Table 4.

Aspects of the Intervention That Were Added, Adapted, or Confirmed on the Basis of Identified Barriers or Recommendations

Barrier(s) or recommendation(s)	Corresponding aspect(s) of the intervention
Lack of knowledge about palliative care among patients or clinicians Low health literacy among patients Concern about ability of CHWs to address complex needs and relay concerns to clinicians effectively Recommendation for CHW didactic training	Rigorous preintervention CHW training was designed by the study team in concert with subject matter experts in palliative care, oncology, patient navigation, health disparities, and motivational interviewing. Training incorporated a synchronous training component delivered over one week via videoconferencing, which included a combination of didactic and problem-based learning. Subsequently, there was an asynchronous training component, delivered over four weeks through a series of weekly modules. Modules covered clinical communication, working within care teams, patient activation, health disparities, and understanding the role religion can play for some patients. A final experiential training component included shadowing palliative care providers, identifying community resources, and participating in a site-specific orientation.26
Logistical barriers and financial burdens to receiving care	A standardized initial screening questionnaire was developed for CHWs to use as they began to engage with patients. Based on the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) toolkit,27 the questionnaire evaluates access to care, emotional support, vision and hearing, social program eligibility, transportation, housing, financial resources, food security, and additional needs. After identifying individual patient and caregiver barriers to health care access and associated social determinants of health, CHWs tailor their approach and support to each patient or patient-caregiver dyad.
Negative community and personal experiences within the health system	CHWs were recruited from within the communities served. The hiring process emphasized a history of local community engagement, ability to establish positive relationships, and comfort with discussing patients’ and caregivers’ medical, psychosocial, and spiritual concerns.
Limited access to palliative care providers	The study team developed partnerships with local palliative care staff and organizations. CHWs received dedicated training on palliative care from palliative care providers and shadowed providers to understand their daily operations and establish relationships with members of the team. Each site also established a Palliative Care Liaison from within their palliative care department to serve as an internal “champion” for the intervention and act as resource for CHWs.
Lack of ongoing funding after randomized controlled trial	Trial secondary endpoints include detailed resource utilization metrics, including number of hospital days, intensive care unit days, emergency department visits, hospital readmission rates, health care costs, and time spent with CHWs. Social return on investment (SROI) analysis was added and we engaged a health care economist collaborator to lead our SROI team.
Recommendation to train the clinical team to absorb CHWs into the workflow	CHW training included shadowing oncology and palliative care providers, allowing CHWs to understand preexisting clinic workflow. Oncology and palliative care teams received a presentation on the intervention prior to implementation. A short video explaining the role of the CHW is being produced to provide asynchronous information for clinicians.
Recommendation to balance standardized versus individualized follow-up frequency	CHWs began with an initial standardized evaluation and screening questionnaire to assess access to care and social determinants of health. Follow-up was then individualized after this point at the discretion of CHWs. Regular all-site CHW meetings occur on a biweekly basis, facilitating consistency and dissemination of best practices across sites. CHWs also receive ongoing mentorship from the study’s lead CHW, creating an opportunity for individualized advice and support from a highly experienced colleague.