:04the control group in the intervention.
29:06It was blocked randomized
29:08by cancer diagnosis.
29:09And because it was in the
29:10VA and we had claims data,
29:11we could conduct an intent to treat analysis.
29:13So despite loss of follow up,
29:16we were actually able to complete
29:18the entire ITT for the patients
29:21that were initially randomized.
29:23And what we found was shocking to me.
29:27This is goals of care documentation
29:28by the oncologists,
29:29many of whom were opposed to this model,
29:32many of whom didn't even
29:34know that it was happening.
29:36It was in the background.
29:38No interaction between the
29:39Community health worker,
29:40lay health worker and the oncologist,
29:43but yet patients were being
29:46activated to tell their physician,
29:48I don't have the goals of care
29:51document and can you print it out
29:54because the community health worker
29:56was helping to engage patients in
29:58these conversations saying if your
29:59oncologist doesn't bring it up,
30:01you need to bring it up.
30:03And we found that this also led to
30:05improvements in advanced directives.
30:07As we anticipated,
30:08if you have tailored assistance,
30:10you're more likely to be able to complete
30:12the advance directive documentation.
30:13And this changed over time.
30:15We had to dispel the myth that
30:17because you have an advance
30:18directive that you can't change it.
30:20You actually can change it.
30:21So it's a living,
30:22it's meant to be a living document.
30:24And so we would update the advance
30:28directive as People's Life course changed.
30:31We found that patient satisfaction went up.
30:33This was using the consumer assessment of.
30:35Of healthcare providers and
30:37healthcare systems General survey,
30:39the question of would you recommend
30:41care on a scale of zero to 10?
30:44How satisfied are you with
30:45your clinical team?
30:4610 being a very high satisfaction,
30:480 being low satisfaction and what we
30:51found over time in the blue line is
30:54that the intervention group improved
30:56and the control group decline.
30:58We did not cause harm.
31:00So unlike Jennifer Tumels model,
31:02which I'll show you,
31:03we improved palliative care.
31:04We didn't find a survival benefit,
31:06but we dispelled the myth that we
31:09were making people die faster.
31:13But what we showed was at the end
31:15of life there was better care,
31:1995% reduction in acute care use,
31:21almost doubling of Hospice utilization and
31:24the baseline in the BA is high as you know,
31:26because we can provide Hospice
31:28concurrently with care.
31:30Why that's not closer to 100%.
31:32There are many issues,
31:33but we were able to actually
31:36double that to close to 100%.
31:38And we found in the last month of
31:40life not only were total cost,
31:42median total cost lower,
31:44but you see that variation.
31:46This is amazing to me is how
31:50narrow that variation is.
31:53You've removed the outliers 1 outlier,
31:571 outlier can do you in.
32:01That variation is really what
32:03we want to try to improve upon.
32:06And so at the same time,
32:07I wanted to test the symptom
32:09management model, right,
32:10the Community health worker conducting
32:12this proactive symptom assessments.
32:13It wasn't a novel idea.
32:15Kurt Kerlan Key and the VA had
32:17been conducting this with a nurse.
32:19What was novel about it is that
32:20you would have a lay health worker,
32:22community health worker conducting this.
32:24It was novel at the time because we
32:26really had very limited proactive
32:28reach out to patients across the
32:30United States to assess symptoms.
32:32And so I went to Southern California
32:35and interestingly enough I had
32:37been giving presentations about
32:39this model hoping that we would
32:41find pilot test partners.
32:43Most of the time I got the door slammed in
32:45my face again was was before the A/C A,
32:47so payers did not want to be involved
32:50in something that seemed like thanks
32:52to Sarah Palin going to death panel.
32:55Even though we had payers at
32:57the table designing the model,
32:58they did not want to be involved in it.
33:01And so care more the woman that was
33:03in charge of care more at the time,
33:05laviba, she ended up having breast cancer.
33:10And so this story resonated with
33:12her on a personal level.
33:14And she said, look,
33:15if you can find an oncology
33:17practice that's willing to help,
33:19we will do one piece of your model.
33:21Actually,
33:21we'll do the advanced care planning.
33:23And we'll do the symptom management again.
33:25We didn't have the data from the
33:27VA because it was at the same time,
33:29well,
33:29we found an oncologist practice
33:30that was willing to do the symptom
33:32management piece.
