Factors related to implementation of outpatient palliative care for advanced cancer patients in a safety-net health system: A qualitative analysis.

315 Background: American Society of Clinical Oncology strongly recommends oncology providers refer all advanced cancer patients for early intervention by a specialized palliative care (PC) team during active treatment. Studies indicate cancer patients receiving care in a safety-net system often experience low rates of outpatient PC referral and delays in accessing care. Yet, few studies have examined factors influencing early PC implementation in settings predominantly serving underserved populations. This study evaluated the multilevel (patient-, provider-, clinic-level) factors that influence early integration of PC for advanced cancer patients seen at the primary safety-net provider of cancer care for under- and uninsured adults in Dallas, TX. Methods: We conducted semi-structured interviews with medical oncology and PC clinic staff (attending physicians, fellows, advanced practice providers, registered nurses, administrators) who manage outpatient care for patients diagnosed with solid tumor cancers. The interview guide was informed by the Theoretical Domains Framework to understand challenges, potential facilitators, and experiences with PC delivery. We analyzed interview transcripts using qualitative template analysis to identify salient themes. Results: We interviewed 20 participants, including 17 clinicians (12 medical oncology, 5 PC) and 3 administrators. Four prominent domains and specific sub-themes emerged. (1) Environmental context and resources: barriers to PC access and referrals included transportation costs, competing priorities faced by patients (e.g., work, childcare), lack of patient awareness about PC, and clinician availability/time constraints, while a facilitator included availability of PC clinic nurses to educate patients. (2) Knowledge: clinicians reported limited familiarity/awareness of clinical practice guidelines and institutional PC referral protocols. (3) Beliefs about consequences: PC was perceived as providing many valuable benefits once patients established care, including access to critical resources and improved care coordination. (4) Behavioral regulation: strategies to support PC uptake included patient education materials, training for oncology clinicians/staff, institutional protocols, and electronic health record reminders for PC referrals. Conclusions: Study findings suggest some challenges in implementing PC services for advanced cancer patients treated in a safety-net setting that can be mitigated. The results will be used to inform development of a multilevel, multicomponent strategy to improve early PC delivery and cancer outcomes for medically underserved patients.