Screened but still struggling: Challenges in delivering financial assistance after positive financial toxicity screens.

4 Background: Financial toxicity (FT) in cancer care is associated with delayed treatment, decreased quality of life, and worse survival. While FT screening is increasingly implemented in clinical settings, a critical gap remains between identifying distress and delivering effective interventions. We assessed follow-up actions and barriers encountered by patient financial services (PFS) staff after a positive FT screen. Methods: FT screening was implemented as part of routine care at a large urban comprehensive cancer center. Patients in breast, gynecologic, gastrointestinal, and thoracic clinics received an electronic survey through the patient portal prior to a treatment visit; an iPad was offered at check-in if needed. The screening included a 12-item FT assessment and an essential needs checklist. Upon a positive screen, the patient was given the option to be contacted by PFS. This analysis focused on outcomes after a positive FT screen, collected between March 2023 and December 2024. We examined the proportion of cases in which PFS staff documented an attempted follow-up, successfully intervened (defined as any documented action), or connected patients to financial assistance programs. Patients could be referred to multiple interventions. Barriers to intervention, including inability to contact patients and patients declining assistance, were also characterized. Results: PFS documented attempted follow-up in 3,383 positive screens. Of those, 45% (n = 1,510) resulted in a documented intervention. Barriers to intervention included inability to contact the patient (43%, n = 1,464) and patients declining assistance (13%, n = 428). Among those with interventions, counseling was the most common action: 29% (n = 983) received information on financial assistance programs and 12% (n = 402) received insurance-related counseling. Referrals to formal assistance programs occurred in 20% (n = 666) of follow-up attempts. Among 815 total referrals, 56% (n = 457) were to the Financial Assistance Program (FAP), 40% (n = 329) to social work for other support, 31% (n = 255) to the quality-of-life fund, and 4% (n = 35) to co-pay assistance, with multiple referrals possible from responses to the FT screen. Conclusions: Even after screening positive for FT, many patients did not receive an intervention. The absence of an intervention may not necessarily indicate a lack of action, but reflect patients declining PFS contact after a positive screen, limitations in contacting and follow-up with patients, and the strain on an already busy PFS team, which had taken on approximately 300 additional positive screens each month since the survey’s launch, without a corresponding increase in staffing or support. These findings underscore the importance of pairing screening initiatives with sufficient infrastructure to ensure timely, meaningful follow-up.