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Telemedicine has the potential to improve access to cancer care, particularly for patients with functional limitations, high symptom burdens, or financial or geographic constraints. However, there is also a risk that telemedicine can widen healthcare disparities among patients facing systemic disadvantages like those with technological barriers, poor digital literacy, older age, or non-English language preferences. To optimize telemedicine usage, we must implement practical strategies like video onboarding programs, user-friendly technology platforms, optimizing the clinicians environment, and best practices for using interpreters. Policy changes such as state licensing requirements, controlled substance prescribing requirements, and payment parity are also crucial. This Perspective highlights these practical strategies and policy recommendations to ensure accessible and equitable cancer care augmented by telemedicine.

The Latinx population faced higher rates of infection and severe illness during the COVID-19 pandemic, resulting in an increased need for palliative care services. We describe the creation and impact of a formal palliative care initiative developed for seriously ill, Spanish-speaking patients during the COVID-19 pandemic at a tertiary care academic medical center. Patients were enrolled in the Spanish Palliative Care Initiative during a two-month period starting in April 2020. Selected patients were longitudinally followed by a rotating team of Spanish-speaking palliative care clinicians. Following the intervention, a retrospective chart review was conducted to evaluate the impact of the program. We enrolled 22 patients. The most frequent palliative care task completed during the initial visit was information giving (77%) and during follow-up visits were goals of care discussion (59%) and coping support (59%). Fifteen patients (68%) had a change in code status and 4 patients (18%) were discharged to hospice. The creation of a focused clinical program targeting a historically marginalized population offered opportunity for early palliative care intervention in clinical care for Spanish-speaking patients. This underscores the need for Spanish-language concordant palliative care to improve serious illness care, and end-of-life care, by providing continuity of care, spiritual care, and ICU team support. [ABSTRACT FROM AUTHOR]

1. Describe barriers to advance care planning in a nationally representative sample of older adults with serious illness. 2. Understand worries people have in the setting of current or future serious illness, and place these in the context of how advance care planning must change to adequately address people's concerns. In a nationally representative sample of adults (20% of whom had serious illness), only 55% had discussed advance care planning (ACP) with loved ones, 22% discussed with clinicians, 31% documented ACP in writing. Yet, participants were very worried about not getting the best care because of their race/ethnicity, age, income, or disability. ACP must grow to adequately address people's concerns. Engagement in advance care planning (ACP) is low and poorly understood among people with serious illness. Assess associations between serious illness and three ACP outcomes: discussion with loved ones, discussion with clinicians, and documentation. We administered a survey 4-5/2021 in English/Spanish and online/telephone to a nationally representative sample of adults. Primary predictor was having a serious illness (yes/no). Self-reported covariables were age, gender, race/ethnicity, income, metropolitan area, US region, marital status, importance of faith/spirituality, and self-efficacy. We also assessed barriers to documenting ACP and worries in the setting of current or future serious illness. Among 1,854 participants, 20% had serious illness. 66% had engaged in some form of ACP (76.5% among those with serious illness vs 62.6% without; P< 0.001); 55% discussed with loved ones, 22% discussed with clinicians, 31% documented. People with serious illness had higher odds than those without of discussing ACP with loved ones (aOR 1.57 [95% CI 1.19-2.07]) and with clinicians (2.16 [1.63-2.88]). There were no differences by serious illness in documenting ACP. Barriers to documenting ACP were: not having thought about it (43%), feeling their loved ones would know what they want (32%), having too many other things to worry about (31%). In the setting of current or future serious illness, 37% of participants were very worried about not getting the best care because of their race/ethnicity, age, income, or disability and 32% about their loved ones not making the best/right decisions. In a nationally representative sample of adults, we found that ACP engagement is low, even among people with serious illness and particularly in terms of discussions with clinicians and documentation. Our novel findings understanding how people's worries about serious illness care may impact their engagement in ACP highlight areas in which ACP must grow to adequately address people's concerns. Scientific Research / Communication [ABSTRACT FROM AUTHOR]

