Fundamentals III: Patient Counselling and Barriers to Care  

Kristi Kay Orbaugh: All right. So gosh, we've really had some meat and potatoes, if you will, with our first 2 presentations. And what we're going to talk about now is how do we, as APPs, set up both a relational but yet therapeutic, if you will, connection with our patients to enable us to educate better, to counsel better, and to hopefully overcome barriers that we might find.  

[01:29:23] 

Pretest 4

So here is a pretest. How confident are you in your ability to identify and address socioeconomic and geographic barriers to improve therapeutic connections with patients and support their optimal health outcomes?  

All right. Across the board, it – most of you are kind of falling right, middle of the road. And – and I appreciate that. I certainly do.  

[01:30:08] 

Optimizing Education: The Patient Perspective  

All right. So I think just start. Here's our patient, right. Every single new patient we have is unique. They – they come with their own culture, their own race, their own ethnicity, their own geography, their own educational occasional history, their religion, if that's important to them and their sexual orientation.  

And all of that plays into how we're going to educate these folks. And it also plays into what education they need. So I think the biggest thing, and this is just – I realize I'm preaching to the choir. I get that I, that all our APPs on here, but we have to remember that each time we walk into that room to educate, it needs to be unique for that person, and we need to prioritize what their educational needs are. I loved what Kim said earlier, she said, we've got to see what they're ready for because maybe they're ready for, you know, a fifth-grade discussion on MAOs of ADCs and maybe they're ready for kindergarten discussion on mechanism of action for our ADCs. So we've got to feel that out.  

Also what's going on with the patient? I walked in a room the other day to do a patient teach, and the patient was writhing in pain. It – my educational priority in my educational agenda went right out the window, right? We had to get that patient's pain under control before he could hear or respond to anything. I was attempting to teach him about the drug that he was going to receive. And nothing makes me any happier, right, than to walk in a room and see a support person there.  

A support person that has a pen and paper makes me even happier, right? Because you – you really have some added confidence then that that hopefully they're taking notes and going to have this information then at home in addition to all the written information we're going to get them.  

The other thing – and Sara – Ms Sara, she really hit on this is we've got to be real honest and real transparent with what side effects to expect. I love to be Susie Sunshine and think no one's ever going to have a toxicity, and that's just unrealistic, right? So when we set that patient down, we've got to let them know, hey, these – these are the common toxicities. And here's what you need to have on hand. Here's when you need to start it. Here's when you need to call the office. Here are the numbers to call. They've got to have that plan.  

And then we have also talked about the importance of a multidisciplinary team. Don't forget we've got pharmacists on board that can be helpful if we have toxicities you know pulm toxicities, there's pulmonologists. GI toxicities. We just can't forget to call in those other specialists if – if we need to.  

The other thing – and again this goes without saying, right, people are going to look up resources. They're all going to contact Dr Google. And really if we're all honest we have all called Dr Google as well from time to time. But the important charge we have as APPs is giving patients trustworthy resources, here is a good website. here is a good, you know, support group to look at.  

And we kind of talked about that earlier when we were with Kim, and Kim was talking about educating people about the – the mechanism of actions and how ADCs really work within the body. And don't forget those really nice resources that pharmaceutical companies can have.  

[01:34:32] 

Language Barriers

Language barriers, right. Now, I will be real transparent. I'm in the Midwest and we don't always have a lot of different language barriers, but on a pre-call we were discussing the importance of making sure, you know, that you had interpreters and such, and Kim just offered such wonderful information on that. And we'll be calling on her a bit later to tell us some of her sources.  

But if you don't work at a place that has multiple interpreters, there are many – we have – we call it the little green machine. And we have – we bring it into the room, and you can actually dial up to an interpreter who's very, very helpful. You have to, you know, put in the patient's language of origin.  