33:32Again did not want to have anything
33:34to do with the advanced care
33:35planning and they said we need a
33:38per member per month fee to do this.
33:41This was before OCM,
33:42the oncology care model,
33:43which now reimburses or had been
33:45reimbursing for some of these
33:47services and now there's a new OCM.
33:49So this was before that time and
33:51it was kind of unprecedented for a
33:53payer to be providing a lot of this
33:56upfront payment to many of these practices.
33:59And then we did a back of the envelope
34:02calculation and there is a misalignment.
34:04All this work that we do in our clinics
34:06to try to save patients symptoms,
34:09try to improve their symptoms,
34:10it's going to reduce emergency
34:12department visits and hospitalizations.
34:14And if it's not an integrated system,
34:17guess what? You've input a lot of effort
34:20into something that you're getting no
34:22reimbursement for as a practicing oncologist.
34:25So we took that model to care more and said,
34:27look, you're getting this much,
34:29if it were to work, which we think it will,
34:32you're going to get X percentage, right?
34:33We think that we're going to save
34:3520% net implementation costs.
34:36So if we think that you're
34:39going to save the money,
34:40it's important that you
34:42pay for the intervention.
34:43And we're going to make it a low cost
34:45intervention using lay health workers,
34:46not a nurse sled model.
34:48And you can create a shared savings model
34:51where a third will go back to the patient,
34:541/3 will go to the clinical team
34:56and a third will go into you.
34:58And they agreed the oncology practice
35:01then had one more negotiation.
35:03They wanted all market share.
35:06Every beneficiary from this Medicare
35:08Advantage group was going to go singly
35:12in Fullerton to this one clinic.
35:14Care MORE agreed,
35:17so we tested it.
35:19Lay health worker was embedded,
35:21paid for by care more advantage,
35:23Medicare Advantage embedded in the clinic,
35:26did weekly phone calls with patients.
35:28Initially we started with patients
35:30that had advanced stages and then we
35:33moved more upstream to patients with
35:35all stages after a couple of years
35:37because the clinic really liked it.
35:38And we showed in two they would
35:41review symptoms using esass,
35:42how many of you all know esass
35:44Edmonton Symptom assessment system,
35:46it's a scale of zero to
35:4810 with multiple symptoms.
35:49I think there's nine or ten.
35:50And then there's also another category
35:5310 being worse symptom symptomatology
35:55and sympto burden 0 being less symptoms.
35:59And what we found was essentially
36:01for patients and we built this
36:02into the protocol that any score
36:04of four above or that changed by
36:06two points from that assessment.
36:08Would then get triaged and reviewed
36:11with a nurse practitioner.
36:12The nurse practitioner,
36:13FTE was also covered by the payer.
36:19And then we decided, wait a minute,
36:21the nurse practitioner is
36:22reviewing all of these symptoms.
36:24Let's build out an automatic referral
36:27with waived prior authorization.
36:29Because we're working with the payer,
36:30we can do that.
36:31For symptoms that are escalating,
36:33they would go directly to
36:35palliative care and bypass the
36:36nurse practitioner review.
36:38Or they would go to the behavioral
36:40health services because we were also
36:41screening for anxiety and depression
36:45in a cohort study of 800 patients.
36:48The the cohort of patients that
36:51were receiving intervention versus
36:52a match cohort in the year prior.
36:54We found for Edmonton symptom
36:57Assessment System survey assessment
36:58tools that essentially the
37:00main scores reduced over time.
37:02In this 12 month intervention
37:05the control group went up.
37:07And we also found, not surprisingly,
37:10better anxiety and depression,
37:15no harm. So we also can't
37:20replicate Ethan Bosch's work.
37:21But we did find, again,
37:23very similar reductions.
37:24And again, this was for all patients,
37:27not just patients with advanced stages,
37:30but reductions in acute care use and
37:32reductions in total costs of care.
37:35And for the cohort of
37:36individuals that had died,
37:38we found very similar findings
37:39as the VA where at the end
37:41of life it was better care,
37:44better experiences and lower
37:46total cost of care with again
37:48drawing in drawing your attention
37:50to the variation in cost.
37:54And so we just finished randomized
37:56trial of both interventions.
