Addressing health-related social needs for cancer patients: An implementation assessment.

Abstract

1575 Background: Health-related social needs (HRSNs) are associated with delayed diagnosis and treatment, worsened quality of life, and higher recurrence and mortality rates for cancer patients. Health systems are beginning to recognize the tremendous impact of HRSNs by recommending standardized HRSNs screening and referral in cancer care. Further research is needed to effectively design and implement HRSNs interventions for cancer patients. We evaluated the implementation of a novel community health worker (CHW) referral and navigation intervention to address unmet HRSNs in a National Cancer Institute (NCI)-designated comprehensive cancer center serving a highly disadvantaged community of patients in Bronx County, NY. Methods: We conducted a retrospective study of cancer patients utilizing data from HRSNs screenings, clinician CHW referral orders, and CHW navigation services between October 2023 and March 2025. Patients were identified as eligible for CHW assistance if they were screened for and self-reported at least one unmet HRSN. We organized process and outcome measures using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) implementation framework and evaluated measures through descriptive statistics. Results: There were 30 cancer center clinical practices who adopted the HRSNs screening tool. A total of 8,591 patients were screened for unmet HRSNs, with 20.5% self-reporting at least one unmet HRSN. Of those with at least one unmet HRSN (n=1,758), 43.4% were referred to CHWs by clinicians. Referral rates to CHWs ranged from 26-55% by clinical practice. Of patients referred to CHWs, 794 (64.5%) were assisted with HRSNs navigation by CHWs, with the most common HRSNs identified as financial (50.3%), housing (48.7%), and food insecurities (45.5%). CHWs were successful in outreaching referred patients (95.5%) in a timely manner (Median: 3 days from referral order, IQR: 1-6 days), connecting patients to at least one social service (98.9%), and resolving or improving at least one social need (97.6%). The median annual cost to implement and maintain the CHW referral and navigation intervention to address unmet HRSNs was $345.58 per patient. Conclusions: Implementation of CHW referral and navigation services within an NCI-designated comprehensive cancer center was feasible and effective in addressing unmet HRSNs within a safety-net cancer population. CHWs were successful in reaching patients and connecting them with essential social services that helped to resolve their HRSNs. Further research is needed to improve clinician screening and referral and understand the impact of CHW navigation on oncologic care delivery and clinical outcomes.