Practical Insights for Embedding Whole-Person Care into Clinical Pathways

At CPC+CBEx 2025, the session “Integrating Comprehensive Care Needs into Clinical Pathways” delivered a provocative and inspiring argument for redesigning cancer care to better meet the full spectrum of patient needs. Led by Barbara McAneny, MD, CEO of New Mexico Oncology Hematology Consultants, and Alan Balch, PhD, CEO of the Patient Advocate Foundation, the session explored a new model of care that goes beyond clinical treatment to address the financial, logistical, and social realities that define a patient’s journey.

Reframing Integration and Value in Cancer Care

“I think value-based care has lost its way,” Dr McAneny stated. She opened the session by challenging the prevailing definition of value-based care, which she argued has strayed from its patient-centered origins. In her view, the concept has become more about delivering value to payers and enabling the consolidation of large systems, rather than improving outcomes or experiences for patients. She pointed out that integration is often seen through a financial lens—where “everyone gets their paycheck signed on the front by the same guy”—instead of as a coordinated, holistic care model.

In her own oncology practice, Dr McAneny has developed an approach that places the patient’s experience at the center of care design. While oncologists often see their workday as a linear list of appointments, patients experience their care horizontally. They navigate a complex series of visits, decisions, and symptoms that ripple into every aspect of their lives. Her model seeks to understand and support patients through that entire continuum.

Preventing Crisis Through Proactive Triage

A major focus of Dr McAneny’s approach is a triage system designed to prevent hospitalizations through early intervention. Inspired by her leadership experience with Albuquerque’s Emergency Medical Services Authority, she applied emergency response principles to cancer care. Non-clinical staff are trained to ask critical screening questions related to life-threatening symptoms, and any affirmative answer triggers an immediate handoff to triage nurses. These nurses, equipped with clinical decision support tools, follow predefined pathways to determine the appropriate level of care, whether it be an urgent office visit, diagnostics, or hospital referral.

The results have been striking. Dr McAneny noted that hospitalizations for conditions like neutropenic fever have become extremely rare in her practice. By encouraging patients to call at the first sign of symptoms—before they become critical—and offering same-day in-office care, the clinic is able to manage most issues without emergency department visits. This not only improves outcomes but also spares patients the disruption, cost, and health risks associated with hospitalization.

Economic Realities and the Burden on Patients

Dr McAneny also spoke candidly about the financial strain patients endure, especially under high-deductible insurance plans. She recounted how many patients delay care because they cannot afford copays or are afraid of the financial consequences of treatment. Her practice employs dedicated financial counselors—not bill collectors, but advocates who help patients access copay assistance, charity care, and foundation support. The clinic even created a 501(c)(3) foundation to cover nonmedical expenses such as transportation, car repairs, and utility bills to keep patients in care and out of crisis.

“We’re not going to solve poverty, we’re not going to solve social determinants of health, but we’re going to take care of the patient in front of us,” she noted.

From her perspective, the burden of care often falls disproportionately on patients, even when they’re insured. Rising premiums, out-of-pocket costs, and the indirect costs of illness (like lost income and caregiving expenses) can quickly lead to financial catastrophe. She noted that half a million Americans file for bankruptcy each year due to medical costs, and two-thirds of them have insurance.

Expanding the Definition of Personalized Care

Following Dr McAneny, Dr Alan Balch offered a broader policy and data-driven perspective, rooted in the work of the Patient Advocate Foundation. His message reinforced the idea that personalized care must extend beyond genomics or treatment selection to include the logistical and financial barriers that patients face daily.

Dr Balch described “basic needs care” as a category of intervention that deserves equal footing with clinical and palliative care. This includes addressing food insecurity, housing instability, transportation issues, and utility shutoffs. For many low- and middle-income patients—particularly those with incomes under $50 000—these are the issues that most directly affect whether they can access, adhere to, and complete their treatment.

Survey data presented by Dr Balch showed that patients are not only willing to discuss these challenges with their care teams, but they expect support. However, there remains a significant gap between patients experiencing hardship and those who actually have conversations about those needs with their providers. Even among those who ask for help, nearly half report receiving none.

Dr Balch emphasized that the language used to talk about financial and social needs matters. The term “financial toxicity,” while common in academic and clinical discussions, was rated by patients as among the least preferred. Alternatives like “financial hardship” or “economic challenges” were viewed more positively and encouraged trust rather than shame.

Importantly, Dr Balch stressed the need to introduce these conversations early in the patient journey—ideally at the same time care plans are being developed. Waiting until financial or logistical challenges become visible often means it is already too late to avoid disruptions. Just as clinicians aim to catch disease early, practices must also be proactive in detecting and managing social risk factors.

“The worst thing you can do in a workflow is screen for something, find a positive response, and then not intervene,” Dr Balch cautioned.

Navigation as the Engine of Comprehensive Care

The session concluded with a shared emphasis on navigation as the critical infrastructure needed to deliver this model of care. Whether provided by nurse navigators, social workers, or financial counselors, navigation services ensure that patients are not only identified as at risk but also meaningfully supported. Dr Balch’s data showed that patients who received assistance overwhelmingly credited navigators and provider staff as the key figures who helped them through hardship.

“The key is making sure that the patients get help, making sure that they have trust and understand why this is part of their health care, that the right care was decided at the right time,” said Dr Balch. “We’re not just waiting and trying to deal with these things as they become problems.”

Ultimately, this session offered a vision of care that is not only more efficient and cost-effective but also more humane. By designing clinical pathways that account for the full scope of patient needs—not just medical ones—Dr McAneny and Dr Balch argue that health care can move closer to its core mission: improving lives.

Reference

Balch A, McAneny B. Integrating Comprehensive Care Needs into Clinical Pathways. Presented at the Clinical Pathways Congress; September 6, 2025; Boston, MA.