But we ran into something the other day that I thought was really interesting is we put the patient's language of origin in, but that wasn't their dialect, and they couldn't even understand the interpreter because, again, it wasn't their dialect. So anything we can do to help that.  

You know, I've traveled overseas before and just think of being in a foreign country, how scary that can be. And when I was overseas, I wasn't ill, I wasn't in a hospital, I wasn't seeking health care.  

So anything we can do to help with literacy issues or language issues, having materials written in the patient's primary language. And there's many online sites that will help with that. But we really need to be charged with that.  

[01:36:24] 

Shared Decision-making  

Shared decision-making. Now, I know you all know what – what this is and – and how important it is. I'll just give you an example of a patient that we just had recently that really took the oncologist, the APP, the patient, the support person, and the pharmacist to really work through this.  

This patient is a nationally renowned course surgeon. Now, remember, I'm in the Midwest, so that's a really big deal. Okay. That's like – it's a big deal that he's a horse surgeon. And he has a malignancy that would typically be treated with a regimen that would cause a lot of peripheral neuropathy.  

Now that's a big deal to a surgeon, right? They can't be dropping, you know, instruments in – in their patient. And he was very, very articulate in letting us know that part of his quality of life involved allowing him to continue to be able to be a surgeon. And so that really helped guide where we went with his – with his treatment. It was really important in the collaboration.  

And there's – there's many other ways that we can think about shared decision-making in terms of goals and – and lifestyles. But I thought my patient that I had a month or so ago really – really helped drive that point home.  

[01:38:08] 

Navigating the Healthcare Ecosystem: Addressing Potential Healthcare Disparities 

And then when we think about how we're going to navigate this healthcare system and address potential healthcare disparities, I think it's important to remember that evidence clearly links that provider and patient communication is really, really important in patient satisfaction, patient adherence and healthcare outcomes.  

So remembering that just communicating, just educating having that therapeutic but relational connection can really alter how a patient stays on – on therapy or how – how their outcomes are.  

[01:39:03] 

Barriers to Adherence: Patient Factors  

Thinking about more patient-centered factors. And I'll go through these really quickly. Look, I promise we're going to stay on time. But as a patient comes in, think about their health literacy. Do they have social support? What's their cultural bias? Do they have a history of noncompliance? Do they have a history of mental illness? Do they have reliable housing? All of those things are important. We have a patient right now that's – that's basically homeless. And our social team is working very closely with her.  

And, you know, where does she house her medicines. And these types of things are very, very important.  

[01:39:47] 

Barriers to Adherence: Treatment-Related Factors  

The other thing is think about transportation to the clinic. It doesn't matter what a wonderful regimen that we have developed for them, if they can't get themselves to the clinic, that's – that's a difficult problem.  

And then looking at patients in the treatment-related factors, right? So, if we all pulled ourselves things that I might think were truly unacceptable in terms of toxicity, maybe Kim would think that's not such a big deal. And maybe Sarah would think that would bother me a little, but not a lot.  

So I think we have to just remember that what is very bothersome or really alters one person's quality of life doesn't necessarily alter another. I think we've all probably had that patient come into clinic and, you know, just say, I can't take X medicine anymore. It totally alters my quality of life. I've just got no quality of life left. And they list what's bothering them. And in your mind you're thinking, hmm, that doesn't sound like it's altering a quality of life to me, but yet that's the patient's definition of quality of life.  

And we need to remember that. The other thing is making sure patients understand the importance of their treatment. If they understand the importance of it, that might give them motivation to stay on. Whoops, a little too fast there.  

[01:41:26] 

Barriers to Adherence: System Factors  

Making sure – transportation we already covered. Employment issues. You know, what does that look like for the patient? Do they have time-off? Do they need FMLA? All of those types of things are very, very important. Do they feel understood by their – their provider?  

[01:41:50] 

Barriers to Adherence: Financial Factors

And then these financial issues. I have really found at our particular clinic, we have a team that works very closely with patients that have financial issues that I find helpful.  