1. Describe the prevalence of certain communication-related healthcare experiences from a large, nationally representative sample of US adults. 2. Highlight that people with serious illness are more likely to have negative communication-related healthcare experiences that clinicians should recognize to communicate and care for them more effectively. We sought to understand communication-related health experiences for people with and without serious illness. People with serious illness were more likely to report leaving a visit feeling unsure, being afraid to ask questions, and feeling talked down to than those without serious illness. This demonstrates people with serious illness experience inequities in communication and highlights the importance of empathetic communication. High quality communication is critical to the well-being and quality of life of those facing serious illness.[1,2] How people with serious illness engage in care and their care experience is different compared to those without serious illness.[3] We sought to better understand communication-related health experiences of individuals, including people historically marginalized: Black and Latino individuals, older adults, and people with low income or serious illness. To understand if there are differences in communication-related healthcare experiences between people with and without serious illness. We conducted a quantitative survey 4-5/2021 of a nationally representative sample of US adults, assessing participant communication experiences as outcomes. The primary predictor was having serious illness (yes/no). Self-reported covariables were age, gender, race/ethnicity, income, living in a metropolitan area, US region, and marital status. We conducted chi-square tests and multivariable logistic regression models adjusted for covariables to assess associations between serious illness and communication outcomes. We engaged 1,854 survey participants, 19% of whom had serious illness. People with serious illness were more likely than those without serious illness to report leaving a healthcare visit feeling unsure- 18.8% serious illness vs. 8.8% no serious illness (aOR 2.33 [95% CI 1.64-3.30]); more likely to report being afraid to ask questions, speak up, or disagree- 20.5% serious illness vs. 10.5% no serious illness (aOR 2.21 [95% CI 1.57-3.11]); and to report feeling talked down to or made to feel inferior- 12.5% serious illness vs. 8.7% no serious illness (aOR 1.89 [95% CI 1.24-2.90]). These findings show that people with serious illness experience inequities in healthcare experiences and highlight the importance of empathetic communication in high-quality care. Recognizing these inequities is a critical step in improving quality of care for people with serious illness. Communication / Patient Outcomes [ABSTRACT FROM AUTHOR]

1. Through didactic lecture, participants will be able to identify the revisions in the Serious Illness Conversation Guide, the rationale for the changes, and how they relate to diversity and equity. 2. Through didactic lecture and discussion, participants will identify how they could use the new Guide, or questions from it, in their practice, particularly with patients and family/caregivers from underrepresented or marginalized communities. To make the Serious Illness Conversation Guide more acceptable and inclusive for marginalized communities, we involved over 100 experts, clinicians, patients, and family caregivers in an iterative user-centered revision process. Multiple changes were proposed and the final Guide, more balanced in hope and positivity, was rated favorably by a panel of seriously ill patients from Black, Latino, and Asian communities. Ariadne Labs' Serious Illness Conversation Guide has been adapted, implemented, and studied across many patient populations and clinical contexts worldwide. Clinicians serving marginalized communities have reported that changes are needed to make the Guide more suitable for their patients. to refine and improve the Serious Illness Conversation Guide to be more inclusive and acceptable for diverse populations. We employed a user-centered multi-step iterative revision process emphasizing diverse stakeholder input. Data included a mixture of focus groups, individual interviews, and surveys from the following sources: a virtual convening of 35 serious illness and diversity experts; webinars to elicit input from 105 program experts, clinicians, and patient/caregiver advocates from the SICP Community of Practice; and a panel of 11 Black, Latino, and Asian seriously ill patients and caregivers. We performed a multi-step rapid analysis process to identify key-themes and revisions to the Guide. Using participant surveys to create 'heat maps', we identified areas of the Guide that needed the most attention. One or more revisions were made to these Guide elements: introducing the conversation; eliciting patient understanding of illness; talking about uncertain or functional prognosis; and asking about critical abilities. An element was added to ask about and align around hope. Nine out of 11 patient or caregiver participants completed a closing acceptability survey evaluating the revised Guide. All 9 strongly agreed that the Guide includes questions that are important to discuss with their clinician(s) and caregiver(s) and 8/9 strongly agreed or agreed (one neither agreed nor disagreed) that the Guide feels sensitive to their culture and identity. While it's not possible to make a conversation guide ideal for everyone, we were able to make the Guide more acceptable and inclusive for diverse patients and caregivers, largely by including more room for hope and positivity. Communication / Diversity, Equity, Inclusion, Belonging, Justice [ABSTRACT FROM AUTHOR]

