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Context The integration of palliative care into standard oncologic care has been shown to improve multiple outcomes in patients with advanced cancer. Ideal methods for integrating these disciplines is an ongoing area of discussion. One method of integration is a palliative oncology tumor board (POTB). Objectives To describe the implementation of a POTB in a community cancer center as a method of integrating oncology and palliative care by providing a forum for multidisciplinary discussion of complex cases. Methods During development of the POTB, multiple influencing factors and barriers were considered including the setting of implementation, culture prior to implementation, design elements, engagement of stakeholders, and evaluation of implementation. The focus of this POTB was to address the identified communication gap between inpatient and outpatient care teams. Two complex hospitalized oncology patients were selected to be discussed weekly. Results Conferences were attended by an average of 23 individuals. The highest proportion of attendees were members of oncology support services (including nurse navigators, social workers, chaplains, dietitians, financial counselors; OSS; 31%), followed by medical oncology (25%). The most common theme of discussion was methods of communication with patient and/or family (68% of cases). Thirty days after presentation, a total of 50 new referrals were placed to inpatient palliative care, OSS, and outpatient palliative care and 11 new advance care plans were documented in the electronic medical record. Conclusion This paper describes a sustainable method to implement a POTB in a community cancer center setting, which is one method of integrating palliative care into standard oncologic care.

113 Background: Patients with hematologic malignancies are referred to palliative care less than patients with solid tumor malignancies. Clinical trials are underway at academic centers exploring early inpatient palliative care for patients newly diagnosed with AML receiving induction chemotherapy. Feasibility of such interventions have not been studied in a community setting. We structured a multi-faceted intervention for our community hematology and palliative team on the benefits of early palliative care in hematologic malignancies with the aim to increase utilization. Methods: In 2017, 24% of patients with AML admitted to Lancaster General Hospital for induction chemotherapy received an inpatient palliative consultation. Needs assessment performed on the hematology and palliative teams demonstrated a need for integration of palliative care into clinical pathways, automatic triggers for consultation, a need for increased education on AML, and creation of standard elements in inpatient consultations. Results: In the spring of 2018, we integrated palliative care into institutional AML clinical pathways such that all patients receive inpatient palliative consultation within 72 hours of admission. A consultation trigger was placed within the admission order set and is currently being incorporated into the chemotherapy treatment protocol. An educational program on AML was created and presented by the hematology team to the inpatient palliative team. This intervention included creation of minimum standards for inpatient palliative consultation including provider assessment within 72 hours of referral, two visits per week by a provider and a minimum of one visit by the interdisciplinary team during admission with a focus on symptom management, psychosocial assessments, and advanced care planning. Conclusions: We have demonstrated feasibility of creating standards for early palliative care intervention in AML patients with collaboration from the hematology and palliative teams. Next steps will include assessing whether these interventions increase uptake of palliative care utilization and specific patient outcomes.

Context: Palliative care in oncology provides multiple benefits, however access to specialty palliative clinicians is limited in community cancer centers. Individual support services are more often available, but little is known on the utilization and impact of these services. Objectives: To describe the utilization of outpatient support services in the advanced cancer population and the association with ED and hospital use in a community setting. Methods: A retrospective chart review of 314 patients with advanced cancer of lung, gastrointestinal, genitourinary, and gynecologic origin was conducted. Data collected included demographics, descriptive data, type and number of support services (symptom management, nurse navigator, social worker, nutrition, financial counselor, chaplain, and oncology clinical counselor) within 90 days of diagnosis and descriptions of ED visits/hospitalizations within 12 months of diagnosis. Support services were available to patients by referral. Results: 29.6% of patients were deceased within 6 months and were considered to have severe disease. Patients with severe disease had a significantly greater mean number of support services than patients with non-severe disease (8.9 vs 6.0, p=0.001) and had a greater mean number of visits per year to the ED (6.4 vs 1.8, pConclusion: Our data demonstrated that advanced cancer patients with severe disease had increased healthcare utilization in all areas measured. Despite high utilization, outpatient support services used in a reactive manner were not effective in reducing ED or hospital visits.

Health literacy is becoming increasingly important in areas such as cancer care, where treatments are relatively difficult to navigate. This study aims to describe the how health literacy is associated with healthcare outcomes and health system usage among patients with lung cancer. Data include retrospective medical record data from 456 patients with lung cancer; half were age 70 and older. Patients were coded as having adequate or limited health literacy based on their response to their Single Item Literacy Screener (SILS). Data were collected from a 12 month period following diagnosis for each patient. One-third of patients had limited health literacy; this was significantly more common among adults age 70 and older. Patients with limited health literacy were more likely to have newly diagnosed lung cancers of stage 3B or higher (59.18% vs. 42.76%, p = 0.0011) compared to those with adequate health literacy. Patients with limited health literacy had higher median levels of depression based on the PHQ-9 questionnaire (4.0 vs. 3.0, p = 0.0082) and a higher median number of emergency department visits (1 vs. 0, p = 0.0156) and unplanned hospitalizations (1 vs. 0, p = 0.0044). Furthermore, patients with limited health literacy were more likely to have an emergency department visit or unplanned hospitalization sooner (p < 0.0001). These data illustrate a lower quality of life and a higher dependency on healthcare services for patients with limited health literacy. Assessment and interventions may be necessary to ensure access to quality healthcare.

