Matt Manning, MD, FASTRO, Chief of Oncology, Cone Health
Healthcare is increasingly delivered in an outpatient setting. This shifts responsibility to the patient for the logistics of care superimposed on complex medical and social determinants creating potential disparities in care. Transportation represents a social determinant of health. Barriers in access to outpatient care is especially troubling in the field of radiation oncology. The protracted daily treatment schedule spread across multiple weeks represents an ambulatory medicine crucible for patients with limited transportation and social support.
A radiation treatment regimen can be relatively easy for privileged populations to complete while others find it difficult or impossible to present to the clinic on a regular basis over several weeks of treatment. Previously, interruptions in planned treatment were broadly labelled as noncompliance, connoting personal failure on the part of the patient. As we evolve into an era of population health, it is incumbent on change leaders to ensure that the responsibility for access and treatment completion is shifted from the patient to the healthcare system and to the community. This requires a deeper understanding of the complex factors contributing to the access disparity phenomenon and new solutions.
Given the difficulties associated with an extended daily treatment regimen a certain level of treatment noncompliance has been expected, and ultimately accepted. However, delays and interruptions in radiation treatment can negatively impact the ability to control disease. It was clear to our team that failure to meet the logistical burden associated with radiation treatment regimens represents an important preventable cause of disparities in oncology outcomes.
"It was clear to our team that failure to meet the logistical burden associated with radiation treatment regimens represents an important preventable cause of disparities in oncology outcomes"
High capital and operational costs restrict the geographic availability of radiotherapy to a limited number of facilities. In many communities, all patients are served by a single radiation oncology clinic. Cone Health operates one of the busiest radiation treatment facilities in the North Carolina, treating over 120 patients per day with four linear accelerators. Certified by the American College of Radiology (ACR) as a top performing radiation oncology department, the team strives to provide exceptional care to the community. However, none of the current ACR quality of care metrics track treatment compliance or disparities of care. So, wicked problems may flourish, even under the guidance of the well intentioned ACR, when a diverse community is expected to adapt to the procedures of a complex health system. The central North Carolina Triad community is economically and racially diverse with sizeable African American and Hispanic populations as well as a significant political refugee community from Southeast Asia. In order to facilitate a healthier and more equitable community Cone Health recognized that it is imperative to adapt to the unique circumstances of each patient, rather than the reverse.
In the past, we addressed patient compliance issues with a standard mixture of support and encouragement. Patients have been referred to social workers based on a screen for “distress,” the clinical gestalt of healthcare providers, or specific problems that arise during the course of therapy. Tragically, the social work support system was not afforded the resources to actually close the gaps, because of our lack of understanding the complexities of this insidious problem. Breakdowns in care result in efforts to “get back on track,” but it is impossible to nullify the impact of unexpected interruptions in care that have already occurred. Accordingly, Cone Health sought new tools to become proactive in identifying and supporting at-risk individuals prior to deviations in care. Only in this manner would we be able to ensure all members of the community benefit from the care that is available. Therefore, we explored novel intervention strategies to better serve the entire community.
Cone Health implemented a novel virtual logistics hub platform, capable of managing rideshare, taxis, wheelchair accessible vehicles, vehicles with car seats for children and stretcher vehicles. Through this commercially available tool, it is possible for patients to receive free transportation from a health system. Following acquisition of the tool, Cone architected a complex playbook for implementation. A pilot study was performed applying this model in radiation oncology to establish proof of concept and measure the financial results and patient satisfaction.
Over a four month period, patients consulted in radiation oncology who volunteered concerns about transportation were enrolled into a free rideshare program. Those who received rides for radiation treatment were included in this study. Each patient's personal historic no show rate in the health system was recorded. The anticipated financial loss per no-show radiation treatment was established based on aggregated historic data. The opportunity cost was calculated as the product of their no show rate, the cost of a no-show for radiation treatment and the number of rides for treatments. In addition, the cost of the transportation was recorded and subtracted from the opportunity cost to calculate the return on investment. The pilot experience demonstrated a 10-fold return on investment for the health system. Patients received surveys following each ride to rate their experience. 82% of patients responded to survey questions that their ride experience was above average and 92% indicated that they would not have able to attend their appointment without the ride.
Take Away Points
In summary, outpatient healthcare relies on transportation. Interruptions, cancellations and no shows can introduce delays that lead to worse clinical outcomes. In the current study, the cost of rideshare transportation was significantly less than the increased revenue. The magnitude of benefit will certainly vary by medical specialty and procedures. This limited study suggests that a proactive virtual transportation hub can help improve clinical outcomes and benefit the health system with favorable patient satisfaction. This ambulatory strategy promises to decrease access disparity in vulnerable populations. Cone Health aspires to improve the delivery of all primary and specialty ambulatory care by applying lessons from radiation oncology and scaling up the playbook and tool throughout the entire health system enterprise.