We also are blessed that we have navigators for every single disease state. So frequently, our nurse navigators will hear about the financial issues, sometimes before the – the – the provider does. So that's really important that we work together with that.  

[01:42:30] 

Barriers to Appropriate Treatment  

And then I had to throw these in because when we pull people across the – the nation, we have data that shows that not all patients are being biomarker tested. Not all patients are undergoing genetic testing. All of those things fall into precision medicine. If those patients aren't allowed to have biomarker testing or undergo genetic testing, next-generation sequencing, etc, that really can limit their treatment options.  

It can really alter their treatment journey, as a matter of fact. And that's a barrier. That's a huge barrier to what I like to call appropriate treatment.  

The other thing is, we know that many minorities are not well represented in clinical trials. And where you work, do you have a – do you have clinical trials? Do you have the opportunity to use that as a treatment option for – for patients? And what's the provider's comfort level in treating patients that have this long list of comorbidities as well as, you know, their oncology diagnosis. So all of those are really important.  

[01:44:07] 

Health Disparities

Health disparities. I know you are all up to date and know this definition, but I just love it. Health disparities, differences in health outcomes that are closely linked with social, economic and the environmental disadvantage are often driven by social condition in which the individuals live, learn, work and play. And we have to keep that in mind.  

[01:44:39] 

Overcoming Health Disparities

So ways that we can overcome healthcare disparities. And these are just a few. This is certainly not all inclusive by any means, but think about telehealth. We do a lot of video visits in our clinic. Actually, we started doing them. We were just kicking them off in January of 2020. Now think about that.  

So we – thank goodness we were kind of kicking that off and prior to Covid because then we had to really, really use those. But that's also a really good way for patients to have the opportunity to see other disciplines. For example, if they don't have a pulmonologist in their area or they don't have a neurologist in the area, you can do virtual consultations. Don't forget about those patient assistance programs and referral to any low-cost resources.  

I'm sure each and every one of you work with social workers. I tell you, I think they find resources that you just don't ever even think about or – or don't even – aren't even aware of. So don't forget utilizing those folks in our healthcare team and using them to help support the patient as well.  

I know at our clinic we have an entire team. I think it's 2 or 3 folks that all they work on – not all they work on, but they just do patient assistance programs and finding people help with those kinds of things, grants, all of that type of thing.  

[01:46:30] 

Patient Communication Recommendations  

And then, Sara really covered this. So for time we won't cover it, but just remembering when we have a patient on an ADC and we know the – the tough toxicities or the most common toxicities, making sure that we're covering these and that patients are prepared for them. That needs to be an ongoing process.  

Kim really hit it on the head. When we think about not only readiness, but when patients come in, they – they are going to be educated the first time. But the education happens time and time and time again. So reinforcing of that education.  

[01:47:24] 

Posttest 4 

All right. So after that I know that was kind of speed talking, but I want to keep – I want to keep on time. I don't want to keep anyone over this evening. So how confident are you in your ability to identify and address socioeconomic and geographic barriers to improve therapeutic connections with patients and support their optimal health outcomes? So we'll have you vote on this again.  

Okay. We have a few more people that moved over to the confident and a few more people that moved over to modestly. So that's – that's good to – that's good to know.  

[01:48:23] 

Poll 9

All right. Now, how often do you see health disparities in your clinical practice? I'm anxious to see the answer to this because, when Sara and Kim and I met and we went over this, each one of us had a different answer. Okay, so just a few rarely. Most of you see – say sometimes, and others of you say frequently.  

[01:49:09] 

Skill Building and Feedback III: AE Mitigation and Overcoming Obstacles in Adherence

Okay, so let's pull my friends in here. I'm going to phone a friend, Kim and Sara, and we're going to talk about, my patient Lucy. Now she's 58, and unfortunately, she has recurrent metastatic breast cancer. She's getting ready to start treatment with an ADC. English is not her primary language. And transportation to clinic is very, very difficult for her.  

