Care Coordination for Complex Cancer Survivors in an Integrated Safety Net System

This project is a pragmatic trial. The investigators propose a quasi-experimental design
where data will be collected both pre- and post-intervention on distinct cross-sections of
patients with one or more highly prevalent ambulatory-sensitive chronic conditions (diabetes,
hypertension, chronic lung disease, chronic kidney disease, depression, or heart disease) and
newly diagnosed with breast, colorectal, or gynecologic cancers (complex cancer survivors) in
the Parkland Health & Hospital system (Dallas, TX).

Guided by the "Primary Care Change Model", Parkland will implement evidence-based care
coordination strategies to improve care for complex cancer survivors in this integrated
safety-net system as a part of quality assurance/quality improvement activities (Aim 1), then
this study will comprehensively evaluate how these strategies are implemented in the
safety-net setting (Aim 3), and whether implementing these strategies improves care
coordination and care outcomes (Aim 2) within the Parkland Health and Hospital System.
Investigators expect approximately 1000 new survivors with ≥ 1 prevalent chronic condition to
be eligible. The project does not include patients diagnosed with in situ and metastatic
disease (Stages 0 and IV) due to insufficient evidence for routine follow-up and management;
many of the latter continue indefinitely on active treatment for symptom management. The
chronic conditions selected for inclusion are the most prevalent conditions cancer survivors
have at Parkland as well as nationally.

- Aim 1: (Quality Assurance/ Improvement) Implement a system-level EMR-driven intervention
for approximately 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: (Research component) 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: (Research Component) 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. Investigators will collect
quantitative (EMR data, patient surveys) and qualitative (structured observations,
patient and provider interviews, EMR audits) data throughout.

Inclusion Criteria:

1. Adult patients over 18 years of age;

2. AND diagnosed with Stage I-III incident breast or colorectal cancers;

3. AND with one or more of the following highly prevalent ambulatory-sensitive chronic
conditions (diabetes, hypertension, chronic lung disease, chronic kidney disease,
depression, or heart disease).

Exclusion Criteria:

1. Patients with in situ cancers (Stage 0) and those with metastatic disease (Stage IV);

2. OR Patients with impaired hearing or speech;

3. OR Inability to speak English or Spanish.