Implementation and evaluation of the Routine Assessment and Integration of Screening for Employment (RAISE) program in adults with metastatic breast cancer

Abstract

Purpose

Adults living with metastatic breast cancer (mBC) often have unmet employed-related needs. To address this gap, we developed, implemented, and evaluated the Routine Assessment and Integration of Screening for Employment (RAISE) program for adults with mBC.

Methods

We designed a quality improvement project informed by the Specific, Measurable, Attainable, Relevant, and Timebound framework. In Phase 1 (development), we built and integrated an English/Spanish screener into the electronic health record (EHR) platform. In Phase 2 (implementation), 48 h before an oncology visit, patients received alerts through the patient portal that a screening assessment was available. Patients who reported needing support for employment-related concerns triggered an EHR alert to a patient navigator who reached out to offer educational resources (physical booklet and/or mobile app). Phase 3 (evaluation) was guided by the RE-AIM framework and included surveys and interviews with patients, providers, and staff to evaluate acceptability and feasibility of RAISE.

Results

Between March 2024 and August 2025, 179 patients with mBC completed the RAISE screener Of these, 22 (22/179, 12.2%) requested assistance/navigation and were provided with educational resources. Among 41 (41/179, 23%) patients surveyed (evaluation phase), 33 patients had completed the screener, and 8 had not. Of those who completed the screener and the evaluation survey, 91% (29/33) reported they were somewhat or very satisfied with RAISE and 78% (25/33) reported the EHR screening questions were clear to them. Key themes that emerged from 5 patient and 10 provider interviews included utility of the resources offered, screening preferences, and barriers to incorporation of screening into the clinical workflow.

Conclusions

Screening for unmet employment needs and delivering resources and navigation is preliminarily feasible and acceptable to patients with mBC, providers, and staff at two NYC hospitals, though key barriers to implementation exist, including low pre-visit screening uptake and integration into the clinical workflow.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1007/s10549-026-08089-y.

Introduction

Approximately 170,000 women and men are living with metastatic breast cancer (mBC) in the United States, with the number projected to grow considerably by 2040 [1, 2]. Whether an individual is newly diagnosed or has been living with mBC for several years, a mBC diagnosis and its associated treatment can have a pronounced impact on an individual’s physical, psychosocial, and financial well-being.

Employment concerns in early-stage breast cancer have long been a focus of cancer survivorship research. Importantly, the need to work while receiving systemic therapy is not limited to patients undergoing curative treatment. In a study of cancer patients surveyed at a palliative care clinic, 58% reported working, of whom 40% wanted to increase their work hours; 56% of those not working desired a job [3]. Because many individuals with mBC live increasingly longer with their disease and often must manage ongoing treatment and side effects, knowing how to effectively negotiate employment-related challenges is an unmet need for this population. Prior research has shown that employment challenges are common among mBC patients from diverse racial, ethnic, and socio-economic backgrounds [4]. Employment disruption is associated with a loss of financial independence, increased financial hardship, and psychological distress [5], underscoring the downstream consequences of employment changes and interruptions due to a cancer diagnosis and treatment [6]. Cancer-associated job loss results in difficulty paying bills, accumulation of debt, and bankruptcy [7, 8]. Given the significant and sustained impact of mBC on employment, interventions to support employment needs and job retention may reduce financial toxicity.

In the United States, immigrant and minority populations with cancer are at higher risk of cancer-related financial hardship and its consequences, including bankruptcy [7–10]. A recent study found that Black patients with cancer were twice as likely to experience a negative financial impact of cancer and five times more likely to be denied health insurance compared to White patients with cancer [11]. Prior research also found that Hispanic patients work in less supportive settings, with fewer accommodations, increasing their risk of job loss [12]. Therefore, improving the ability of cancer patients to continue to work and maintain an income could abrogate an important disparity in cancer outcomes and promote health equity.

