Bridging gaps to improve referrals to cancer rehabilitation and exercise services for older adults: Co-creation of a primary care referral process through qualitative interviews.

INTRODUCTION: Cancer rehabilitation and exercise services (CaRES) improve physical function and survival. Yet, CaRES remain underutilized by survivors, despite the availability of ≥2000 CaRES nationwide. To date, CaRES referrals have originated primarily from oncologists. Primary care providers (PCPs) are an untapped potential referral source, particularly for older cancer survivors (≥65 years) who often have long-term PCP relationships. This study aimed to explore multi-level perspectives on primary care referrals to CaRES and co-create a prototype referral process.

MATERIALS AND METHODS: Individual semi-structured interviews were conducted with three groups: (1) older cancer survivors (≥65 years), (2) PCPs, and (3) CaRES directors. Semi-structured interview guides were developed with guidance from the Pragmatic Robust Implementation and Sustainability Model (PRISM) to understand factors that could influence PCP referrals to CaRES. Two rounds of iterative feedback on a prototype CaRES referral process were obtained. Interviews were recorded, transcribed, and deidentified. Transcripts were analyzed using rapid matrix analysis with domains mapped onto PRISM. After the completion of all interviews, the final prototype referral process was distributed to all participants for member-checking.

RESULTS: PCP-initiated CaRES referrals were viewed as appropriate by survivors (n = 5), PCPs (n = 6), and CaRES directors (n = 7). However, PCPs were not aware of CaRES, "…you'd have to make sure that providers are aware of it… I wasn't aware of it," (3-PCP). Two key needs for the referral process were: (1) initial PCP education about CaRES and (2) embedding the referral process into existing workflows. CaRES directors stated that successful referral processes to date have required tailoring to individual clinics, "We…discuss what their referral process is internally, and how we can fit this referral with what's already going on in their workflow" (11-Director). Iterative feedback on the referral process resulted in a wireframe prototype of a clinical decision support tool for CaRES referrals.

DISCUSSION: The PCP-initiated CaRES referral process was of interest to cancer survivors, PCPs, and CaRES directors, but will require tailoring to individual clinic workflows. PCP-initiated CaRES referrals may expand the reach of CaRES by providing another opportunity, in addition to the oncology care team, for patients to learn about and connect with CaRES.