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AP-011

Myeloma, 26 to 64, urban, Medicaid, limited English

CAR-T · Phase 6, Recovery & Follow-up · 34 days in stage · 10 barriers, 4 blocking

Falling behind34 days in recovery and follow-up, past the 28-day target

Delivery

Navigation plan

12 tasks are on this plan, 0 still open. The engine suggests 29 in total from this patient's barriers, so 17 have no owner yet. Statuses persist here.

Completion criteria, in order

Three things that each have to be true before treatment can happen. Work here unblocks everything downstream, which is why it sits above the rest of the plan rather than inside it.

Step 1 · Reach a center

1 flag

referred and accepted for evaluation

In the way: Late referral / progression before treatment

  • Refer early — at first relapse / by 2nd line; do not wait

    Referring / community oncReach: Treatment center37 days overdue
    Done

Step 2 · Be accepted as a candidate

Clear

the center recommends treatment

Nothing on the plan clears this criterion yet.

Step 3 · Secure approval to proceed

3 flags

authorization and coverage in place

In the way: Insurance coverage & prior-authorization · Coverage lag after approval · Single-case agreement / out-of-network

  • Verify benefits and secure prior authorization before apheresis

    Treatment-center teamReach: Payer / health plan37 days overdue
    Done

  • Check the payer’s current medical policy and timeline before committing

    Nurse navigatorReach: Payer / health plan37 days overdue
    Done

  • Start the single-case agreement / out-of-state enrollment as early as possible

    Treatment-center teamReach: Payer / health plan37 days overdue
    Done

  • Secure authorization before apheresis to avoid a stalled start

    Treatment-center teamReach: Payer / health plan37 days overdue
    Done

Feasibility and support

Work that makes treatment possible and bearable rather than permitted. Regroup it along whichever axis matches how you are working today.

Refer & establish candidacy

3 tasks

  • Set up a single point of contact / intake coordinator with the center

    Nurse navigatorReach: Treatment center37 days overdue
    Done

  • Use a standardized identification trigger (If they RECUR, refer)

    Referring / community oncReach: Internal — no outside contact37 days overdue
    Done

  • Fast-track the pre-apheresis work-up to shorten decision-to-vein time

    Treatment-center teamReach: Treatment center37 days overdue
    Done

Confirm coverage & authorization

4 tasks

  • Track PA and keep appeal-letter templates ready

    Nurse navigatorReach: Payer / health plan37 days overdue
    Done

  • Apply Manatt Medicaid coverage solutions; escalate to society advocacy

    Advocacy / CBO partnerReach: Community / advocacy org37 days overdue
    Done

  • Advocate for rapid-coverage pathways post-approval

    Advocacy / CBO partnerReach: Payer / health plan37 days overdue
    Done

  • Advocate to carve the therapy into fee-for-service where possible

    Advocacy / CBO partnerReach: Payer / health plan37 days overdue
    Done

Handoffs

An explicit transfer of responsibility, tracked separately from tasks because the failure mode is different: nobody is late and nobody is idle, the work simply has no owner until somebody acknowledges it.

Referring / community oncNurse navigator

Referral received and accepted for work-up.

Acknowledged

Every task traces back to a barrier that actually fired for this patient.

  • The plan is not separate authoring. It is the assessment projected forward.
  • That is what makes it maintainable at all.