Table 2.

Barriers to Implementation: Illustrative Quotes from Key Informants

a. Patient-level barriers
Lack of knowledge: “Knowledge of it is probably the biggest [barrier]. Nobody really knows that it exists or that it’s out there until their oncologist or their inpatient hospitalist says, ‘I’m going to consult palliative care … And they get scared to meet with us. Or, you know, there is a huge misconception that it’s the same as hospice.”—Palliative care clinician (participant 13)
Readiness to focus on symptom management: “I’m thinking about a particular instance where the patient, very advanced, came in in a wheelchair. Had been admitted, I don’t know, it was many, many times … And they had heard about palliative care from multiple other doctors … So I think that the barrier was probably that the denial, you know, that that was where that needed to be.”—Oncology clinician (participant 16)
Logistical barriers and competing priorities: “They already have so many appointments. They’re going here and there and everywhere, and this is just another thing that they have to go do, and, ‘Why can’t my oncologist manage all these things? Why do I have to go talk to another person about the same issue?’”—Cancer center leader (participant 11)
Negative experiences within the health system as a community or individual: “Whether it is implicit or not, unconscious, or not, we know that black patients and families are not getting the same care, period. And so where is that happening in the system? I think a place that I see it is around decision making and sort of what is being offered and assumptions that are being made around what social support people have or what resources people have.”—Palliative care clinician (participant 19) “It could be any patient who has a background in drug use and they will naturally assume that they are drug-seeking. You know, they are not looking at the fact that they have cancer. Or any other illness that may cause them to be in a lot of pain.”—Community health worker (participant 4)

b. Clinician and facility-level barriers
Concerns about potential for disruption to existing clinical workflows: “We were in the way. We were in the way with the social workers … The doctors—we did develop relationships with the doctors one-on-one. But the barrier was that you’re in the way … And even the front desk, we were in their way. ‘You’re slowing up progress … Just wait. Let me get this person checked in.’”—Community health worker (participant 21) “I think if they cause me more work because they didn’t understand, and they didn’t have the education they needed or the training they needed to be successful, and they were causing me chaos, then … the program would fail. But if you had a really good [CHW] who really provided good support and was able to think independently and, you know, figure things out, then yeah, I think it’d be great.”—Oncology clinician (participant 9)
Addressing complex medical and psychosocial needs: “Some counseling element, people always have lots of issues and anxiety, some just distress to some degree about all the different aspects of cancer—‘How do I manage this with my job? What about my caregiving?’…some training around those aspects I think would be key. Providing just some oncology background I think obviously would be helpful. That’s a challenging part because you can’t do hundreds of [hours]—I mean how much is enough? I don’t know.”—Oncology clinician (participant 18) “I had a patient’s husband ask me to call back yesterday and I called back, the patient had fallen … the longer I spent on the phone with him … what he was describing is what I think of as failure to thrive. The woman also has more than one cancer … So I don’t know that a lay navigator would have necessarily picked up—she may have known to recommend the emergency room, but she may have not picked up on what to communicate to the physician level.”—Care navigator (participant 20)
Oncology provider knowledge and acceptance: “We used to have an oncologist—he still works there, but he’s better now with palliative care—who would not refer anybody to us, and still we have to text him and message him before we see a patient and ask his permission, but at least now he lets us see people … he has made the comment to my physician and to several of us, ‘Well, that's just giving up.’”—Palliative care clinician (participant 15)
Potentially underutilized navigation programs may already exist: “We had a lay navigator briefly [and] she actually would come and sit down in our office. We don’t really even know 100 percent what she does. There were lay navigators. One thing I think they're supposed to do is find out the patient's distress level up front and I'm not sure who they notify of that because those aren't coming to me.”—Care navigator (participant 20)

c. Health system-level barriers
Challenges with funding and cost-effectiveness: “I think we need to show that it may be more cost, because it will be more cost, but [that] in the long run it’s cost-effective, and it promotes quality of life. It’s going to decrease health care utilization because … I mean unfortunately that’s the system we have. It boils down to what it’s going to cost us … I think until we demonstrate with data and comparative effectiveness, I think it’s going to be very hard to show the value to the health care system.”—Cancer center leader (participant 24) “If we had more staff, [patients] could be seen more quickly because [providers’] schedules wouldn’t be already so full. So I think that’s one thing, and obviously, that comes with funding and justifying the resource. A lot of times, these services are not reimbursable, and so it’s not often revenue generating, and non-revenue generating activities are often very hard to resource.”—Cancer center leader (participant 23)
Limited access to palliative care services: “So many patients with solid tumors that are admitted are admitted for palliative care issues … The single palliative care team is just extraordinarily overwhelmed, and I think that it really contributes to a lot of suffering and a lot of delay in care. The volume is so much that the palliative care team can only go by and see the patient and titrate like once a day because they’re—they’ve got a huge number of people to take care of … and then that’s magnified by the acuity of the problem, right? It’s not just like, ‘Hey, I’ve got some nausea that I’m not handling well,’ but it’s like it’s so bad that a person has to be hospitalized. Plus, we are not able to make as quick adjustments as we might want to make.”—Oncology clinician (participant 8)
Care fragmentation: “The other thing is integrated care. Our health care is very fragmented, very fragmented, and then you just do referrals. This patient goes there, and what I see a lot from where I sit in the leadership of the cancer center, is the patient does not have a quarterback, and who is going to be the quarterback for that patient to be sure to integrate out that information? … So I think that’s from the system level.”—Cancer center leader (participant 24)