Assessment of Early, Standardized Palliative Care Referrals in Patients with Metastatic Gastrointestinal Cancer: A Quality Improvement Initiative

Patients with advanced cancer often present with high symptom burden and decreased quality of life. Metastatic gastrointestinal cancers can be especially debilitating with 5-year relative survival rates ranging from 2%-15%. Early involvement of palliative care has shown to improve symptom management, quality of life, and quality of care in patients with advanced cancer. Criteria-based, or systematic palliative care referrals have emerged as a strategy to promote early involvement of palliative care in patients with advanced cancer but have not yet seen widespread uptake by the larger oncology community. The implementation site was a gastrointestinal oncology clinic within a nationally-recognized cancer hospital and research center in the urban Salt Lake region, which includes in-house palliative care specialty services. First, patients with gastrointestinal cancer who might benefit from systematic palliative care referrals were identified. New patient intake algorithms were then modified to include an automatic palliative care referral according to developed inclusion and exclusion criteria. Education was provided to the clinic staff regarding the intervention prior to the implementation date. Following a ten-week trial period, staff completed a post-intervention survey to assess feasibility, usability, and satisfaction of the early, systematic palliative care referrals. Palliative care referrals increased from 19% (3/16) in the pre-intervention group to 62% (8/13) in the post-intervention group (p < .05). Clinic staff feedback was positive, with 92% of survey participants who checked "agree" or "strongly agree" that early palliative care intervention benefits patients, families, and caregivers. All survey participants (n=12) answered "yes" to the continuation of the intervention in the gastrointestinal oncology clinic. The implementation and evaluation of early, systematic palliative care referrals in patients with metastatic gastrointestinal cancers successfully increased referrals to palliative care and proved to be usable, feasible, and sustainable within the clinic. Further study is needed to directly measure patient outcomes and address identified barriers to early palliative care intervention.

1 Assessment of Early, Standardized Palliative Care Referrals in Patients with Metastatic Gastrointestinal Cancer: A Quality Improvement Initiative Valkyria R. Bayer & Julie Gee College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III April 3, 2022 2 Abstract Background: Patients with advanced cancer often present with high symptom burden and decreased quality of life. Metastatic gastrointestinal cancers can be especially debilitating with 5-year relative survival rates ranging from 2%-15%. Early involvement of palliative care has shown to improve symptom management, quality of life, and quality of care in patients with advanced cancer. Criteria-based, or systematic palliative care referrals have emerged as a strategy to promote early involvement of palliative care in patients with advanced cancer but have not yet seen widespread uptake by the larger oncology community. Methods: The implementation site was a gastrointestinal oncology clinic within a nationally-recognized cancer hospital and research center in the urban Salt Lake region, which includes in-house palliative care specialty services. First, patients with gastrointestinal cancer who might benefit from systematic palliative care referrals were identified. New patient intake algorithms were then modified to include an automatic palliative care referral according to developed inclusion and exclusion criteria. Education was provided to the clinic staff regarding the intervention prior to the implementation date. Following a ten-week trial period, staff completed a post-intervention survey to assess feasibility, usability, and satisfaction of the early, systematic palliative care referrals. Results: Palliative care referrals increased from 19% (3/16) in the pre-intervention group to 62% (8/13) in the post-intervention group (p < .05). Clinic staff feedback was positive, with 92% of survey participants who checked “agree” or “strongly agree” that early palliative care intervention benefits patients, families, and caregivers. All survey participants (n=12) answered “yes” to the continuation of the intervention in the gastrointestinal oncology clinic. Conclusions: The implementation and evaluation of early, systematic palliative care referrals in patients with metastatic gastrointestinal cancers successfully increased referrals to palliative care and proved to be usable, feasible, and sustainable within the clinic. Further study is needed to directly measure patient outcomes and address identified barriers to early palliative care intervention. 