37:57So layering the the advanced care
37:59planning and the symptom management,
38:02which is always how it was supposed to be.
38:05Right. You can't keep people out
38:06of the hospital if you're not.
38:08And that may be their goal if they're
38:11not adequately and appropriately
38:13managed for their symptoms.
38:16So they really go hand in hand.
38:18And so we conducted a randomized trial.
38:20Now this was a different patient population.
38:22It was privately insured.
38:23So we did it in the VA with
38:25advanced care planning.
38:26Intervention with the Medicare
38:28Advantage group was mostly
38:30older Hispanic Latinx adults.
38:32In Fullerton, CA and here now,
38:35it was a younger population
38:37that were privately insured.
38:39We randomized in the acute care use and the
38:43healthcare use goal was our primary outcome.
38:45We randomized a total of 128 into
38:48the intervention and conducted an
38:51ITT and we found,
38:53lo and behold,
38:54even better reductions in acute care use.
38:57And this was not just at the end of life,
38:59this was at 12 months.
39:00I think there was a very small
39:02proportion of patients that had
39:04actually died in this study.
39:05And so consistently we found robust
39:08effects that were consistent
39:09across multiple studies.
39:11And better yet,
39:12we also found that there was a net savings
39:15where a lot of interventions like I
39:18talked about before tend to not save money.
39:20They may be effective,
39:21but they may not save money is because your
39:24implementation inputs are too expensive.
39:27But we had a very low cost,
39:29high touch.
39:31Patient centered solution that utilized
39:34perhaps people that can reach patients
39:37better than we as clinicians can and
39:40that was a tough pill to swallow.
39:41I think for many of us that think we are
39:44the greatest thing next to slice white bread,
39:47but we really do.
39:48It takes a team and what it
39:51did was it enhanced provider
39:53relationships with their patients.
39:54So we have another study where we
39:56looked at across all the stakeholders
39:59what their experiences were.
40:01And we pulled the oncologist
40:03across 12 different sites and
40:05overwhelmingly many have chosen to
40:08continue utilizing this model because
40:10of the benefit for not having to
40:12do when your patients are better
40:15managed from a symptom perspective,
40:17you get that opportunity to really connect
40:20with patients on a different level.
40:22And so many of you know that equity is,
40:25is really why I went to medical school.
40:28And taking evidence based interventions
40:32and plugging and chugging them into
40:34community settings is not a one size fit all.
40:37So a labor union organization
40:39called Unite here,
40:40how many of you have heard of unite here?
40:42Oh great.
40:43So unite here essentially provides
40:46a labor union organization for
40:48hourly low wage workers.
40:51At McCormick we all go to McCormick.
40:54Most of us,
40:55many people that work in
40:56McCormick are part of this union.
40:58Hotel workers, casino workers,
41:01restaurant workers,
41:02taxi drivers.
41:03And unfortunately because they
41:05are hourly wage workers,
41:06they don't have health benefits.
41:09So as part of the Union,
41:10what they decided was that they were going
41:13to skim off a very tiny fraction of people's
41:15paycheck and put it into a health fund.
41:17And so the health fund really
41:19wants to provide high value care,
41:22meaning very high quality at low cost.
41:26And they have the Union backing them, right?
41:28They're part of the union.
41:29The Union is very and the Members of this
41:32Union very much trust unite your health.
41:35There's this engender trust
41:36because it's one and the same.
41:38And so they had heard of the work and
41:40they knew that at the end of life for
41:43many of their hourly low wage workers,
41:45they were having poor experiences,
41:48especially as they were dying.
41:50And so they asked us if we
41:52could embed our model.
41:53And so I'm glad I did that public health
41:56degree because I took a step back and said,
41:58Okay, well, let's,
41:58let's see how we would embed
42:00this model in your population.
42:02So we created a Community Advisory Board.
42:04So I pulled people from
42:06Atlantic City and Chicago,
42:07as well as the Union members
42:09and the Union President.
42:11And can someone take a wild guess
42:12as to what a patient told me when
42:14I talked about this intervention
42:16about a community health worker,
42:17a healthcare advocate,
42:18reaching out to them to talk
42:20about advanced care planning?
42:25I didn't know either.
42:26I was actually very shocked.