Despite the substantial and well-documented impact of a mBC diagnosis on employment and financial well-being, interventions or initiatives that target these critical issues are lacking. To address this gap, we designed a quality improvement (QI) project to pilot the Routine Assessment and Integration of Screening for Employment (RAISE) program, with the goal of systematically identifying mBC patients with unmet job-related needs, connecting them with a patient navigator, and offering patient-centered resources to help address these needs.

Methods

The RAISE program was designed and piloted in two outpatient oncology clinics that are part of the NewYork Presbyterian (NYP) healthcare system in New York City. Weill Cornell Medicine (WCM) is an academic medical center located on the Upper East Side of Manhattan, and Brooklyn Methodist Hospital (BMH) is a community hospital located in Brooklyn. Eligible patients were English or Spanish-speaking adults with mBC receiving care at NYP-WCM or NYP-BMH. Patients with stage IV breast cancer at initial diagnosis (de novo) and those with early-stage disease who subsequently experienced a metastatic recurrence were included. Eligible patients had: (1) two or more medical encounters with a diagnosis of breast cancer listed (ICD-9-CM 174.x or ICD-10 C50.x) that were at least 30 days apart, and (2) two or more medical encounters with a diagnosis of the same distant secondary malignant cancer (ICD-9 197.x-198.x, 199.1, and ICD-10 78.x-79 [13] x (Appendix). Only patients who had previously established care (i.e., those who had at least one prior medical oncology visit at either facility) were eligible to be sent the screener. Given that this was a quality improvement initiative, the WCM Institutional Review Board deemed this as exempt (not human subjects research IRB# 23-08036435-01).

Design and framework

The QI project included three phases: (1) development of an electronic health record (EHR)-based employment screening assessment (screener); (2) implementation of the RAISE program (screening and delivery of navigation/resources to patients requesting assistance); (3) evaluation of RAISE implementation (preliminary feasibility, acceptability, appropriateness) through surveys and interviews with a small group of patients, providers, and staff. The project objectives, metrics, and designated endpoints metrics were informed by the Specific, Measurable, Attainable, Relevant, and Timebound (SMART) framework [14]. Table 1 details each SMART component mapped to representative metrics, corresponding to each study phase

Table 1.

SMART domains corresponding to each project phase

SMART domain	Development Phase 1	Implementation Phase 2	Evaluation Phase 3
Specific	· Build an employment screening tool that is integrated into the EMR	· Systematic screening and delivery of resources/navigation to patients who indicate a need	· Conduct surveys and interviews with patients and staff/providers
Measurable	· # of notifications sent via patient portal · # of patients completing screener via patient portal · # of patients completing in clinic	· # of patients who screen as having a need who are delivered resources	· Completion of patient surveys and interviews · Completion of staff/provider interviews
Attainable	· Successful integration of screener into EMR · Screening implemented into clinical workflow	· % of patients in need who are offered navigation/ resources	· Project staff implementing follow-up plan to reach patients for evaluation components · Staff/providers re-engaged at the end of the study for feedback
Relevant	· Employment screening supports health system’s overall mission to integrate routine SDOH screening	· Negotiating employment challenges is an unmet need in adults with mBC	· Identify barriers and gaps associated with RAISE, informing refinement of the screening process/intervention · Inform expansion of SDOH screening/actionability
Timebound	· Screener implemented into clinical flow 6 months after EMR build initiated	· Delivery of resources for duration of pilot	· Patients were surveyed ~ 1. month and interviewed ~ 3 months after screening · Staff/providers surveyed and interviewed following pilot

EMR, electronic medical record; NYP, NewYork Presbyterian; SDOH, Social Determinants of Health; mBC, metastatic breast cancer