When Lucy's APP initially meets with her, she seems hesitant and somewhat dis – distressed -distrusting, excuse me, of the healthcare system. Now I'm just going to throw it out to Kim and Sara. I'm not going to go down each individual point. How – how would you handle Lucy? What are some of the first steps you'd take with Lucy?  

Kimberly Podsada: Well, if – if – actually, I'd – I'd like to answer a question in the Q&A, if I may, or start that discussion, because that may even be a part of – of what you're talking about. So we've been asked which team members complete FMLA, disability, etc., paperwork, APPs or other team members?  

So I – so for patients that need disability, I do request that they go online and fill out the EDD paperwork that's online. And as far as FMLA goes, we have LVNs and social workers and nurses that that team tends to fill out the – the paperwork. If it's for a family member, then we ask them to at least write on a separate sheet of paper what they're looking for, the days they want off, the – the hours they want off, and for – and for what reason.  

So when people come in with blank sheets, it's like, no, you got to help me out here. What are you – what are you looking for?  

Sara Cooper: I definitely support that a fair amount with my patients because I'm in community practice, so I don't have as much of a support staff. So I think it's always a team effort. And sometimes when you have a larger practice, you get a little more support. I want to go to Kristi’s patient here. Because I've worked both in academic practice where I've had been in a major metropolitan area with a lot of health disparities, and now I work in a community practice where I do see fewer health disparities. So there's obviously varying things.  

And Lucy is a patient that I've had often in my past, especially working in the Los Angeles metropolitan area, where there's a lot of Spanish speaking patients. And I think it's common to gain trust or to need to gain your trust, really being in your patient's language. So it is so important to use appropriate interpreter services. You know, we have staff members that speak Spanish. We have family members that speak Spanish. But it's really important to practice, you know, very trusting medicine by using the people who can explain it properly and making sure they're getting the clear information directly to the patient.  

Because sometimes you worry that the family member may not communicate everything or they don't understand what they're communicating. So that's one of the ways that I have built trust with patients in the past who particularly do not speak English.  

Kristi Kay Orbaugh: That's –

Kimberly Podsada: We fortunately - I had a new consult today, and her language was Creole. And so luckily I was able to – for their – for patients with their first new consult appointment, we are allowed to get an in-person interpreter. So for subsequent visits we'll be using, you know, the Marty machine or the language line on the phone. But that is always really helpful for our first visit, where I'm reviewing a lot of complicated information about their diagnosis and what treatments I'm recommending.  

So to have someone in person, again, that that triangle of they're speaking on my behalf, and I'm hearing from the patient with someone that just speaks their language is – is a huge key, I feel for even what our institution is saying about how – what the kind of care we want to give her.  

Sara Cooper: And having patient materials in their language, it's hard in community medicine. We don't always have access to that. But when we do have access to it, it is obviously very helpful. As Kristi said, it's hard to be in a foreign country already and not be sick and imagine being somewhere and being sick. So really just trying to be there for them, utilizing your support system, social work, sometimes they can also have really good resources for patients as well.  

Kimberly Podsada: And don't forget to send in your comments or any questions, some of the barriers that you experience in your clinic and how you overcome them.  

Kristi Kay Orbaugh: And we've just got a few minutes left. And I want to make sure that we're being very respectful of everyone's time and that we log off at – at the correct time.  

Sara Cooper: There was a question that someone asked earlier about using ChatGPT for patient education. I have not embraced that yet. I'm looking forward to learning more about it, and I think that can really apply in our issue with language barrier is can ChatGPT can be – can it be helpful for language barriers, maybe in the community where interpreter services aren't as readily available, you know, like where Kim has for the initial consult. Can ChatGPT maybe listen in on the consult and then resummarize, you know, these consults and patient education in the patient's language? I would love to see that be something that develops in the future.