42:28What they said was you try having
42:31a conversation about goals of
42:32care when you're worried about
42:34where your family is going to
42:37live and how you're going to get
42:39food on the table for your family.
42:41You're asking me to do something that
42:43I think is going to hasten my death.
42:46Then who is going to provide for my family?
42:50Eye opener.
42:52So guess what, we tabled the
42:56intervention and we focused on
42:59addressing health related social needs.
43:01We integrated that.
43:02We didn't table the advanced care planning,
43:04but we integrated the health related
43:07social needs first and foremost
43:09and we used community engagement to
43:12build partnerships with industry.
43:15One issue is transportation.
43:16How are people going to get to
43:18and from their clinic visits?
43:19Well, guess what?
43:21Lift can provide free transportation,
43:25better value, better quality, lower cost.
43:28If people are adhering to their treatments,
43:31people have no place to live.
43:34Local Housing Authority let's
43:36build in places for people to
43:38live while they're getting care.
43:42Let's think about ways
43:44to invest in social care,
43:47because then as an organization,
43:48you, not your health, has.
43:50Individuals with lots of diseases,
43:52not just cancer. Cancer is 1 slice.
43:55If we invest in social services,
43:58we are likely going to do better for not
44:01only our Members but also reduce costs.
44:04And so we built this in and then we also
44:06heard from unite your health that there
44:08were some crooked groups and some ecologists,
44:11that perhaps we're not providing the highest
44:14and most evidence based care for patients.
44:17And that is an area of research for me where
44:19we know patients by race and ethnicity,
44:21socioeconomic status,
44:21where you go determines the care you get.
44:25And so making for example,
44:27the Yale out in the community is a
44:32fantastic idea because providing
44:34evidence based care is a way to
44:37overcome many of the disparities.
44:39It's not due to patient level factors.
44:43I know we go there.
44:45It's actually due to what people are
44:47receiving once they're diagnosed.
44:48And now we've shown study after
44:50study after study that if you get
44:52the care that you need and the
44:53care that's evidence based,
44:55your outcomes are the same,
44:56if not better, then more white,
44:59more affluent white individuals
45:01who usually do much better.
45:03And so we picked through.
45:04I went through their claims,
45:06I went out to Atlantic City in
45:07Chicago as a fellow multiple times,
45:09looked over claims data and tried to
45:12identify the highest performing providers.
45:14And in Atlantic City there was
45:16an MD Anderson clinic.
45:17It was very costly but it also
45:21provided evidence based care.
45:23And so the union said Okay Manali,
45:25redesign, let's redesign the benefits.
45:27Okay, what do we need to do?
45:28And I said let's not reduce market share.
45:31People want a choice.
45:32I want a choice when I'm diagnosed
45:33with cancer and that's what we heard
45:35from the Community Advisory Board,
45:36you want a choice of where to go,
45:38but so don't remove the choice
45:40and have a narrow network.
45:42But rather expand the network and
45:44give people an incentive to go to
45:47the higher providing provider.
45:48So let's waive copays for people
45:50that choose to go to MD Anderson
45:52in the clinic in Chicago,
45:54your copays or waive,
45:57you still have choice,
45:58but you also get additional funding.
46:00If you choose to go to this,
46:01you know you have less out of pocket costs.
46:04So as part of this study,
46:05the Union asked us to do a randomized trial,
46:08which was actually very shocking to me.
46:10But they really wanted answers
46:12quickly and so we randomized patients,
46:13they would everybody got that free
46:15benefit of free cancer care services.
46:17So as part of usual care,
46:19every patient received that extra
46:21benefit of waiving costs.
46:23But every all the other patient
46:25population that were randomized
46:26received the added benefit of the
46:29Community health worker screening
46:30for health related social needs,
46:32conducting advanced care planning
46:33and symptom management.
46:35We randomized 160 across Atlantic
46:37City and Chicago.
46:39And this just goes to show,
46:40I don't want to go over all the details,
46:41but a very different patient population,
46:44younger patients, more females,
46:46high proportion of Latinx, black
46:49patient populations and Asian subgroups.
46:51Which made us have to translate all
46:54of these documents and to also hire a
46:56lot of Community health workers from
46:59communities that spoke the patient's
47:01preferences of language and that was costly.