1. Describe the inequities in access to effective and culturally appropriate serious illness communication for historically marginalized populations. 2. Highlight findings of a qualitative study focused on understanding how Black, Hispanic/Latino, and Spanish-speaking patients prefer to have serious illness conversations. Historically marginalized individuals participate less in advance care planning, experience lower-quality communication, and feel less understood by clinicians. We conducted focus groups with Black, Hispanic/Latino, and Spanish-speaking patients to elucidate preferences to improve serious illness communication and advance care planning. Four themes emerged as elements of quality serious illness conversation. The benefits of serious illness communication (SIC) are well described,[1-2] though access to effective and culturally appropriate SIC is inequitable.[3] Historically marginalized individuals participate less in advance care planning (ACP), experience lower-quality communication, and feel less understood by clinicians.[4-5] Systemic racism, mistrust, and structural inequities contribute to inequities.[1] It is not known how to optimize SIC/ACP for Black and Hispanic/Latino patients. To elucidate preferences of Black and Hispanic/Latino patients to improve SIC/ACP delivery at a community health center. Focus groups were conducted virtually in English and Spanish with Black and Hispanic/Latino patients who receive care at a community health center in a New England urban metropolitan area. Transcripts were analyzed using thematic coding and themes refined by interprofessional, multilingual research team. Focus groups were conducted with 24 participants: 15 women (63%), 13 Hispanic/Latino (54%), 11 non-Hispanic Black (46%), and 10 (42%) Spanish-speaking. Mean age was 55 years (range 42-73). Prior to study, two participants had completed ACP documentation, and one had had an SIC with their clinician. Four elements of quality SIC emerged: (1) there are specific aspects of a therapeutic relationship (e.g., empathy, competence), that facilitate trust-building and SIC/ACP engagement; (2) many individuals had prior exposure to SIC/ACP through personal/family experience, which positively influences their desire to engage in SIC; (3) to set up a successful SIC, clinicians should consider factors including conversation triggers, emotional support, and whether family or friends should be present; and (4) individual factors including language, culture, faith, family dynamics, and information preferences influence how people want to engage with SIC/ACP, so clinicians should ask the individual their preferences. This study explores how to tailor SIC to patient preferences to promote equitable access. Future interventions should support primary care practices in engaging patients in high-quality SIC. Diversity, Equity, Inclusion, Belonging, Justice / Communication [ABSTRACT FROM AUTHOR]

Charged with transforming geriatric emergency care by applying palliative care principles, a process improvement team at New York City's Mount Sinai Medical Center developed the GEDI WISE (Geriatric Emergency Department Innovations in Care through Workforce, Informatics, and Structural Enhancements) model. The model introduced workforce enhancements for emergency department (ED) and adjunct staff, including role redefinition, retraining, and education in palliative care principles. Existing ED triage nurses screened patients ages sixty-five and older to identify those at high risk of ED revisit and hospital readmission. Once fully trained, these nurses screened all but 6 percent of ED visitors meeting the screening criteria. Newly hired ED nurse practitioners identified high-risk patients suitable for and desiring palliative and hospice care, then expedited referrals. Between January 2011 and May 2013 the percentage of geriatric ED admissions to the intensive care unit fell significantly, from 2.3 percent to 0.9 percent, generating an estimated savings of more than $3 million to Medicare. The decline in these admissions cannot be confidently attributed to the GEDI WISE program because other geriatric care innovations were implemented during the study period. GEDI WISE programs are now running at Mount Sinai and two partner sites, and their potential to affect the quality and value of geriatric emergency care continues to be examined. [ABSTRACT FROM AUTHOR]