ACCESS-PC: Advancing Care Coordination to Enhance Shared Care for Complex Survivors in Primary Care

PROJECT SUMMARY/ABSTRACT Cancer survivors with cardiovascular disease risk factors (complex cancer survivors) are a growing population and their morbidity and mortality risks are significant. Despite strong clinical evidence bases and established guidelines to manage CVD risks, cancer survivors often forego necessary chronic condition care especially

during cancer treatment. A shared care model (when two or more clinicians of different specialties care for the same patient) is the optimal care delivery model for complex cancer survivors and has been shown to produce optimal comorbidity management when primary care is involved. Nevertheless, in the U.S. cancer survivorship

focuses on static approaches such as providing survivorship care plans and guidelines for primary care without addressing the implementation context and care delivery processes. These approaches have proven insufficient to shift care paradigms and produce shared care for complex cancer survivors. Many currently proposed and

tested cancer survivorship care strategies are considered oncology-centric and do not align with primary care generalist orientations in managing patients with multiple chronic conditions or fit in real-world contexts of primary care practices. Results from our ongoing and recent research studies indicate that survivors managing chronic

conditions should not be disconnected from their primary care team. Therefore, feasibility issues must be addressed using stakeholder-informed strategies to enhance the translational potential of shared care that aligns multiple stakeholders (i.e., cancer care team, patients, primary care teams) understandings of this paradigm of

care and build team-based care capacities. This study employs a designing for dissemination, theory guided perspective, blending implementation science and care delivery conceptual frameworks Exploration, Planning, Implementation, and Sustainment (EPIS) and Cancer Multi-team System (cMTS) to understand and address the

multi-level factors of implementing shared care in a health system. These perspectives will shape tailoring and implementation of Primary Care Connect (PC2), a health system intervention designed to align complex cancer survivors, healthcare team members, and health system implementation actors’ understandings, capacities, and

practices to promote the adoption of shared care delivery models for complex cancer survivors. Using a hybrid type III effectiveness-implementation study design it aims to: (1) engage diverse primary care and health system stakeholders to tailor PC2 to maximize implementation strategies fit to the health system and primary care

practice contexts; (2) conduct a randomized controlled trial (n=266 patients) to test the effectiveness of PC2 on primary care connection, chronic disease management, and patient-reported outcomes; and, (3) evaluate PC2 implementation using a mixed methods approach to inform sustainable usage of the intervention. Study results

are poised to have a profound impact on the adoption of shared care delivery models throughout the U.S. to optimally mitigate complex cancer survivors CVD risks.