3 Assessment of Early, Standardized Palliative Care Referrals in Patients with Metastatic Gastrointestinal Cancer: A Quality Improvement Initiative Problem Description Cancer affects all Americans, either directly or indirectly, with more than 15.5 million people in the United States living with active or historical cancer (American Cancer Society [ACS], 2019). While many advances have been made in cancer treatment, cancer remains the second highest cause of death in the United States with a death toll of just under 600,000 Americans per year (Kochanek et al., 2020). Though prognosis varies greatly with type and stage of cancer, the diagnosis often carries significant side effects, either due to the disease itself or the treatment regimen. Patients with metastatic or advanced stages of cancer have a significant physical and emotional symptom burden which leads to a decreased quality of life (Bauman & Temel, 2014; Greer et al., 2013). At the time of diagnosis these patients are often experiencing fatigue, pain, weakness, loss of appetite, anxiety, and depression (Greer et al., 2013). Metastatic gastrointestinal cancers can be especially debilitating, with 5-year relative survival rates ranging from 2%-15% (ACS, 2019). Palliative care, or medical care that focuses on symptom management and quality of life, has emerged within the oncology sphere as a helpful adjunct to the standard treatment approach (National Institute on Aging, 2021). Early integration of palliative care in tandem with disease-directed treatment is known to improve symptom management, quality of life, and quality of care in patients with cancer (Mohammed et al., 2020). Despite the known benefits and an endorsement from the American Society of Clinical Oncology (ASCO), there has yet to be widespread uptake of early palliative care involvement for patients with advanced cancer. Current barriers include misperceptions of palliative care services along with a lack of systematic palliative care referrals (Maltoni et al., 2016). Both providers and patients alike have a limited understanding of palliative care with up to 70% of Americans describing themselves as “not at all knowledgeable” about palliative care, and many providers equate palliative care with end-oflife care (Parikh et al., 2013, p. 2347). In addition to misperceptions, most oncology practices refer patients to palliative care on a “per diem” basis versus a systematic approach. Some palliative care 4 programs have created standardized referral criteria to combat late referrals. These standardized referral criteria have led to early identification of patients who would benefit from a palliative care consultation (Heitner et al., 2021). In a patient population such as metastatic gastrointestinal cancers, the lack of standardized, criteria-based referrals results in delayed palliative care involvement in patients whom the intervention would benefit. Available Knowledge Due to the morbidity and mortality associated with cancer, the integration of palliative care within oncology has been an area of interest among researchers over the past 20 years. Though the positive impact of palliative care has been established, the optimal patient population, timing of the intervention, and referral process was and continues to be explored. Researchers have focused on numerous patient populations within oncology, but most commonly advanced disease states and cancers with limited life expectancy (Greer et al., 2012; Schenker et al., 2017). The culmination of this research led the ASCO to recommend early palliative care in addition to usual oncology care for all patients with advanced cancer (Ferrell et al., 2017). The authors defined advanced cancer as patients with distant metastases, late-stage disease, cancer that is life-limiting, and/or a prognosis of 6-24 months. In addition to the ASCO guidelines, Huan et al. (2017) conducted a Cochrane review that focused on adults with advanced cancer and concluded that early palliative care can improve quality of life and decrease symptom intensity. The benefit of early involvement of palliative care compared to involvement just prior to the endof-life has been established through several randomized-controlled trials. Bakitas et al. (2015) demonstrated significantly improved survival in patients with early versus delayed palliative care. Quality of life and symptom impact were also improved in the early palliative care group, but the results were not statistically significant. Zimmerman et al. (2014) explored the effect of early palliative care on four aspects: quality of life, symptom severity, satisfaction with care, and problems with medical interactions. Zimmerman and colleagues found significant differences favoring the early palliative care group in all measures with the exception of problems with medical interactions. 5 In specifically examining a systematic approach compared to a per diem approach, Maltoni et al. (2016) sought to establish the optimal way to activate early palliative care in oncology. The research team randomized patients with advanced pancreatic cancer to either standard care plus on-demand palliative care or standard care plus systematic palliative care. The patients in the systematic palliative care group met with a palliative care specialist within two weeks of enrollment as opposed to the patients in the control arm who only met with the palliative care team if they, their families, or the treating oncologist requested a palliative care consultation. Maltoni et al. (2016) found that there was no difference in survival for the patient groups, but significant improvements in quality of life for the patients in the