Care Coordination for Complex Cancer Survivors in an Integrated Safety-net System
Nearly 70% people living with cancer are "complex cancer survivors" who are also dealing with multiple other chronic conditions. These complex patients need highly coordinated care to ensure optimal outcomes for their cancers, co-existing chronic conditions, and overall quality of life. However, following initial cancer treatment, needs of complex cancer survivors are not well met, resulting in poor health outcomes. To fill this gap, the project involves implementing care coordination strategies shown to be effective for primary care conditions among complex cancer survivors at Parkland Health & Hospital System.
Implementing three evidence-based care coordination strategies:
- EMR-driven registry to facilitate patient transitions between primary care and oncology care
- Co-locating a nurse practitioner trained care coordination within a complex care team
- enhancing teamwork through coaching
The effectiveness of the intervention on system- and patient-level outcomes will be evaluated using a mixed method approach to elucidate system and patient factors that facilitate or hinder implementation.