Using stakeholder engagement to build cancer survivorship care coordination capacity between primary and oncology care

INTRODUCTION: Cancer survivors experience gaps in access to timely and well-coordinated care. We describe stakeholder engagement activities across a university-based comprehensive cancer center and a primary care-focused federally qualified health center, which informed implementation and sustainability of community-focused cancer care coordination interventions to optimize care for underserved cancer patients in specialty and primary care. 

METHODS: Methods were systematic, iterative, and flexible to establish and maintain trust, honesty, and collaborative decision-making between academic, community, and clinical partners. First, we collaboratively identified clinical (N = 43) and patient (N = 16) stakeholders and their needs through in-depth interviews and focus groups. Then, we planned, implemented, evaluated, and modified strategies to improve cancer care coordination in response to challenges and new information. 

RESULTS: Primary care providers reported needing more information about cancer survivorship care and wanting more complete information about their patients' cancer treatment. Patients described concerns about cancer recurrence, challenges managing comorbid conditions, and economic concerns. These findings influenced the focus and implementation of a community navigation program at the academic cancer center and informed bi-directional information-sharing interventions with primary and oncology care partners, which included face-to-face meetings, service-learning opportunities, and improving data transmission through the electronic health record. 

HEALTH EQUITY IMPLICATIONS: Health systems' mutual learning and resource sharing enhance patient cancer care coordination to address social determinants of health. Engaging partners at different levels within health systems (e.g., administrative staff and clinical leadership) ensures sustainability of relationships, interventions, and advocacy for cancer patients with significant social needs.