systematic referral arm. The study supports, at least in advanced pancreatic cancer, the idea of a systematic approach to palliative care intervention. An additional perspective brought forth by Heitner et al. (2021) explored the use of referral criteria in palliative care programs and the advantages and disadvantages of their use. Heitner and colleagues found that the referral criteria were most commonly implemented as a result of late palliative care referrals. Overall, the referral criteria led to positive outcomes, but two identified disadvantages were increased staff workload and inappropriate referrals. The research conducted to date highlights an opportunity to improve patient quality of life through the creation of a standardized, criteria-based system to refer patients to palliative care services. Rationale The initiation of systematic palliative care referrals in patients with metastatic gastrointestinal cancer will be guided by the Ottawa Model of Research Use (OMRU). Logan and Graham (2010) developed a framework that facilitates transferring research into practice through assessing barriers and support, monitoring the process and degree of use, and evaluating the impact of the intervention. The model is dynamic, acknowledging that quality improvement is an interactive, synergistic process. As a systematic approach to palliative care will involve coordination between specialty groups, the assessment of barriers and facilitators from all stakeholders is key to ensuring sustainability of the intervention. The OMRU model also emphasizes outcomes on a patient, practitioner, and systems level (Logan & Graham, 6 2010). Specifically, the project utilizes the six steps of the model through first identifying the existing resources available and the key stakeholders that will be responsible for implementing the change. The intervention will then be specified and communicated to all involved parties through various forms of educational activities, including group presentation, email, and individual discussion. Barriers and facilitators to the intervention will be addressed through close collaboration with the stakeholders including an assessment of attitudes, perceptions, and knowledge of the clinicians. The adoption of the intervention will be monitored through assessment of the change in referral frequency. Lastly, though this project does not have the scope to directly measure patient outcomes, practitioner feedback on the feasibility, useability, and satisfaction of the intervention will be measured. This will in turn inform systems level outcomes. Specific Aims The purpose of this Doctor of Nursing (DNP) quality improvement project is to implement early, systematic palliative care referrals in patients with metastatic gastrointestinal cancer, as part of a larger aim to improve quality of life in patients with advanced cancer. Following implementation of the modified referral process, the intervention will be evaluated for feasibility, useability, and satisfaction by the providers and nurses involved. The purpose of this report is to synthesize and disseminate the findings of this quality improvement project so health care professionals can learn from the information and modify internal processes as appropriate. Methods Context The setting of this quality improvement project was a gastrointestinal oncology clinic within a nationally-recognized cancer hospital and research center in the urban Salt Lake region. The clinic serves patients with active and historical gastrointestinal cancers from Utah and the surrounding mountain west region. Clinic staff consists of thirteen medical and surgical oncologists (MDs), six advance practice clinicians (APCs), twelve registered nurses (RNs), and nine medical assistants (MAs). The number of patients seen weekly ranges from approximately 200 to 300 patients. This project focused on the medical 7 oncology group, as they follow the patients with metastatic cancer. The medical oncology clinic staff was composed of six MDs, four APCs, thirteen RNs, and four MAs. Also integral to this project was the inhouse, multidisciplinary specialty palliative care team, which includes social workers, medical oncologists, APCs, wellness experts, and survivorship specialists. Intervention(s) The intervention began with identification of patients that would benefit most from systematic palliative care referrals within the gastrointestinal oncology clinic. This was completed by analysis of patient factors, including onset of cancer, type of cancer, staging of cancer, and associated life expectancy and symptom burden. Once the target patient population of newly-diagnosed metastatic gastrointestinal cancers was identified, the new patient intake algorithms (see Appendix A) were modified to include systematic palliative care referrals according to pre-established inclusion and exclusion criteria. Inclusion criteria consisted of biopsy-confirmed gastrointestinal cancer (esophageal, gastric, colon, rectal, pancreatic, and cholangiocarcinoma) with evidence of metastatic disease. Exclusion criteria consisted of the patient seeking a second opinion, the patient seeking participation in a clinical trial, the patient declining the referral, the patient already following with a pain/symptom management specialist, the