Referral Toolkit Implementation to Improve Access to Care for Rural Oncology Patients

Oncology patients residing in rural locations face considerable disparities in healthcare access due to geographical distance and scarcity of specialized oncology providers. These disparities result in delayed care, missed appointments, and poorer outcomes compared to patients residing in urban areas. Preventable hospitalizations are considerably higher in rural settings, and emergency department (ED) utilization has increased significantly over the past several years. Local Problem: A regional cancer care center (RCC) operates an oncology hospital at home program as part of its mission to extend specialized care to rural areas. The oncology hospital at home rural program (HHR) operates within rural communities to address oncology patients' access to care and symptom management. The HHR has successfully managed high-risk oncology patients at home. This project aims to increase referrals to HHR to improve access to care for rural oncology patients. Methods: We created a referral toolkit that includes pre and postimplementation questionnaires, chart reviews, reports and a QR code. We employed a pre-implementation questionnaire (PREIQ) to assess RCC oncology staff's awareness and perception of HHR. We developed tailored educational presentations to four RCC outpatient clinics discussing the HHR program, benefits, services, area eligibility, and success managing high-risk oncology patients at home. Then, we conducted a 100-day retrospective chart review to establish a baseline for comparison of referral rates from RCC outpatient oncology clinics. We compared the pre-implementation referral data collected to the post-implementation referral data. We analyzed feasibility, usability, and satisfaction with a post-implementation questionnaire (POSTIQ) completed by outpatient oncology staff. Interventions: We dispensed informational cards with a quick response (QR) code linked to the HHR website to seven clinics and asked staff to disperse to patients in counties covered by the program. We developed an eligible outpatient report (EOR) identifying patients in the HHR service area with upcoming clinic appointments. We performed chart reviews using the EOR and emailed providers about patients who may benefit from services or had symptom burden. Results: Forty-one clinical staff responded to the PREIQ. Nearly half n=18 (44%) reported being unfamiliar with HHR, n=27 (66%) had not previously referred to HHR and access to care n=15 (37%) was reported as the primary concern about patients between visits. Nineteen clinical staff responded to the POSTIQ. Post-intervention, 90% (n=17) of respondents reported being very likely or likely to refer to HHR. The respondents reported that 90% (n=17) agreed the presentation showed HHR's ability to improve access to care for rural oncology patients. Referral rates increased from 11% (n=5) 100 days before implementation to 31% (n=12) 100 days following implementation. Four of the 12 referrals resulted from the EOR, and eight were spontaneously placed. All respondents (n=19) were satisfied with the presentation's content, and 90% (n=17) reported the presentation applied to their concerns about rural oncology patients. Conclusion: The increase in referrals to HHR in response to the toolkit has shown that it has value to both patients and providers. The outcomes support further studies such as an electronic health record (EHR) flag or algorithm to identify eligible patients. Access to specialized, high- quality care in rural localities will mitigate preventable hospitalizations and ED visits, reduce financial toxicities, and improve overall health outcomes for rural oncology patients.