Care Coordination and Communication Program in Oncology for Tribal Health Systems

PROJECT 3: C3PO CARE COORDINATION: PROJECT SUMMARY Despite significant improvements in their overall health, AI/AN populations continue to face marked disparities in cancer outcomes. While reasons for this are multifactorial, suboptimal coordination of care contributes to fragmented care, less comprehensive supportive services, and delayed access to cancer treatment.

Coordination of care between the AI/AN health care system and cancer care systems is particularly challenging due to the need to coordinate health services for patients across multiple agencies, levels of government, and the private sector. The AI/AN health care system comprises the federally operated Indian

Health Service, tribally operated health services, and Urban Indian Health Clinics, collectively known as the ITU system. ITUs must generally refer their patients with cancer to non-ITU specialists, who may not understand the nuances of the ITU referral processes, nor understand locally relevant Indigenous Knowledge

and values. These barriers lead to decreased access to cancer care services and delays in treatment. The Care Coordination and Communication Program in Oncology for Tribal Health Systems (C3PO) proposes to improve cancer outcomes for AI/AN patients by implementing a novel, navigation-based, collaborative care model grounded in Indigenous Knowledge and centered on telehealth care coordination

meetings, or “Huddles,” between an NCI designated cancer center and ITU facilities. C3PO will test the implementation and effectiveness of this patient-centered intervention comprising clinical and supportive staff from the Stephenson Cancer Center and partnering ITU facilities in Oklahoma. This project features a hybrid

effectiveness-implementation type I randomized controlled trial (RCT) involving AI/AN patients to assess C3PO's impact on patient-reported and clinical outcomes. Specific aims include: (1) Explore the unique needs of AI/AN persons with cancer to inform C3PO's approaches to addressing these needs from the perspectives

of AI/AN patients, caregivers, referring ITU clinicians, and SCC clinicians; (2) Assess the impact of C3PO on patient-reported and clinical outcomes in an RCT, hypothesizing that participants assigned to C3PO will have higher patient-reported satisfaction, fewer missed visits, treatment initiation, and fewer treatment interruptions

compared with participants assigned to usual care; and (3) Identify facilitators and barriers for C3PO implementation, adoption, and maintenance using the PRISM RE-AIM framework and cost of the implementation and maintenance to assess sustainability. By bridging communication gaps between ITUs and a large cancer center, C3PO seeks to improve cancer outcomes for AI/AN patients with cancer through a novel

and scalable collaborative care coordination to address the clinical, financial, social, and cultural needs of AI/AN cancer patients.