lack of metastatic disease, the lack of completed staging, and a neuroendocrine pathology of the gastrointestinal cancer (see Appendix B). Prior to implementation of the modified algorithms, the clinic staff was educated regarding the process change. The project lead and educator was a DNP student. The RNs and MAs attended a staff meeting that included education on the evidence base, rationale, and referral criteria for the standardized palliative care referrals via PowerPoint (PPT) presentation (see Appendix C). Following the presentation, the RNs and MAs were sent a survey via REDCap to evaluate the clarity of the presentation, attitudes towards the intervention, and anticipated barriers (see Appendix D for survey). The providers were notified of the referral criteria via email, with the PPT attached for additional information (see Appendix E for provider email). The providers submitted an attestation that they received the email and understand the modified process. 8 The baseline data collection began ten weeks prior to implementation of the modified algorithms, tracking appointment date, patient demographics, cancer type, treating oncologist, palliative care referral placement, and completion status of palliative care referral. The post-intervention tracking occurred for ten weeks following implementation, tracking the same variables. At the end of the 10-week trial period, a post-survey was sent via REDCap to the clinic providers, RNs, and MAs to evaluate the feasibility, usability, and satisfaction of the criteria-based, systematic referral process (See Appendix F). Study of the Intervention(s) The impact of the intervention was assessed weekly and at two key timepoints: just prior to the implementation of the modified algorithms and following the 10-week trial period. A survey was sent out to the clinic RNs and MAs after the presentation and prior to the implementation date to assess attitudes, perceptions, and knowledge of the intervention. A post-survey was sent to the clinic providers, RNs, and MAs following the 10-week trial period to assess feasibility, usability, and satisfaction of the intervention. Data collection of process outcomes occurred weekly starting at the baseline period of ten weeks through the implementation phase of ten weeks, for a total data collection period of 20 weeks. As there was no former process in place to initiate palliative care referrals and there were no simultaneous efforts to increase palliative care referrals, it can be reasonably assumed that any changes in the number and timing of referrals were due to the intervention. Measures Survey development included the creation of a post-presentation attitudes survey and a postintervention survey to evaluate the feasibility, usability, and satisfaction of the intervention. The postpresentation survey (see Appendix D) consisted of four questions to gather demographic data, five questions on a Likert scale to evaluate understanding and perceptions of the intervention, one select-allthat-apply question on potential barriers, and one open-ended comment box for any suggestions or comments. The Likert scale consisted of five points ranging from “strongly disagree” to “strongly agree”. The survey was distributed via email using REDCap. The post-intervention survey (see Appendix F) focused on the feasibility, usability, and satisfaction of the intervention and was also distributed via email 9 using REDCap. The survey consisted of six questions to gather demographic data and five questions to evaluate the feasibility, usability, and satisfaction of the intervention. Of the five questions that evaluated the intervention, one question was on a five-point Likert scale (as above) and two questions had an openended component to explore barriers to the interventions and suggestions for improvement. Data collection consisted of weekly, manual EHR checks conducted by the project lead on gastrointestinal oncology new patient visits measuring process outcomes. The new patients were filtered by the pre-established inclusion and exclusion criteria (see Appendix B), then demographic variables of age, sex, treating oncologist, and cancer type were collected, along with process outcomes of palliative care referral status and completion status of initial palliative care appointment. Referral tracking was assisted by the use of a keyword “gipall” in the comments section of the systematic palliative care referrals. The completeness and accuracy of the data were ensured by attention to detail and a final review of the weekly data prior to analysis. The completeness of the surveys was ensured by requiring an answer for all questions before submission, with the exception of a comment box for additional feedback. Analysis The demographic data and process outcome variables were described using appropriate summary statistics for central tendency and variability. A chi square test was utilized to analyze the pre and post intervention data for statistical significance. The survey data were analyzed using a content analysis for open-ended survey questions. For the content analysis, the words were read word for word and categorized, organized, and summarized. Ethical Considerations This project was quality improvement in nature and was not subject to Internal Review