1) Development: We built and integrated an English and Spanish screening assessment with branching logic into NYP’s EHR platform. The screener (developed in partnership with patient advocates) started with a single item: “Some people have questions or concerns about how having cancer might affect their jobs. We have resources available to help people who have had challenges at work related to their cancer or who are worried about how cancer might affect their job in the future. Are you interested in learning more about these resources?” Response options included: “Yes, I would like help finding work/I would like to learn more”; “Yes, I would like help managing challenges at my job”; “No, I do not want help right now.” Patients who selected either “Yes” option were prompted with two multiple-choice questions that asked whether they had experienced any employment-related problems since their mBC diagnosis (e.g., had wages/paycheck reduced, been laid off, or been encouraged to retire) and if their ability to work had been negatively impacted (e.g., if cancer or its treatment had affected their physical ability or relationship with co-workers). Individuals who indicated they did not want help were offered the option to be recontacted in 6 weeks.

2) Implementation (Fig. 1): From March 2024 to August 2025, eligible patients received an automated message through their EHR patient portal 48 h before a follow-up medical oncology appointment asking them to complete the screener before their next appointment. Patients who reported needing support for their employment-related concerns triggered an alert to a patient navigator, who reached out directly to the patient to offer access to educational resources (delivered as a booklet and/or virtually via mobile app, per patient preference). These materials included both national and local, NYC-based resources that covered legal assistance, employment rights, insurance (disability, health), financial resources, social support, transportation/lodging, and treatment information. Other topics covered included questions to ask healthcare team, symptom management, legal rights; working following diagnosis/during treatment, sharing your diagnosis with boss/co-workers, requesting accommodations, including letter templates, and negotiation strategies. Because most patients treated at our community site either did not use their online portal account or were not used to checking messages from their providers online, the navigator contacted these patients over the phone or in-person to administer the screener. Out of concern that capture of eligible mBC patients may be incomplete, between April 2025 and July 2025, we expanded the list of ICD-10 codes (which had been limited to codes specific to distant metastatic sites) to include additional codes representing “unspecified” and “overlapping” sites of the breast. The non-specificity of these codes resulted in both mBC and some patients with early-stage breast cancer receiving the screener. Patients with early-stage breast cancer who requested follow-up via the screener were contacted by a patient navigator and were offered a brief resource sheet. In a limited capacity over the course of the pilot, we offered in-clinic screening via a tablet computer to eligible patients who did not complete the screener in advance of their visit. To support identifying these patients at check-in, an EMR “flag” was integrated to nudge staff to offer the tablet to patients who did not complete the screener before their medical oncologist visit. Due to resource and staffing constraints at each study site that coincided with the timing of the pilot implementation phase, we were unable to consistently offer the tablet screening option to all patients.

Fig. 1.

RAISE program workflow

3) Evaluation: Preliminary evaluation of RAISE was guided by the implementation science framework, RE-AIM, and included the following evaluation metrics [15]. For feasibility, we documented if RAISE could be integrated into the EHR, if the screener could be incorporated into the clinical workflow at the two hospital sites, and if patients reported completing the screener. Another indicator of feasibility was delivery of requested resources and navigation to individuals who complete the RAISE screener and endorsed wanting assistance. We also considered the reach of RAISE, which was measured by the number of patients with mBC who received the screener. In terms of acceptability and appropriateness, we asked respondents about their satisfaction and relevance of RAISE in surveys. For providers and staff, we assessed preliminary acceptability and feasibility through interviews. Given the pilot nature of this study, we did not pre-specify reach, acceptability or feasibility thresholds.

Surveys: A subset of mBC patients, inclusive of patients who completed the screener and those who did not complete the screener, were approached approximately 1 month after being sent the employment needs screener and asked to complete a brief 5–10-minute survey to assess their experience with RAISE. All individual who were approached for surveys but had not completed the RAISE screener had been sent the screener through the online portal. Surveys were available in English only and available to complete through REDCap or on paper, depending on patient preference.