47:05Unite your health, did it.
47:07Again, very low annual household incomes
47:10and very low educational attainment
47:13and what we found using the functional
47:15assessment of cancer therapies general,
47:16was that patients health related
47:19quality of life improved.
47:20Makes sense.
47:21If you're screening for
47:23health related social needs,
47:24you're likely going to have
47:26better quality of life.
47:27How much of this was from the other
47:29interventions is what I get asked
47:30all the time. Why does it matter?
47:32Shouldn't we be doing this in our practice?
47:37I think so. And parsing out one piece
47:39from the other doesn't really make sense,
47:41especially when you think
47:43about the patient population.
47:44And then if you look at the similar
47:46reduced reductions in emergency
47:49department use in hospitals,
47:51but you see that the higher there's a
47:53higher mean with this patient population,
47:55very complex patient population
47:57utilizing acute care services more so
48:01than patients in our other studies.
48:04But over all stages,
48:05so again this was all stages of cancer,
48:07I guess 12 month intervention,
48:09we found reductions in total cost of care.
48:13Is this scalable?
48:16We're now launching a 24 site
48:19cluster randomized control trial.
48:20To me doing usual care is kind of unethical.
48:26We know that palliative care
48:28in these services work.
48:29So comparing to usual care is really
48:31kind of a no go for me anymore.
48:34And so we've now started embedding
48:36technology delivered tools where the
48:38same exact tools that the Community
48:39health worker uses in her interactions,
48:41his or her interactions with the patient,
48:43the patients will receive
48:45passively in the control group.
48:48And I also want to make sure that
48:50we've got every single type of facility
48:53where people receive care included.
48:55So we've got community practices,
48:57we've got integrated systems,
48:58we have the VA academic systems and
49:01also our safety net hospital systems.
49:06Years later, Don Berwick wrote
49:07another article and I'm almost done
49:10so we can take questions in 2023,
49:13if you all have time.
49:15Just a couple of months ago,
49:16I would love for you to pick up that
49:17article and juxtapose it against
49:19what he wrote in 2008 because
49:22it's very sobering, sombering.
49:27Even the title the existential
49:29threat of greed in the United States,
49:31United States healthcare system.
49:34And in that article, it makes me question,
49:37are we going in the wrong direction?
49:40Is it worsening?
49:43Because now we see how many
49:44of you all have seen what ASCO
49:47has done for Wellness burnout.
49:51Of course our ask the President
49:53knows you closure ears.
49:53When I used to want to talk about this,
49:55if we don't get at the root of the problem,
49:58everything else is a Band-Aid.
50:00The problem is the healthcare system,
50:04the way that it's financed.
50:05I did not go into medicine to be
50:08a paper pusher and to argue with
50:12payers about prior authorization
50:14for services that I know work,
50:17nor did I go into medicine.
50:20To make a huge buck.
50:21And I know that may be different,
50:23but I also don't think that as a society,
50:26capitalizing off of people when
50:28they're sick is where we want
50:30to go or where we should go.
50:34And now hospices
50:37sadly profiteering why
50:42this is shocking to me.
50:44It's really not because we're part of
50:47the American ecosystem where there's
50:49this desire to want to capitalize,
50:52but it really makes our,
50:53our jobs harder as physicians to
50:55think about what we were trained in
50:57medical school not to think about,
50:59but it's impacting all of us.
51:02This is the why for me,
51:03why do I keep going even
51:04though it seems like, you know,
51:06the system is a big wave
51:08and crashing us all over?
51:09I really don't feel that way.
51:10I'm actually still bright eyed
51:12and bushy tailed and naive.
51:14How many of you all know Paul,
51:14Farmer,
51:17humanitarian. And for me,
51:19this is the why health really
51:22is a fundamental human right.
51:25It's not something that we if we
51:28live in the right neighborhood,
51:30if we have the right parents,
51:32if we have the right education,
51:33if we speak the right language,
51:36that we may or may not be able to
51:37attain our highest health possible.
51:43And why also is because we see change.
51:46The A/C A was huge,
51:47opened up the door to being able to
51:49take away this idea of death panels.
51:51We actually get reimbursed for having
51:54conversations that should be part of
51:56the fabric about how we deliver care.