Board oversight at the University of Utah. There are no conflicts of interest to disclose. Results Over the course of the intervention, palliative care referrals for patients who met criteria increased from 19% (3/16) in the pre-intervention group to 62% (8/13) in the post-intervention group (p < .05). Clinic staff feedback was positive overall, with 92% of survey participants who checked “agree” or 10 “strongly agree” that early palliative care intervention benefits patients, families, and caregivers. All survey participants (n=12) answered “yes” to the continuation of the intervention in the gastrointestinal oncology clinic. Tables 1 and 2 show patient and clinic staff demographics, respectively. The timeline of this quality improvement project consisted of three phases: phase I involved 10 weeks of pre-intervention data collection, phase II involved staff education and subsequent implementation of the intervention, and phase III involved 10 weeks of post-intervention data collection and distribution of the post-intervention survey (Figure 1). Within phase I, 16 patients met the established criteria for a systematic palliative care referral (Table 1). Of those 16 patients, three had a palliative care referral placed by the end of the clinic day. Of the three patients with referrals placed, only one patient completed the palliative care appointment- one patient refused the referral and one patient went on hospice. In phase II, clinic staff were educated through an in-person presentation (RNs and MAs) and through email (MDs and APCs). Due to the COVID pandemic, in-person attendance at the staff meeting was lower than expected and those who did not attend could not view the associated PowerPoint in realtime. There was a 50% (8/16) return rate of post-presentation surveys, and 100% (8/8) of participants checked “agree” or strongly agree” that the presentation was informative, that they understood the patient requirements for a systematic referral, that they felt confident explaining the intervention, and that they believed the intervention would benefit patients, families, and caregivers. Following the education via email for providers, 60% (6/10) of providers attested that they read and understood the criteria and modified process for palliative care referrals. Once staff education was complete, the new patient coordinators were instructed to begin implementing the modified patient intake algorithms which included criteria-based, systematic palliative care referrals. Phase III data collection began one week following implementation of the modified algorithms, due to a lag time of approximately one week in appointment scheduling for new patient visits. Postintervention patient data was then collected for 10 weeks, and demonstrated 13 patients that met criteria for a systematic palliative care referral (Table 1). Of the 13 patients, eight patients had a palliative care 11 referral placed by the end of the day. Of the eight patients with referrals placed, seven patients completed the palliative care appointment since one patient refused the referral. Patient volumes for the post intervention period were lower than expected, possibly due to major holidays (Thanksgiving, Christmas, New Year’s) falling within the time frame. Following the 10-week intervention period, the post-intervention survey (see Appendix F) was distributed to the clinic staff. From a total of 27 potential respondents, 12 clinic staff responded (Table 2). There was a provider return rate of 50% (5/10), a RN return rate of 46% (6/13), and a MA return rate of 25% (1/4). The post-intervention survey revealed that 92% (11/12) of clinic staff checked either “agree” or “strongly agree” that the intervention was beneficial for patients, families, and caregivers. One respondent selected “neither agree nor disagree” due to not having any patients during the intervention period that qualified for the systematic palliative care referral. The participants identified barriers to the intervention (Table 3), which, from most common to least common, included a patient lack of understanding of palliative care (4/12), too many appointments (4/12), and patient financial concerns (3/12). Four of 12 respondents (25%) did not believe there were any barriers, and no respondents (0/12) identified “inappropriate referrals” as a barrier. Four respondents (25%) marked “other” barriers, and, in an open-ended response, described a delay in the scheduling of palliative care appointments due to staff workload, as well as the palliative care team only addressing pain management versus discussing goals of care. One respondent identified the referral criteria itself as a barrier, indicating that second and third opinions should be able to participate since the patients typically end up actively following with a clinic oncologist. Apart from the one participant that would like second and third opinions to be able to participate, 92% of clinic staff (11/12) indicated that they would not make any changes to the referral criteria. Clinic staff were satisfied with the intervention, as 100% (12/12) of participants responded “yes” to the continuation the criteria-based, systematic palliative care referrals within the gastrointestinal oncology clinic. Through an open-ended email query to the new