Patient interviews: To complement the survey evaluation, a convenience sample of patients were also invited to participate in a short interview with the purpose of gaining additional feedback about the implementation of RAISE. For patient interviews, our sampling strategy focused on attaining sufficient “information rich cases,” [16] including patients who completed the screener and requested follow-up to assist with employment needs, patients who completed the screener but did not request additional follow-up, and patients who were sent the screener but did not complete it. The interview guide was developed in collaboration with our patient advocate partners and included open-ended questions regarding perspectives on questionnaires that assess other social determinants of health, the main reason for not requesting additional follow-up as part of the RAISE program (if not requested during the screening process), and use of the mobile app/booklet (among those who were navigated and were provided access to these resources).

Provider interviews: Using convenience sampling, we invited providers (e.g., medical oncologists, nurses) and staff (e.g., social workers, front desk staff) who had direct involvement with the RAISE program, as well as those not directly involved with RAISE at the two NYP sites, to participate in a brief interview. Questions focused on perspectives regarding broader implementation of screening for social determinants of health, including frequency of screening, approaches to minimizing disruptions to the clinical workflow, addressing barriers to in-clinic completion (i.e., tablet implementation), and identification of personnel and staff who might be best equipped to assist with future screening efforts. Among providers and staff involved with RAISE, we asked about the feasibility of the RAISE screening process, appropriateness of the screening questions, and their overall impression of the RAISE program.

Analyses: We used descriptive statistics, including counts, proportions, and means, to summarize implementation metrics. Analyses were conducted using Stata. Interview data were reviewed independently by two members of the research team, summarized and organized by key themes that emerged upon review of notes from the five interviews.

Results

Patients screened and navigated (Fig. 2): Over the duration of the pilot (March 2024-August 2025), a total of 1,362 unique patients (inclusive of both mBC and early-stage patients) received the screener, 428 completed it; of these, 179 had mBC and 249 had early-stage breast cancer. Among the 179 mBC patients, 22 (12.2%, 22/179) requested navigation, met with the navigator, and received the employment-related materials as an app, booklet or both. Among the 249 with early-stage breast cancer, 35 (14%, 35/249) requested assistance and were provided a one-page resource sheet and referral to a navigator.

Fig. 2.

Number of patients who received and completed the RAISE screener and asked for assistance, March 2024 – August 2025

Evaluation of RAISE among MBC patients: We administered an evaluation survey to 41 individuals, 33 of whom completed the RAISE screener and 8 patients who were documented as having been sent the screener but who did not complete it. Of those who completed the screener, 88% (29/33) reported that they were somewhat or very satisfied with RAISE, and 79% (26/33) reported that the screening questions were clear to them. Regarding the timing of RAISE, 9% (3/33) recommended administration before the first medical oncology visit, 49% (16/33) recommended administration at the first medical oncology visit, and 42% (14/33) recommended administration within one month of that visit. Among the 8 patients who did not complete the RAISE screener, reasons for noncompletion included not knowing what RAISE was, not remembering getting the email to log in and complete the screener, having it sent at an inconvenient time, thinking the questions were not applicable to their situation, and preferring that a nurse or patient navigator ask the questions (vs. completing them independently online).

Table 2 summarizes findings from patient and provider/staff interviews. Key themes that emerged from five patient interviews focused on utility and format of resources provided as well as preferences regarding health-related social needs (HRSN) screening. While four of the five patients interviewed reported using the booklet, none used the app. Key themes that emerged from provider/staff interviews (n = 10) focused on issues related to workflow, personnel involved in the screening/referral process, and timing. Primary barriers to implementation of HRSN screening that were noted included staffing shortages, as well as constraints related to technology, time, space, and privacy.

Table 2.