51:59But also remember that site that
52:00I told you in Fullerton that said
52:02no way to advance care planning.
52:03We'll do the symptoms stuff if
52:05you give us a bunch of money.
52:06They now are advertising on their website.
52:11This program is part of one of
52:13their critical services and
52:14care more decided to pull out.
52:16They said we're not paying for it anymore.
52:18But guess what?
52:20This oncology group is continuing with it
52:22now and has expanded across three states.
52:25A couple of months ago,
52:26we trained all of the health
52:28advocates at unite your health.
52:30So all of the health advocates
52:32across the United States, Las Vegas,
52:34New York, Boston, the food industry,
52:36they were all trained on this model and.
52:39I firmly believe in advocating policy change.
52:43We always forget about the outer bucket.
52:46But it's so important to think
52:48about how to advocate for change.
52:50So with community partners,
52:51we were knocking on the door in
52:54Sacramento every month saying community
52:57health workers need to be reimbursed.
53:00And so now,
53:01as a medical benefit,
53:03as of July,
53:03the work that my community members
53:05and Community health workers
53:07are doing are now reimbursed.
53:11I have a lot of other projects now focused
53:13on that other side of EU shaped curve,
53:15really trying to improve equitable
53:17evidence based care delivery.
53:19And for me it really is people over profits.
53:21And I think all of you in this room,
53:22because you came to this talk number one,
53:26really believe the same thing
53:30when you think about the people at the table.
53:32We've got the governor's office,
53:34you can see the big capital,
53:36we've got the county.
53:39Department of Public Health,
53:42you think about who's at the table,
53:44who even knows that a table
53:46exists and who's not there,
53:48who may not know that the table exists.
53:49Bring them all together and you can
53:53create sustainable interventions
53:54like I talked about in Honduras.
53:56And that's it.
53:57That's a wrap.
54:05We have a couple time. This is our lab.
54:06And so if anyone wants to check it out,
54:08please, we've got a bunch of other
54:10studies ongoing and then certainly
54:12some questions. Yes, in the back.
54:15Oh, thank you Sir.
54:25One of the beauties of
54:26community that expresses
54:28the support you said really get to vote yes
54:32really the whole 1000 importance of that.
54:34Did you identify any particular cultural
54:36barriers and or facilitators within
54:38the community that she's engaged with?
54:42Very good question.
54:43So the question, did everybody
54:45hear that maybe for online folks,
54:47the question was did you with
54:50community based participatory research
54:51really knowing the communities
54:53and if we identified any cultural
54:55barriers or facilitators in the
54:57communities that we identified with.
54:59So yes, and I'm really glad that
55:01you asked that question because
55:03there were some considerations
55:05especially among some of the
55:07Asian patient populations about.
55:09Patients may be potentially not
55:10wanting to engage in discussions,
55:12but that their caregivers would.
55:14And so we expanded the intervention
55:17to allow for cultural humility.
55:19If that is how that is in their family,
55:23who am I to say I want to talk
55:26to the patient directly about
55:27what the patient wants?
55:28That is how and especially in my family,
55:31the same goes in my family.
55:33We want the patient to be engaged,
55:35but is that how,
55:36if that's how they've set up.
55:38And that's how they've been
55:39that is part of their culture,
55:41in the fabric of their culture.
55:42We should try to begin to tweak
55:45our interventions again,
55:46using that same concept of
55:48not going in with blinders,
55:49of thinking that this is the
55:51way this intervention should be,
55:52but rather thinking about how
55:54to codesign the discussions.
55:56Facilitators was faithbased,
55:59so in Atlantic City we found
56:01community partners that were
56:03faithbased organizations across
56:05multiple demographic groups.
56:07Who really came to charge and would
56:10talk about filling out five wishes?
56:13In their sermons on Sunday?
56:16We found Hindu priests discussing
56:18advanced care plan and we provided
56:20them with the materials and so
56:22they expanded that reach and
56:25normalized these conversations
56:26long before we had to even engage.
56:29Very good question.
56:30Did that answer some of your questions?
56:37I mean the technology,
56:39you never go by higher funding costs.
56:42Yeah. How do we change capitalistic
56:47model we see in there versus
56:49every other technology sector?
56:51Like why are they so different?
56:52Is it beer and black information?