patient coordinators, who are responsible for following the algorithms and placing the referrals, 100% (4/4) revealed that the referral process is “sustainable on our end” and “we don’t have any suggestions”. Additional open-ended comments on the 12 post-intervention survey included that patients “absolutely benefit” from the palliative care intervention and that it should become “standard of care” for the patients. One suggestion was to “add more histologies”. Of note, though there was a statistically significant increase in referral rates from the preintervention period to the post-intervention period, the referrals were not always placed as a result of the modified algorithms. For three of the eight patients with positive palliative care referrals placed during the intervention period, the referral was placed by the provider as it was missed by the new patient coordinators. Of the five patients that met criteria from whom the referral was missed, one had a diagnosis of peri-ampullary cancer, which was not specifically designated in the inclusion criteria. The other four patients had no explainable factors as to why the referral was not placed. Discussion Summary The results demonstrated a significant increase in early palliative care referrals in the target patient population as well as clinic staff feedback that supported the feasibility, usability, and satisfaction of the modified referral process. Notably, all survey respondents indicated that they would favor continuation of the criteria-based referrals. Barriers to early palliative care were identified, with the most common barriers being a patient lack of understanding of palliative care, too many appointments, financial concerns, and delays due to palliative care staff workload. The identified barriers were in line with barriers previously described in the literature (Heitner et al., 2021), with the exception of inappropriate referrals- all survey participants felt the referral criteria resulted in appropriate referrals. Per the OMRU framework, the quality improvement process is dynamic and ongoing. There is a need for continued monitoring of the referral process and referral criteria with modifications as necessary to fit patient and provider needs. Interpretation The established inclusion and exclusion criteria provided a framework for the early palliative care referrals. The criteria were in-line with the literature surrounding palliative care referrals for patients with 13 advanced cancer, as they focused on patients with limited life expectancy and distant metastasis (Ferrell et al., 2017). Thus, the creation of the referral criteria and the coordination of a sustainable referral process resulted in both increased referrals and a process that can continue seamlessly without the involvement of the project lead. The project provided evidence that criteria-based palliative care referrals, when crafted with patient and site-specific factors in mind, can benefit both the patient and the oncology clinic staff. Though the project did not have the scope to directly measure patient outcomes, clinic staff believed that the intervention did benefit patients, family members, and caregivers. Although the total observed number of patients was relatively low, due to the nature of the referral process many parties were involved in the intervention: the oncology team, the oncology new patient coordinators, the palliative care team, and the palliative care new patient coordinator. On a systems level, the post-intervention survey identified a potentially higher workload for the palliative care team and new patient coordinator, leading to a delay in appointments for new patients. The observed outcomes were essentially congruent with the anticipated outcomes, though a number of referrals were missed for patients who did meet palliative care referral criteria. One reason referrals may have been missed is that the criteria did not specify guidelines for rare gastrointestinal cancers, such as peri-ampullary adenocarcinoma. The most plausible factor for additional missed referrals is human error in the context of increased workload. Cost was not directly addressed in this project, but arguments could be made for both cost-savings and increased costs. Through increased referrals, healthcare consumption is higher overall leading to increased costs to the payor. Alternatively, patients who are ensuring their care is aligned with their wishes may opt to discontinue expensive life-prolonging treatments earlier than those without palliative care involvement. Further attention to cost could be explored in more depth on subsequent studies. Limitations The project has a number of limitations. First, this quality improvement initiative was conducted at a single gastrointestinal oncology clinic in Salt Lake City, Utah. Though patient demographics were consistent with the Mountain West region, it is possible that the results may not be generalizable to other 14 geographic regions. Additionally, the project was conducted at a comprehensive cancer center with an inhouse palliative care team, where patients could see both their oncologist and palliative care specialist in the same building. Other cancer centers with less resources may not have that luxury, leading to greater appointment fatigue. Another