Key interview themes and findings

Patient interviews	Theme	Example
	Utility of resources for navigating mBC/employment concerns	• Compared to the app, the booklet was preferred and most utilized• Legal services content was highlighted as especially helpful
	Information delivery	• Flyers with QR code could facilitate in-clinic access to resources • Online website or booklet (vs. app) to streamline delivery of information
	HRSN screening preferences	• Autonomy in the HRSN screening process preferred rather than a facilitated conversation with a patient navigator • Screening for HRSN in clinic may not be optimal due to patient-reported anxiety surrounding medical oncology appointments
Provider interviews	Theme	Example
	Workflow/structural	• RAISE program is feasible with the need for some workflow optimization • Technological, time, space, and privacy constraints are persistent barriers to HRSN screening and referral • Need to ensure information collected is accessible/known to clinical team
	Personnel	• Human interaction (e.g., with a medical assistant or navigator) is important for sensitive screeners and conversations surrounding HRSN • Front desk staff, navigators, and medical assistants can facilitate HRSN screening in-clinic • Patient navigators and social workers are best suited to lead HRSN referrals • Short staffing is a persistent barrier to HRSN screening and referral
	Timing	• Preference for baseline (e.g., soon after mBC diagnosis) and periodic HRSN screening based on patients’ needs.

mBC, metastatic breast cancer; app, application; HRSN, health-related social needs

Discussion

Following recommendations from organizations such as the National Cancer Institute [17], National Comprehensive Cancer Network, American Cancer Society [18], and the National Academies of Sciences, Engineering, and Medicine [19], systematic screening and navigation for unmet HRSN has been rapidly expanding across healthcare settings, including as part of outpatient oncology. A 2022 survey of 258 National Cancer Institute Community Oncology Research Program practices found that a majority (79%) had implemented a screening process for HSRN including transportation, housing, and food insecurity [20]. While it is encouraging that oncology practices across the country are now routinely screening patients for unmet needs and referring them to relevant resources, challenges to optimally implement these programs are common. In our QI pilot program, though our sample size was limited, screening for employment-related needs appeared to be acceptable to patients surveyed as part of our evaluation, though we did encounter barriers that hindered systematic screening, including relatively low pre-visit screening uptake of the questionnaire and challenges with integration of in-clinic screening (e.g., through kiosks or tablets) into the clinical workflow. Further, we found our original algorithm did not capture all patients with mBC, underscoring the challenge of using ICD codes to systematically identify patients with a specific clinical diagnosis.

Navigation to resources also was feasible for the subset of patients who requested additional follow-up (n = 22), though this number of patients was also lower than we had projected. One potential explanation is that we did not restrict screening to certain age groups or to people who reported employment. As such, we had some older respondents who might be retired or not be as concerned by employment issues. If we had limited screening to a younger sample, we expect we would have observed higher proportional uptake.

In recent years, digital literacy (defined by the American Library Association as “the ability to use information and communication technologies to find, evaluate, create, and communicate information, requiring both cognitive and technical skills”) [21, 22] has emerged as a significant or ‘super’ determinant of health [23]. At our community site, the designated navigator contacted patients to administer the screener to ensure these patients were offered the same opportunity to have unmet employment needs identified and addressed. While this strategy increased our completion rate and was feasible given the relatively low volume of eligible patients (~ 2–4 patients per week), direct outreach in oncology practices with few resources or with larger patient volumes may not be feasible or sustainable given that it can be a labor and time-intensive approach. Similarly, a recent QI project at another academic cancer center found that HRSN screening completion in a gynecological oncology clinic increased when medical assistants helped to support completion of the social needs screener [24], contributing to the success of this program. In addition to the observed low uptake of screening via the patient portal, our evaluation revealed that the paper booklet that was provided to patients by the navigator was primarily used by patients and not the app that they were also offered access to, highlighting the importance of asking patients their preferences around educational resource format and delivery.

Another observed barrier in both our academic and community practice settings was related to the incorporation of screening into the existing clinical workflow. While tablet computers were available at appointment check-in as well as an EMR “flag” to prompt staff to offer the tablet to patients who did not complete the screener before their medical oncologist visit, in-clinic screening was inconsistent. Specifically, the lack of a designated staff member to systematically identify eligible patients or help patients deal with technological questions while using the tablet proved to be a barrier to integrating and maintaining this approach into the check-in workflow. Our experience indicates that adaptation of our implementation strategies will likely be necessary, including modification of the current clinical workflow, to more effectively and efficiently integrate screening in the future.