Introduction: Studies have shown aggressive cancer care at the end of life is associated with decreased quality of life, decreased median survival, and increased cost of care. This study describes the patients most likely to receive systemic anticancer therapy at the end of life in a community cancer institute. Materials and Methods: We performed a retrospective cohort study of 201 patients who received systemic anticancer therapy in our institution and died between July 2016 and April 2017. Data collected included primary malignancy, hospice enrollment, healthcare utilization, Oncology Care Model (OCM) enrollment, and clinical assessments at last office visit prior to a treatment decision before death. We defined our outcome variable as the receipt of anticancer treatment in the last 14 days of a patient’s life. We evaluated 20 clinical exposure variables with respect to the outcome classes. Risk ratios along with their associated confidence intervals and P values were calculated. Significance was determined using the Benjamini-Hochberg procedure to account for multiple testing. Results: Of the 201 patients who died of cancer, 36 (17%) received anticancer therapy within the last 14 days of life. Several risk factors were significantly positively associated with receiving anticancer therapy at the end of life including hospitalization within 30 days of end of life, number of hospitalizations per patient (≥2), death in hospital, enrollment in OCM, and a diagnosis of hematologic malignancy. Conclusion: Our findings demonstrate those enrolled in the OCM and those with hematologic malignancies have a higher risk of receiving anticancer therapy in the last 14 days of life. These observations highlight the need for better identifying the needs of high-risk patients and providing good quality care throughout the disease trajectory to better align end-of-life care with patients’ wishes.

66 Background: Studies have shown that aggressive cancer care at end of life is associated with decreased quality of life, decreased median survival, and increased cost of care. This study describes the patients most likely to receive aggressive anti-cancer therapy at the end of life in a community cancer institute. Methods: We performed a retrospective review of 213 patients who received anti-cancer therapy in our institution and died between July 2016-April 2017. Data collected included primary malignancy, death date, date of last anti-cancer treatment, hospice enrollment, healthcare utilization, Oncology Care Model (OCM) enrollment, and clinical assessments at last office visit prior to a treatment decision before death. Data were analyzed using univariate logistic regression to determine feature importance. Results: Of the 201 patients who died of cancer, 36 (17%) received anti-cancer therapy within the last 14 days of life. Several factors were significantly positively correlated with receiving anti-cancer therapy at end of life, including enrollment in OCM (p < 0.001), frequency of hospital utilization (p < 0.001), death in hospital (p

73 Background: It is recommend that no more than 10% of patients receive chemotherapy within 14 days of death. Aggressive end of life interventions like chemotherapy and hospitalization are used as measures of quality. However, cancer care now includes immunotherapy and targeted therapies. It is therefore important to understand how all cancer directed treatments are utilized at end of life, to better define the group of patients for whom they are indicated. Therefore, we sought to describe the people in our institution who received cancer directed therapy in the last two weeks of life. Methods: Adult patients who received cancer directed therapy for any malignancy in a single community cancer institute and died from July 2016-April 2017 were included. Retrospective data collection included clinical cancer stage and type, ECOG performance status (ECOG), last cancer therapy, date of death, dates of treatment, type of treatment, treatment goal, demographics and utilization of ED, hospital, palliative care and hospice. Results: A total of 218 patients were included. 13.7% (30/218) received cancer directed therapy within 14 days of death. Of those patients, only four had ECOG of 3, while 26 had ECOG 0-2. The average duration from treatment to death in this group was eight days, with one patient dying on the day of treatment. The average duration from treatment to death for all patients was 166 days (median 59). 20 patients receiving cancer directed therapy at end of life received chemotherapy, while the remaining 10 received targeted therapy (8) or immunotherapy (2). 40% (8/20) of patients in the chemotherapy group died in hospital as did 50% (5/10) of the remaining patients. Most patients in the overall sample (83%) were being treated with palliative intent. 20% (6/30) of the patients who died within 14 days of treatment were being treated with curative intent. Conclusions: Recommendations regarding cancer directed treatment near end of life need to include non-chemotherapy treatments such as immunotherapy and targeted treatments. Although a small sample size, our data suggest that patients on these treatments receive aggressive end of life care at a similar frequency as those who receive chemotherapy.

112 Background: Patients with advanced cancer are at high risk for emergency department (ED) and hospital utilization, which is distressing and costly. Palliative care consultation and symptom management clinics have been shown to decrease ED and hospital utilization, but the frequency and composition of these interventions is still being delineated. More evaluation is needed to determine practical approaches to implementing interdisciplinary management of distress for patients with advanced cancer in the community setting. This retrospective review evaluates healthcare utilization with respect to support services provided in our community based cancer institute. Methods: 157 patients with advanced cancer of lung, gastrointestinal, genitourinary or gynecologic origin diagnosed January 2015-December 2015 were reviewed retrospectively. Descriptive data including demographics, disease characteristics, palliative care consultation, support services utilized and ED visits/hospitalizations were collected for 12 months, or to date of death. Support services included physician assistant–led symptom management, nurse navigator, social worker, nutrition, financial counselor, chaplain, and oncology clinical counselor. Support service referrals were made based on identified needs. Severe disease was defined as death within 6 months of diagnosis. Results: Patients with severe disease had a mean of 6 ED visits per year, significantly greater than patients with non-severe disease (p < 0.001). Patients with severe disease also had more contacts with support services per year (30.3 vs 9.1, p < 0.001). A palliative care consult was placed in 50% of patients with severe disease, and 23% in patients with non-severe disease (p < 0.001). Conclusions: Patients with advanced cancer have evidence of significant needs as reflected by high healthcare utilization in the last 6 months of life. As needed involvement of support services correlated with severity of disease but did not result in decreased ED utilization or hospitalization. This suggests that availability of support services alone is not a feasible strategy to impact unplanned hospitalizations and ED visits.