limitation was the small sample size of both the patient group and the clinic staff group. With an overall survey return rate of 44%, the opinions of more than half of the clinic staff are unknown. Internal validity could have been compromised through human error during the manual chart review of the patient data, although a thorough double-check was performed for each week to minimize any error. Conclusions The implementation and evaluation of early, systematic palliative care referrals in patients with metastatic gastrointestinal cancers successfully increased referrals to palliative care and proved to be usable, feasible, and sustainable within the clinic. The clinic staff asserted that early palliative care involvement benefits the patients, their families, and their caregivers. All staff support the continuation of the modified referral process. Though the idea was piloted in a gastrointestinal oncology clinic, a criteriabased palliative care referral could certainly benefit patients in other specialized oncology clinics within the same institution or spread on a larger scale to other health care organizations. Overall, the project supports the practice of early, criteria-based referrals to palliative care in patients with advanced gastrointestinal cancer. Areas of further investigation include the evaluation of non-gastrointestinal cancers and when to initiate palliative care involvement, as well as a focus on patient outcomes and perception of palliative care. 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Doi: 10.1016/S0140-6736(13)62416-2 19 Tables and Figures Table 1 Patient Demographics Pre-Intervention Characteristic N=16 n Age in years Range 30-74 Mean(SD) 52.5(13.78) Gender Male 10 Female 6 Cancer Type Colorectal 8 Pancreatic 3 Cholangiocarcinoma 1 Esophageal/Gastric 1 Other 3 Note: SD = Standard Deviation % Post-Intervention N=13 n % 46-86 63.4(13.41) 62.5% 37.5% 7 6 53.8% 46.2% 50% 18.8% 6.3% 6.3% 18.8% 7 3 0 1 2 53.8% 23.1% 0.0% 7.7% 15.4% 20 Table 2 Clinic Staff Demographics Characteristic Role MD APC RN MA Age in years 18-29 years 30-39 years 40-49 years Race Caucasian African American Gender Male Female Oncology Experience in years 0-1 years 2-5 years 6-10 years 11+ years N % 2 3 6 1 16.7% 25% 50% 8.3% 4 5 3 33.3% 41.7% 25% 11 1 91.7% 8.3% 2 10 16.7% 83.3% 3 6 0 3 25% 50% 25% 21 Table 3 Barriers to Early Palliative Care Intervention Barrier N % Patient lack of understanding of palliative care Financial concerns Too many appointments Inappropriate referrals Other (see comments) Comments 4 33.3% 3 4 0 4 25% 33.3% 33.3% “Unfortunately my team did not have any pts appropriate for study, due to nature of second and third opinions” “Not ever getting scheduled with SOS or only meeting with the pain team who do not address goals of care” “Delays in appointments” “Difficult getting SOS appts due to them being so very busy” 22 Figure 1 Project Timeline Phase I •10-week preintervention data collection Phase II •Staff education •Implementation of intervention Phase III •10-week postintervention data collection •Post-survey distribution 23 Figure 2 Pre and Post Intervention Palliative Care Referrals and Completion Status Palliative Care Referrals and Completion Status: Pre and Post Intervention 70 60 50 40 30 20 10 0 Pre-intervention % Referred Post-intervention % Completed Referral 24 Appendix A Modified New Patient Intake Algorithms 25 26 27 Appendix B Inclusion and Exclusion Criteria Inclusion criteria (just follow algorithms):   Age > 18 years Gastrointestinal cancer, biopsy-confirmed with evidence of metastatic disease o Esophageal adeno or SCC o Gastric, GEJ adenocarcinoma o Colon adenocarcinoma o Rectal adenocarcinoma o Pancreatic adenocarcinoma o Cholangiocarcinoma Exclusion criteria:       2nd opinion Trial consideration Not metastatic or full staging not yet available NETs Patient declines referral after explanation of risk and benefits Duplicate: patient is already established with a pain/symptom management specialist 28 Appendix C Staff PowerPoint Presentation 29 30 Appendix D Post-Presentation Survey 31 32 Appendix E Provider Notification Email SYSTEMATIC PALLIATIVE C ARE REFERRALS FOR METASTATIC GI C ANCERS Starting November 1st, 2021 through January 7, 2022, Clinic 2B will be piloting a standardized SOS referral process for patients with metastatic gastrointestinal cancer. WHICH PATIENTS ARE ELIGIBLE? HOW DOES IT WORK? • New patients with biopsy-confirmed gastrointestinal cancer with evidence of metastatic disease • GI new patient coordinators place SOS referral at the time they schedule the NPV • Exclusion criteria: • SOS new patient coordinator schedules SOS appointment for symptom management/goals of care after the initial GI medical or surgical oncology appointment • 2nd opinion • trial consideration as primary reason for referral • Full staging not yet available at time of NPV • NETs • Patient declines referral • Duplicate- patient already established with a pain/palliative specialist • Clinic RNs counsel patient on purpose and benefits of SOS appointment • A survey will be sent out in mid-January following the trial period to evaluate the feasibility, usability, and sustainability of the intervention Questions? Please reach out to [e-mail] 33 Appendix F Post-Intervention Survey 34