Both the EHR-based screener, as well as the app and booklet, were only available in English and Spanish. We recognize that this limited our ability to reach patients who may have benefited from the RAISE program but did not speak English or Spanish. Future translation of materials into additional languages prevalent in our hospital system (e.g., Mandarin and Haitian Creole) as well as partnering with a translation service to support navigation of these patients would enable broader access to these resources. Additionally, ensuring patient portals are accessible to patients who speak other languages should be a priority to mitigating digital health literacy inequities. A recent analysis inclusive of over 500 hospitals across the United States found that only about 10% of hospitals offered patient portal access in languages beyond English and Spanish [25].

While the impact on downstream health outcomes has been mixed, there has been some evidence to support the efficacy of addressing unmet social needs on reducing healthcare costs as well as other positive healthcare utilization metrics (e.g., hospital readmissions) [26]. A recent QI project led by the American College of Surgeons that included 194 academic and community oncology sites across the United States systematically identified patients with a history of missed radiation therapy appointments, with sites implementing strategies tailored to their health system including screeners, navigation, and improved workflows, to reduce barriers to care [27]. The program was successful at reducing missed appointments in selected cancer types across both academic and community settings, demonstrating the potential for implementation of tailored, systems-level approaches to improve utilization as well as clinical outcomes [27].

Findings from our pilot should be interpreted in the context of several limitations. We acknowledge that the number of participants reached in our pilot was lower than anticipated. As noted, our algorithm captured a lower than expected number patients with mBC, which limited us from reaching additional patients who would have been eligible to receive the screener. We have continued to work with our informatics team to identify more accurate approaches to better capture diagnoses in a systematic way to enable identification of specific subsets of patients, including those with mBC for future efforts and studies. Additionally, in the evaluation phase, while we had a target survey sample size of 50, we surveyed only 41 patients and the five patient interviews may not have reached the threshold of saturation as intended. Therefore, conclusions about feasibility and acceptability are preliminary and should be interpreted with caution. Additional limitations include generalizability given that the implementation of the RAISE program was limited to two urban hospitals with unique workflows. Despite the availability of the RAISE screener in English and Spanish, due to staffing constraints, we were unable to conduct interviews and surveys as part of the evaluation in Spanish. Additionally, we actively screened patients for less than 18 months; it’s possible that a more extended pilot would have yielded greater impact and allowed us to further optimize workflows.

Conclusions

Findings from our pilot, including feedback obtained from our patient, provider, and staff evaluations, are helping to inform implementation processes and workflows for collection of other electronic patient-reported outcomes, including expanded screening for unmet HRSN and financial hardship among cancer patients across the NYP network. Through this process, we have carefully considered the challenges that were encountered during RAISE (low pre-visit screening uptake and integration of in-clinic screening) to inform the roll-out of these additional HRSN screenings. Our future efforts will include a robust evaluation of these workflow processes with the goal of improved uptake of systematic screening, efficient and targeted deployment of referrals for assistance, with the potential to expand to include patients with other types of cancer who might benefit.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Authors LCP and SR designed the study. CZ, DD, LJ and ZH collected and analyzed data. KE, AM, and DW provided input on study materials, implementation processes, and interpretation of findings. LCP, VB and SR drafted the manuscript with support from all authors. All authors discussed the results and contributed to the final manuscript.

Funding

This work was supported by Pfizer and the Conquer Cancer Foundation. The authors declare no conflicts of interest.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Human ethics and consent to participate

Given that this was a quality improvement project, the Weill Cornell Medicine deemed this as exempt (not human subjects research IRB# 23-08036435-01). As such, we did not collect informed consent from participants.

Competing interests

The authors declare no competing interests.