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Off the Frontier: How the American Society of Clinical Oncology (ASCO)/Conquer Cancer®, The ASCO Foundation is Improving Access to High-Quality Cancer Care Close to Home
September 19, 2023
Image courtesy of kmaassrock
Imagine you were recently diagnosed with stage II colon cancer. You have your first appointment in the morning with an oncologist scheduled in Bozeman, about a two-hour drive from your home in Dillon, Montana. You wake up to find eight fresh inches of snow and the roads impassable.
This is a familiar scenario for many residents living in frontier and rural areas in Montana – the focus population for the American Society of Clinical Oncology (ASCO)/Conquer Cancer®, The ASCO Foundation. As one of eight grantees selected through the Alliance for Equity in Cancer Care (Alliance) to advance health equity and access to cancer care for underserved patients, ASCO is addressing geographic barriers for populations living in remote areas of Montana.
Qualifying as ‘frontier’
Frontier regions are defined by three primary variables: population density, travel time and distance to service or market centers. According to the National Center for Frontier Communities, population density of frontier areas is between 12 and 20 persons per square mile, while distance or travel time to a service center/market is 30 to 90 miles, or 30 to 90 minutes, respectively.
Montana is considered the third-most frontier state in the U.S. based on this definition, with an estimated 75% of residents living in rural or frontier-classified areas. Forty-five percent of residents reside outside of incorporated towns. In addition, there are less than 50 practicing oncologists in the state, serving a population of approximately 1.2 million individuals. With little to no governmental functions for populations living in such remote areas, many social drivers of health affecting patient outcomes are amplified.
For the nearly 6,000 Montanans diagnosed with cancer each year, this presents even greater challenges. It also presents struggles for the few oncologists and primary care physicians providing care and services.
With the help of the Alliance, ASCO took this as a charge and is putting in place methods to help address these statistics.
Marg Hammersla PhD, ANP-BC discusses the barriers to cancer care in rural/frontier areas and how ASCO offers a model to address them, which could be applicable regardless of geographic location.
Identifying unique barriers to cancer care
Racial and ethnic minorities, populations living in rural areas, low-income individuals or those without insurance are often disproportionately affected by cancer and with limited access to cancer screenings, care and treatment.
Other social and economic factors – known collectively as social determinants or drivers of health – also influence timely access to high-quality cancer care, which in turn can significantly affect patient outcomes. These may include economic stability, neighborhood and physical environment, education level, food security and access to resources.
Coupled with extreme weather and impassable roads, these factors can be detrimental to patients seeking screening services or actively pursuing cancer treatment in Montana. It may deter patients from seeking treatment at all. It may also impact the already sparse providers’ ability to reach health care facilities or attend critical meetings regarding patient treatment plans. While telemedicine services can help bridge the gap in some situations, limited access to and/or use of these resources is also common.
Those living in frontier or rural settings also experience an increased financial burden. The average salary in rural areas such as Dillon and Beaverhead County is between $20,000 and $40,000, which is considerably less than the national average. This disparity adds to the financial implications associated with traveling long distances to access specialty care, including lodging costs and loss of income.
Through capacity and relationship building, ASCO is collaborating with Bozeman Health Deaconess Hospital Cancer Center, Barrett Hospital & HealthCare in Dillon and the Montana State University Mark and Robyn Jones College of Nursing to establish a hub-and-spoke care model, where partnering sites serve as the primary point of contact for residents across Montana and are trained in cancer care delivery for rural settings. Leveraging ASCO’s quality infrastructure, the team is working to ensure that the cancer services received in Dillon are equally high-quality as in Bozeman.
Delivering high-quality cancer care closer to home
A recent study utilizing data from the Montana Tumor Registry found a disparity in access to care for residents living 60 miles outside of a county with a Commission on Cancer (CoC) site. Residents in counties without a CoC site are less likely to receive treatment following a cancer diagnosis and are more likely to leave the state for such treatment. Bozeman Health Deaconess Hospital is a CoC facility and the primary ‘hub’ for the Alliance grantee. Bozeman is approximately 115 miles southwest from Dillion.
Through the Alliance, an infusion suite will be established at Barrett Hospital & HealthCare – a spoke site in Dillon – to provide chemotherapy and treatment closer to home without compromising quality or safety. The infusion suite will offer an alternative care site where patients can receive infusion therapy of specialty drugs in a safe, monitored environment. Given Dillion’s proximity to several major highways, this may increase accessibility for patients.
ASCO informally surveyed eleven primary care providers to determine their comfort with the proposed model in which patients would receive an initial diagnosis and treatment plan from an oncologist at a regional center and follow-up care and chemotherapy administration at a local setting, such as Barrett Hospital & HealthCare. More than 90% of primary care providers surveyed felt offering chemotherapy services in Dillon would be beneficial to their patients but that quality and safety were paramount. The hope is that with less travel time to and from Bozeman to receive such treatment that patients can maintain a more regimented treatment schedule.
Building capacity while ensuring scalability and sustainability
With expanded services comes the need for increased staffing and capacity building. Health care reform over the past two decades has seen a shift in delivery of outpatient oncology care to nurse-led clinics. A vital component of this initiative is the training of nurses to manage and deliver care in the infusion suite, particularly in rural settings. To do so, ASCO will draw on its library of evidence-based guidelines and educational resources, including the ASCO-Oncology Nursing Society Chemotherapy Safety Standards. The purpose is to provide training tools and resources that build technical skills and expertise needed for nurses to staff the new infusion suite.
At the health system level, policy changes are underway to ensure the model is both scalable and sustainable. The focus is currently on compliance with ASCO’s Quality Oncology Practice Initiative (QOPI) Certification Standards, which will inform a quality improvement plan for Bozeman Health to move toward QOPI Certification. The team is identifying baseline quality metrics, areas for improvement and providing strategic information about quality considerations during this implementation phase. A primary need identified is the standardization for infusion patient workflow including pre-visit laboratory work, provider visits and scheduling.
While efforts are underway, putting the model into action has not come without its challenges. The team has identified barriers beyond that of winter weather and poor travel conditions. Behind the scenes, the team is partnering with each hub-and-spoke facility which operates on different electronic medical record (EMR) systems to align key patient reporting and care documentation.
Other challenges include recruitment to and overextension of the clinical workforce in Dillon, as rural areas often have difficulty attracting and retaining cancer care specialists. Ongoing involvement of the Mark & Robyn Jones College of Nursing at Montana State University may offer a pipeline to recruit from and expand clinical capacity in Dillon as well as potential future spoke sites.
As ASCO/Conquer Cancer®, The ASCO Foundation enters year two of the Alliance initiative, continued collaboration with key participants and partners will be critical to find sustainable solutions. A continued focus is on communication strategies between care providers and patients, a key goal of the Alliance.
The team also hopes to use these lessons learned as a means to inform new policies and guidelines. ASCO has been a national leader in oncology education, policy and advancement for nearly 60 years. Together with the Alliance, the team hopes to use this model as a blueprint for use by other health care systems to improve cancer care access globally.
Written by: Jennifer Drummond