Optimizing the implementation of systematic financial screening.
Authors: Beauchemin Melissa Parsons , DeStephano David , Raghunathan Rohit R. , Accordino Melissa Kate , Hillyer Grace C. , Kahn Justine , Law Cynthia , Harden Erik , Wright Jason Dennis , Kukafka Rita , Hershman Dawn L. 
Published: September 2022

277

Background: Implementation of routine financial screening is a critical step toward mitigating financial toxicity. Screening facilitates identification and intervention delivery. We evaluate the feasibility and acceptability of systematic financial screening in a large, urban, outpatient cancer center. Methods: We developed and implemented a stakeholder-informed process to systematically screen all patients with cancer for financial hardship and financial worry using two items from the Comprehensive Score for Financial Toxicity. Screening was completed by patients in English or Spanish on paper forms or through the patient electronic portal; all responses were entered into the electronic health record (EHR). Repeated measures were prompted through the EHR monthly. We evaluated the feasibility of the implementation by completion rates, mode of completion and follow-up completion rates; and identified key factors to optimize implementation strategies and improve sustainability through key stakeholder feedback from patients, clinicians and staff. Results: From 3/2021 – 3/2022, 3,500 patients were seen in the outpatient breast oncology clinic and thus, eligible for screening. Of these, 39% (1,349) responded, either by paper or portal, 12% (N = 437) preferred not to answer when checking in via the patient portal, and the remaining 49% (N = 1,714) did not have data in their EHR, meaning screening was not offered or they did not complete the paper forms. Of the 1,349 respondents, most (79%, N = 1,063) responded via portal. Repeated screening measures were completed by 42% (N = 563) more than once. By language preference, response rates were 46% (English), 28% (Spanish), and 29% (Other languages). Completion rates on paper were not sustained after the initial implementation and dropped significantly after 6/2021; this correlated with staffing shortages. After expanding capacity for patients to check-in using kiosks in clinic in 7/2021, completion rates increased 78% in the following 3 months. Significant financial hardship was endorsed by 51% (N = 694), and financial worry by 36% (N = 484). From stakeholder feedback, including patient interviews, components were identified to improve screening completion rates: partnering with staff to facilitate distribution of paper forms for patients who do not use the portal; optimizing patient engagement with the portal; partnering with the electronic health record vendor to ensure non-English access is optimized; and transparent communication to patients regarding the purpose of the screening and resources available. Conclusions: We demonstrate that implementation of systematic financial screening requires an inclusive approach to achieve acceptable and equitable response rates. Electronic data capture contributes to successful financial screening implementation, but inclusive procedures that address language and technology preferences are needed to optimize screening.