APOS PSYCHOSOCIAL
POCKET GUIDE

Patient Risk Factors

·       More likely to not have completed education, have active student loans

·       More likely to have jobs based on hourly wages and less likely to have adequate insurance coverage or paid sick leave

·       Less likely to have significant savings

·       Dependence on parental caregivers

·       More likely to have lower healthy literacy

·       More likely to have difficulty with transportation and lodging

·       Less likely to have adequate insurance coverage or paid sick leave

·       Less likely to able to participate in clinical trials

·       More likely to be living paycheck to paycheck (limited savings or financial cushion for time away from work)

·       More likely to be paying OOP for visits, treatment, and supportive medications

·       Limited access to specialty cancer care or supportive services

·       Limited ability to get medications

·       Less likely to have adequate insurance coverage (due to high-cost COBRA plans, or limited coverage via short-term, limited-duration insurance)

·       More likely to be dependent on charity care and financial support

·       Limited income from disability or unemployment benefits

·       More likely to be denied insurance secondary to structural racism

·       More likely face work related barriers (no sick time, limited work allowances)

·       More likely to have transportation barriers

·       Less likely to have access to cancer screening and thus present at more advanced stages requiring more intense treatment

·       Increased barriers to care include increased transportation and lodging costs

·       Limited access to specialty cancer care, supportive services; more difficulties coordinating care

Disease Risk Factors

·       Cancer types which require multimodality treatment, i.e. surgery, chemotherapy, and radiation

·       Cancer or cancer treatment which causes significant symptom burden which requires time off work and a caregiver

·       Cancer treatments which require prolonged hospitalizations i.e. induction chemotherapy and transplant

·       Advanced disease requiring intense treatment and potentially durable side effects causing debility

·       Metastatic disease which may require life-long treatment

·       Skipping or delaying treatment

·       Unfilled prescriptions

·       Rationing medication

·       Declined recommended supportive services

·       Delayed or missed appointments

·       Avoidance of recommended procedure/tests

·       Suboptimal treatment leading to treatment gaps, disease recurrence/progression, death

·       Higher physical symptom burden, decreased quality of life

·       Lower quality survivorship care, decreased recovery and poorer long term functioning

·       Decrease in recreational activities

·       Decrease spending on food and other essentials

·       Decreased quality of life

·       Decreased nutrition, increased food insecurity

·       Decreased in overall wellness of the patient and family/caregivers

·       Dropping out of school/training

·       Early return to work (including during active treatment)

·       Early retirement

·       Decrease to part time work/decreased responsibilities

·       Decreased earning potential and/or limited career growth

·       Decreased ability to recover from treatment if returning too soon, increased exposure to pathogens, delayed recovery

·       Possible loss of employee-based insurance coverage

·       Loss of income/decreased financial stability

·       Advocate for alternative payment models that incorporate both quality care delivery metrics and patient affordability concerns

·       Increased price transparency

·       Formal training of financial navigators

·       Patient training for communicating with insurance companies

·       Patient paperwork assistance

·       Partnering with community resources to address social influencers of health, support groups, financial tools

·       Parking vouchers for patients

·       Offer telehealth and bundled appointments to limit time away from work and need for childcare

·       Improve facilities to allow for work conducive areas (Wi-Fi in waiting areas and infusion centers; quiet rooms)

·       Expand hours of care

·       Offer on-site childcare services

·       Expand food, transportation, lodging services

·       Decrease low value care via national guidelines like Choosing Wisely⁶

·       Train care team members to collaborate with financial navigators and utilize lower cost sites of care and/or lower OOP cost services; promote conversations about expected and potential unexpected costs

·       Catalogue and distribute financial support resources

·       Encourage visit companions (engage family/friends)

·       Provide accessible personnel to answer questions

·       Create survivorship plans that acknowledge financial concerns

·       Financial harm screening (via validated COST score or single question screening), reassess along cancer treatment path given cumulative burdens

·       Support shared-decision making for financial friction point decisions

·       Discuss financial cost-benefit of medications and potential alternatives with a focus on patient priorities via shared-decision making

·       Provide reassurance that care teams and the health system will remain present for patient even in difficult times (e.g. loss of job, loss of insurance) and connect patients to appropriate resources

·       Provide information on alternative pharmacy cost containment mechanisms (GoodRx, Cost Plus Drugs)

·       Start pharmacy assistance for expensive medications at the time of prescription

·       Alert cancer team to prescribe less costly alternatives via EMR programs sharing patient-specific formulary and out of pocket cost estimates

·       Provide estimates of medication regimen over time for chronic conditions