Frances Feltner

Patient navigation for breast and colorectal cancer in 3 community hospital settings

The Ralph Lauren Cancer Center implemented patient navigation programs in sites across the United States building on the model pioneered by Harold P. Freeman, MD. Patient navigation targets medically underserved with the objective of reducing the time interval between an abnormal cancer finding, diagnostic resolution, and treatment initiation. In this study, the authors assessed the incremental cost effectiveness of adding patient navigation to standard cancer care in 3 community hospitals in the United States.

Effectiveness of Community Health Workers in Providing Outreach and Education for Colorectal Cancer Screening in Appalachian Kentucky

The purpose of this study was to examine the effectiveness of a community health worker (CHW)–delivered cancer education program designed to increase knowledge and awareness of colorectal cancer screening options. The study population was an extremely vulnerable and medically underserved geographic region in Appalachian Kentucky. CHWs enrolled participants in face-to-face visits, obtained informed consent, and administered a baseline assessment of knowledge of colorectal cancer risks and the benefits of screening and screening history. An educational intervention was then provided and participants were re-contacted 6 months later when a posttest was administered. The mean score of the 637 participants increased from 4.27 at baseline to 4.57 at follow-up (p < .001). Participants who reported asking their health care provider about colorectal cancer screening increased from 27.6% at baseline to 34.1% at follow-up (p = .013). Results suggest that CHWs were very effective at maintaining the study population; no loss to follow-up occurred. The results also showed increased knowledge and awareness about colorectal cancer screening education. Implications for social work practice, policy and research are discussed.

Care Coordination for Community Transitions for Individuals Post-stroke Returning to Low-Resource Rural Communities

High rates of hospital readmissions have been shown within 12 months post-discharge from inpatient rehabilitation following stroke. Multiple studies coupled with our previous work indicate a need for care support for stroke survivors’ transitions to the community. The Kentucky Care Coordination for Community Transitions (KC3T) program was developed to provide access to medical, social, and environmental services to support community transitions for individuals with neurological conditions and their caregivers living in Kentucky. This program assessment was conducted to determine the effectiveness of using a specially trained community health worker to support community transitions. Thirty acute stroke survivors were enrolled in this program between July 2015 and May 2016. Data collection included: incidence of comorbidities; access to healthcare, insurance, medical equipment (DME), and medications; type of follow-up education provided; and number of 30-day rehospitalizations and Emergency Department (ED) visits. Participants required navigation in their home and community transition with support in: patient-provider communication; insurance support; accessing follow-up care; education on managing chronic health conditions, the stroke process, transfers and mobility; and accessing DME and essential medications. There were no 30-day ED visits for the KC3T participants and only one 30-day hospital readmission, which was not stroke-related. Individuals returning to rural communities following a stroke require, but often don’t receive, follow-up education on chronic disease management, support in navigating the healthcare system and accessing essential resources. KC3T’s navigator program appears to be effective in supporting the community transitions of individuals poststroke.

Terminate lung cancer (TLC) study—A mixed-methods population approach to increase lung cancer screening awareness and low-dose computed tomography in Eastern Kentucky

For low dose CT lung cancer screening to be effective in curbing disease mortality, efforts are needed to overcome barriers to awareness and facilitate uptake of the current evidence-based screening guidelines. A sequential mixed-methods approach was employed to design a screening campaign utilizing messages developed from community focus groups, followed by implementation of the outreach campaign intervention in two high-risk Kentucky regions. This study reports on rates of awareness and screening in intervention regions, as compared to a control region.

Mental Health Treatment Seeking Patterns and Preferences of Appalachian Women With Depression.

This qualitative study explored social-cultural factors that shape treatment seeking behaviors among depressed rural, low-income women in Appalachia—a region with high rates of depression and a shortage of mental health services. Recent research shows that increasingly rural women are receiving some form of treatment and identifying their symptoms as depression. Using purposive sampling, investigators recruited 28 depressed low-income women living in Appalachian Kentucky and conducted semistructured interviews on participants’ perceptions of depression and treatment seeking. Even in this sample of women with diverse treatment behaviors (half reported current treatment), participants expressed ambivalence about treatment and its potential to promote recovery. Participants stressed that poor treatment quality—not merely access—limited their engagement in treatment and at times reinforced their depression. While women acknowledged the stigma of depression, they indicated that their resistance to seek help for their depression was influenced by the expectation of women’s self-reliance in the rural setting and the gendered taboo against negative thinking. Ambivalence and stigma led women to try to cope independently, resulting in further isolation. This study’s findings reiterate the need for improved quality and increased availability of depression treatment in rural areas. In addition, culturally appropriate depression interventions must acknowledge rural cultural values of self-reliance and barriers to obtaining social support that lead many women to endure depression in isolation.

What Role Can Community Health Workers Play in Connecting Rural Women with Depression to the “De Facto” Mental Health Care System?

The prevalence of depression among rural women is nearly twice the national average, yet limited mental health services and extensive social barriers restrict access to needed treatment. We conducted key informant interviews with community health workers (CHWs) and diverse health care professionals who provide care to Appalachian women with depression to better understand the potential roles that CHWs may play to improve women’s treatment engagement. In the gap created by service disparities and social barriers, CHWs can offer a substantial contribution through improving recognition of depression; deepening rural women’s engagement within existing services; and offering sustained, culturally appropriate support.