56:54Like why are they so different and
56:55how do we kind of break the picture?
56:58Good question.
56:58So the question was why, you know,
57:00in the technology sector there's this desire.
57:03Please correct me if I'm wrong there.
57:05Essentially you can.
57:06Make products that can then lower costs.
57:08But in the healthcare sector,
57:09we're not there yet and it's all
57:11because it's misaligned incentives.
57:13If you think about the different players,
57:15we haven't come together to align.
57:17Consumers really drive change.
57:18And So what we really need to do is
57:21galvanize like we are in these communities
57:23and start thinking together and
57:25collectively about how to change that.
57:27You know, I, I hate to go there,
57:29but a universal payer system,
57:33you see how it works in the VA.
57:36And there are challenges that every
57:37study we've done in the VA and outside
57:40the VA shows that people within
57:41the VA have less disparities when
57:43they get care within the VA system.
57:45And now with the Mission Act that
57:46allows our veterans to receive care
57:48in community based facilities,
57:49we see that when they use community based
57:51facilities, their outcomes are worse.
57:55It is a way to financially
57:58incentivize and to align goals,
58:02not to be a reductionist,
58:03but that's one example.
58:07A comment and a question.
58:10So the comment is that I worry a
58:13little bit about putting patients in
58:16the middle of the cost situation,
58:19partially because the costs
58:20are in many ways artificial.
58:22And I think the real solution is of
58:25course that we should have coverage
58:27for everyone and and then we should
58:30work on figuring out the cost.
58:32The and and I fear that some people
58:34will just say that's just too much
58:36money for me and for maybe the wrong
58:40reasons choose not to get care.
58:42The question I have though is to what extent?
58:46I know in in in at least one of the
58:49studies there wasn't interaction
58:50between the Community health
58:52worker and the medical team.
58:54To what extent in other
58:56situations have you had?
58:57Contact between those two,
58:58yeah I actually that's a good question.
59:00So the question was to what degree
59:02does the Community health worker
59:04engage with the clinical teams.
59:06I think in the in the ideal scenario
59:08you want a highly functioning team
59:10where there is communication across both
59:13unfortunately and and the majority of
59:15the sites have chosen that even if they
59:17haven't chosen that initially they've
59:19come around to really engaging the
59:21community health workers part of the team.
59:23Where we've seen struggles is in
59:25that example in Atlantic City and
59:26Chicago where the oncologist really
59:28did not want to be involved at all.
59:30And so we said, Okay,
59:30we're going to do it with the payer alone
59:32and there was limited communication,
59:34but we also want to make it such
59:36that patients are activated.
59:38These interventions, the,
59:39the proactive symptom assessment,
59:40I think should be longitudinal,
59:43but the advanced care planning,
59:44you really want to give patients
59:45the tools to be their own advocate.
59:48And so in those situations and most
59:50of our studies are really just limited
59:52with that intervention you see,
59:54which I didn't show is an enduring
59:56effect of the intervention long
59:57after the intervention has ended.
59:59And so we,
01:00:00we just looked at the VA study now
01:00:0310 years later and we found actually
01:00:06really big differences at the end
01:00:08of life for the patients that died,
01:00:10perhaps indicating that the skills
01:00:12that patients were learning are
01:00:14like riding a bicycle.
01:00:15You want patients to activate for themselves.
01:00:17And so in those situations where
01:00:19we don't have the Wellfunctioning
01:00:20team in the communication,
01:00:22we have the Community health worker
01:00:24activate the patients to call
01:00:26their clinician and make sure that
01:00:28these symptoms are addressed.
01:00:30So they say,
01:00:30I'm going to get off the phone with you,
01:00:32you're going to call your clinician
01:00:33going to hang up.
01:00:34I'm going to call you again in
01:00:35an hour and see if you did it.
01:00:37And so it helps the patient to then
01:00:39begin there to be their own voice.
01:00:41So that they're not reliant on someone
01:00:43else mediating that relationship.
01:00:45And the reason that's important is
01:00:47because cancer is one part of what
01:00:49a patient may be diagnosed with.
01:00:51And so you want them to have skills
01:00:53that are going to supersede the
01:00:55small narrow piece of medical
01:00:56conditions that we all are are
01:00:58seeing at the surface and treating.