| Sumario: | Significance & Background: Health equity in cancer care depends on addressing social determinants of health (SDOH), which influence outcomes more than genetics or healthcare access. National priorities such as Healthy People 2030 and ASCO's Certified Patient-Centered Cancer Care Standards emphasize connecting patients to resources tailored to their needs. SDOH vulnerability is acute in Harris County, Texas (ATSDR Social Vulnerability Index, Vizient Vulnerability Index, Area Deprivation Index). Nurses are positioned to recognize SDOH barriers, but competing priorities often prevent effective, culturally appropriate intervention. This gap underscores the need for innovative, scalable models that support nurses, leverage technology, address SDOH and improve patient outcomes. Purpose: To evaluate how integrating certified Community Health Workers (CHWs) into an oncology care team in collaboration with nurses, supported by a technology platform, can address SDOH and improve treatment adherence for vulnerable patients. Interventions: An ASCO-certified, independent, ambulatory oncology practice in Houston, TX developed a unified care model, enabled through a workflow and analytics technology platform. CHWs screen patients for SDOH and connect them to critical resources. As CHWs gain insight into patients' situations, they uncover clinical concerns, which are addressed with nurses to keep treatment on track. The platform facilitates care coordination and interdisciplinary communication. Results: The CHW-nurse partnership removed barriers, enabling patients to continue timely, dignified treatment. In each instance, technology simplified SDOH tracking and care coordination. Case 1: A patient facing a bedbug infestation risked treatment delays. Nurses flagged the issue, and the CHW secured free extermination. Treatment continued safely without stigma. Case 2: A patient with thyroid cancer and limited English proficiency missed appointments due to language barriers. Nurses and the CHW ensured clear communication and follow-up, enabling successful treatment navigation. Case 3: A patient with bone metastases required dental work before therapy. The CHW arranged a pro bono dentist; nursing coordinated care, allowing timely treatment. Discussion: Integrated, patient-centered care approaches enabled by technology reduce inequities and improve outcomes. This model addresses gaps in traditional care where nurses alone lack bandwidth to address SDOH. The approach is scalable to vulnerable regions. Future work should quantify outcomes such as treatment adherence, patient satisfaction, and cost-effectiveness to support broader implementation. The practice is part of a study sponsored by a life sciences company and evaluated by a prominent academic institution measuring such impact.
|
|---|