Multilevel Interventions in Health Care Conference: Presentation by Jane Zapka, ScD
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Multilevel Interventions in Health Care Conference: Presentation by Jane Zapka, ScD

So we are going to move now down the line to Jane Zapka.
Jane has been working with us at the National Cancer
Institute for awhile. She has a long history of
working in community and cancer control activities. She is
a professor at the Medical University of South Carolina
and she is a long-time friend, a long-time collaborator and
I am honored to have her here with us and
working with us today.>>>[APPLAUSE]>>>DR. JANE ZAPKA: Good
morning. I wanted to first acknowledge my co-authors on
the manuscript that will be coming out in the
supplement — Doctors Taplin, Ganz, Grunfeld and Sterba. As
Dr. Taplin has illustrated, the cancer care continuum
represents several types of care, each with multiple
technical steps and interfaces requiring communication. In
our manuscript, we use two case scenarios to illustrate
the variability, diversity and interaction of factors for
multi-levels that impact quality of care. These scenarios
included a review of the literature about factors which
could affect various processes and interfaces of care. It was
hoped that the manuscript which would present cases
which put a human face on some of the concepts that
we are talking about. The next step was that we then
used hypothetical examples and we illustrate intervention
strategies at different levels which are hypothesized
to produce complimentary synergistic effects
to improve outcomes. Case 1, screening
in the elderly, was the screening on
the continuum of care. Ms. Smith, 66
years old, a widow, worked for 40 years
in an assembly line. She is using her free time
now to pursue an active social life, and visiting her
daughters. She did not often see physicians because of
limited insurance, and she is generally healthy. She
has not been screened for colorectal cancer or breast
cancer, and has not been screened for cervical
cancer in 25 years. With a respect to the levels
of potential intervention, there are numerous options.
Our paper has a table which illustrates examples from the
literature at each of the levels for each of the cases.
And that table has been included in your handouts
there. We did a review of the literature as we looked at
these issues to illustrate what has been done in a
variety of studies. So, very briefly here, state
health policy may be one way to look at special program
for education, for access. Organizations – are there
community outreach projects that could help with education?
Can the organization promote an outreach reminder system so
that if a patient comes in with a different issue, that
screening can be brought up and highlighted as well. In terms of
provider team interventions, are there certain incentives
which might make a difference? And clearly at the individual
level, health and functional status require patient-centered
approaches, including those which impact knowledge
and attitudes. Ms. Smith’s screening and her
lifestyle may require such an integrated approach. Our second
case illustrated another type of care along the continuum,
cancer treatment, but highlighted that interface
and step from treatment to transition to survivorship. Zoe
is 42 years old, diagnosed with breast cancer on first screening
mammogram 18 months ago, stage II with axillary node
involvement. Surgery, radiation and chemo. Numerous symptoms
persist – fatigue, weight gain, pervasive anxiety. She wants to
return to work, but is having difficulty because of the
symptoms. She senses her family feels she should get on with
her life. She has not seen her primary care physician
since diagnosis. Again, there are several potential
levels for intervention. State policy, for instance, has
a role in insurance mandates and what types of
care may be mandated. Healthcare organizations can
look at the quality of their electronic medical record
and how might that be used to improve communication
between the patient, but also communication
between providers. And does a community cancer
center, for instance, institute a care plan standard of behavior
that they expect their providers and team to carry
out? In other words, is the provider team functioning
then and do they use a good electronic medical record
system. In terms of transitions and treatment and survivorship,
family understanding and communication
is very important. What intervention strategies
might work there to improve knowledge, attitudes
and their own skills? Moving along to the
hypothesized examples for strategies, at the end of the
oval broadly defined is the need to improve patient
centered and appropriate, timely screening. The red
rectangles illustrate potential targets of the intervention
and intervention strategies. So for instance, in the upper
box aimed at the provider team, could a guideline education
and detailing strategy improve behavior to reach
the long-term outcome? Additionally, can patient
education such as mass media, lay educators be put in place?
Here you are targeting the community-level knowledge
outside of the practice system. These two interventions
could improve provider team knowledge, skill and motivation
and also patient knowledge, beliefs and motivation so
that they would then have a productive provider
team patient interaction. The upper right hand box,
however, highlights that an organizational strategy
instituting in their electronic system a health maintenance
template to cue the physician to bring up
prevention issues could actually escalate the impact
of the first two strategies. And thus, you have three
strategies which are designed to improve the
mediator measures, which get you to your outcome.
In terms of the survivorship example, here’s a hypothetical
case of a community cancer center trying to
improve survivorship. The long term oval, again,
being coordinated survivorship care which ultimately
improves health outcome, as well as quality of life.
Backing up to the left part of the diagram, an intervention
targeted at policy, for instance, accreditation
agencies are recommending summaries and
survivorship plans. At the organizational level,
leadership might decide to have designated staff assignments as
nurse and physician champions, as well as appointing a
patient navigator and educator, as well as the usual provider
individual orientation. This would promote a
hospital team readiness. Interestingly, and this is
happening in some of the NCCCP projects, where a community
cancer centers institute a community-focused effort
to involve primary care partnerships. This then coupled
with the patient education and post treatment session, as well
as follow-up telephone call access, will
promote knowledgeable, empowered and
self-efficacious patients. Again, these are two
hypothetical examples based on some of the evidence that we saw
in single targeted subjects. So we hope you will consider
the process of identifying the potential multi-level
determinants of care quality. Do we have models to guide the
prioritization of strategies at various levels to produce
specified outcomes in need of improvement? What problems
within each type of care or interface of care should
be research priorities given the data we have in this
country? Thank you.>>>[APPLAUSE]

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