DESCRIPTION (provided by applicant): Nearly 70% of people living with cancer are "complex patients" with multiple chronic conditions who must deal not only with effects of their cancer but also continuing diseases such as diabetes, depression, hypertension, or heart disease. Poor, under- and un-insured individuals have highest burdens of multiple chronic conditions and this is also true for cancer survivors. At Parkland the Dallas county integrated safety- net system, 72% of cancer patients are racial/ethnic minorities, 70% are uninsured, and more than 60% have three or more chronic conditions that require coordinated management for optimal outcomes. However, survivors are often lost in transition between primary care and oncology care, resulting in fragmented and poor quality care. For example, our preliminary data show only 43% of colorectal cancer survivors with diabetes at Parkland were appropriately followed up for both cancer recurrence and diabetes care. Upon initial cancer diagnosis, the immediate concern is receipt of cancer treatment. But, upon treatment completion, patients need coordinated care for all their chronic conditions, which now include cancer. Care coordination strategies shown to be effective in improving outcomes for common medical conditions seen in primary care include: systematic transitions for patients to and from specialty care; intensive case management; and a team- based approach to comprehensive care. Despite an Institute of Medicine report suggesting these strategies as potential ways to improve care for cancer survivors, their implementation has not yet been evaluated for cancer survivors. To address this gap in knowledge, we will: (Aim 1) Implement a system-level EMR-driven intervention for 1000 complex cancer survivors at Parkland, combining three evidence-based care coordination strategies; (1) EMR-driven registry to facilitate patient transitions between primary care and oncology care, (2) co-locate a nurse practitioner trained in care coordination within a complex care team, and (3) enhance teamwork through coaching and technical assistance; (Aim 2) Test effectiveness of the strategies on system- and patient-level outcomes using a rigorous, quasi-experimental design with outcomes measured before and after implementation; (Aim 3) Elucidate system and patient factors that facilitate or hinder implementation and result in differences in experiences of care coordination between complex patients with and without cancer. We will collect quantitative (EMR data, patient surveys) and qualitative (structured observations, patient and provider interviews, EMR audits) data throughout. Parkland leaders are committed not only to improving care for vulnerable patients but also to collaborating with researchers to learn ways of sustaining and disseminating best practices to provide high quality care. Our longstanding track record of conducting research in partnership with Parkland will enable us to successfully accomplish our aims and to foster dissemination of tested tools and strategies to other safety-net systems seeking to improve care coordination for complex cancer survivors.
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