Community health workers improving diabetes outcomes in a rural Appalachian population

ABSTRACT Community health workers (CHWs) play a key role in the emerging health infrastructure. They are successful in identifying individual or family needs and matching resources to help overcome the social determinants of health, and the lack of trust in the health care system. This study captures the CHW experience as research assistants and evaluates the effectiveness of CHWs’ health coaching and support in improving diabetes health outcomes. By being immersed in the culture and values of the population, CHWs offer research support to assure more representative client samples, increased adherence to study protocols, and in reducing attrition rates.

Effectiveness of an Intervention for Adherence to Follow-up Recommendations for Abnormal Pap Tests in Appalachian Kentucky

OBJECTIVE In collaboration with rural county health departments (CHDs), we developed a patient navigation intervention to increase adherence to follow-up recommendations for women with abnormal Pap tests. METHODS Local women were recruited, trained and placed in CHDs. Navigation was tailored to the follow-up care recommended. Effectiveness was evaluated in a quasi-experimental trial that included 13 intervention CHDs and 13 comparison group CHDs. Participants were enrolled from September 2008 through July 2010. RESULTS A total of 478 participants were enrolled. The proportion that received recommended follow-up care was greater in the intervention CHDs (91.6%) than in the comparison group CHDs (80.8%) (p = .01). CONCLUSIONS These results suggest that development of policy to promote navigation with rural health care delivery systems has great potential to improve patient outcomes.

Reducing 30-day readmission rates in a high-risk population using a lay-health worker model in Appalachia Kentucky

This exploratory study aimed to address the effectiveness of a lay-health worker (LHW) model in addressing social needs and readmissions of high-risk patients admitted in a rural community hospital. A quasi-experimental study design assessed implementation of a LHW model for assisting high-risk patients with their post-discharge social needs. Outcome measures included 30-day hospital readmissions rates during a 4-month baseline period compared with a 6-month post-implementation period. The LHW intervention involved assessment and development of a personalized social needs plan for enrolled patients (e.g. transportation and community resource identification), with post-discharge follow-up calls. There was a 47.7% relative reduction of 30-day hospital readmissions rates between baseline and intervention phases of the study. Simple regression analyses demonstrated a 56% decrease in odds (90% confidence interval 0.20-0.98) in being readmitted within 30-days among those in the intervention phase compared with those in the baseline phase. Once adjusting for education, transportation cost and anxiety symptoms, there was a 77% decrease in odds among those exposed to the LHW program. LHWs offer an effective hospital-based model to improve transitions in care from the hospital setting, especially those at high-risk with persistent social needs.

Abstract B14: Effectiveness of patient navigation for follow-up for abnormal pap tests in Appalachian Kentucky

Introduction. Residents of Appalachian Kentucky experiences significant cancer disparities. The population is characterized, in general, as largely rural with high poverty rates, high unemployment and limited access to health care. Lung and colorectal cancer incidence and mortality rates in this area are among the highest in the nation and although cervical cancer mortality has decreased over recent decades, data from the Surveillance, Epidemiology, and End Results (SEER) program reveals that mortality rates in Kentucky are substantially higher than the national average. In 2003, when this project began, the US cervical cancer mortality rate was 2.7 per 100,000 (95% confidence interval = 2.6-2.7). During the same period, the rate in Kentucky was 3.2 per 100,000 (2.9-3.6). In the 54 Appalachian counties in the state, the rate was even higher, 3.7 per 100,000 (3.5-4.0). Death from cervical cancer is preventable in nearly all cases with screening by the Pap test and adherence with recommendations to obtain follow-up care when abnormalities are detected. Methods. To address the problem of elevated cervical cancer incidence and mortality experienced by rural Appalachian women, a patient navigation intervention program was developed with the goal of increasing adherence with recommendations for follow-up for women with abnormal Pap test results. The intervention was implemented in partnership with county health departments. Intervention effectiveness was evaluated in a quasi-experimental trial that included intervention county health departments (n=13) that provided patient navigation services and a comparison group of county health departments (n=13) that provided usual care. Women with abnormal Pap test results were enrolled in the intervention group county health departments and patient navigation was tailored to the type of follow-up care recommended. Study outcome data were collected from medical records. Participants were enrolled from September 2008 through July 2010. A total of 774 medical record reviews are included in the analysis (230 women in intervention and 544 women in comparison county health departments). Recommendations for follow-up, which were based on the type of abnormality and the age of the patient, included returning to the health department to obtain a repeat Pap test or making an appointment with a community gynecologist under contract with the health department. Key Findings. The proportion of participants that received their recommended follow-up care was greater in the intervention group (91.6%) than in the comparison group (80.8%) (p=.01). The effect of the patient navigation intervention was strongest among women who received follow-up care from the health department as opposed to community gynecologists under contract with the health departments. Conclusions. The results demonstrate the effectiveness of the patient navigation intervention and also provide evidence suggesting that development of policy to promote integration of navigation with rural health care delivery systems has great potential to improve patient outcomes. Citation Format: Mark Dignan, Brent Shelton, Nancy E. Schoenberg, Carol R. White, Stacey A. Slone, Emily Van Meter, Frances J. Feltner, Gretchen Ely, Christopher DeSimone. Effectiveness of patient navigation for follow-up for abnormal pap tests in Appalachian Kentucky. [abstract]. In: Proceedings of the Thirteenth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2014 Sep 27-Oct 1; New Orleans, LA. Philadelphia (PA): AACR; Can Prev Res 2015;8(10 Suppl): Abstract nr B14.