Real World Health Care

Cancer Care Alliance Helps Health Systems Build Patient Navigation Into Routine Care

In 2022, a unique, multi-site alliance was formed to advance health equity by improving timely access to high-quality, culturally responsive cancer care for patients from underserved communities.

Funded by a $20 million investment from a corporate foundation and led by the National Program Office (NPO) at the VCU Massey Comprehensive Cancer Center and VCU Center on Health Advancement, the Alliance for Equity in Cancer Care (Alliance) was established as a five-year initiative to address systemic inequities that cause barriers to care, such as social drivers of health (SDOH). Grantee sites work alongside community organizations to better reach populations disproportionately affected by cancer, developing tools and resources to help cancer facilities deliver care more equitably.

What makes the Alliance’s model unique, said Marcie S. Wright, PhD, MPH, Deputy Director of the Alliance, is that it addresses these issues, not one patient at a time, but holistically, by helping health systems build the support systems needed to make equitable patient care a routine part of cancer care.

Alliance Grantees Advance Best Practices in Patient Navigation

Marcie S. Wright

“Patients with cancer must move between screenings, diagnostics, multiple specialists, multiple treatments, and long-term follow-up care,” Dr. Wright said. “Without proper support, there are many opportunities for patients to fall between the cracks. That can lead to missed appointments, delays in care, and poorer treatment outcomes.”

To help eliminate those cracks by breaking down barriers associated with the complexity of cancer care, several Alliance grantees used their grants to develop or expand patient navigation programs at their organization:

• Mary Bird Perkins Cancer Center (Baton Rouge, LA): Mary Bird’s community partners are providing resources in community-based clinics and remote areas to help patients address SDOH needs. Most patients begin their journey with the Navigation department (comprised of nurse navigators, dieticians, and social workers) at the very first meeting with their physician. The Center is also delivering training to strengthen patient-provider communication and address unconscious bias in patient care.
• RWJBarnabas Health and Rutgers Cancer Institute (New Brunswick, NJ): Through its Oncology Access Center, RWJBarnabas is expanding patient navigation services by training clinicians in patient-centered communication and equipping health teams with technology that streamlines referrals to specialists on oncology support services. Through the patient navigation program, patients are evaluated for SDOH and other barriers. They receive a single point of contact for their oncology care, patient-centered education on clinical trial participation, and referrals to psychosocial and supportive care services and resources.
• University of Kentucky Markey Cancer Center (Lexington, KY): Markey is enhancing coordination of cancer care with digital tools that facilitate psychosocial screening, patient navigation, remote patient monitoring, and patient and provider education. The program emphasizes overcoming geographic isolation, lack of local specialists, and financial distress. They use community-embedded navigators to help patients navigate travel to the cancer center. Markey also developed a mobile app to enhance the flow of information from patients to navigators and/or care providers. Recurring remote psychosocial needs assessments are monitored by team members, and patients are provided with ongoing education and connection to resources.
• Case Comprehensive Cancer Center, Case Western Reserve University (Cleveland, OH): Through its network of community partners, Case is deploying a scalable model, involving patient navigation, support services, and education, to overcome systemic barriers to care and improve the equitable delivery of cancer care. Patient navigators at community sites work with patients who have received a suspicious cancer screening result, using psychosocial screening tools to identify barriers to care and offer support to overcome barriers by providing SDOH referrals to community support organizations.

In addition to the patient navigation programs mentioned above, the Alliance also includes:

• Memorial Sloan Kettering Cancer Center (New York, NY): Working with an extensive network of over 300 partners, the Integrated Cancer Care Access Network facilitates access, education, and patient navigation to improve patient outcomes among New York City’s diverse and limited-English-proficiency populations.
• Conquer Cancer®, the ASCO Foundation (Bozeman, MT): The multi-year pilot program targets geographic barriers to care for remote populations in Montana. It expands treatment and support services at local rural hospitals and clinics, establishing them as primary points of contact so patients can receive high-quality care closer to home.
• National Comprehensive Cancer Network® (NCCN®): NCCN is adapting the Health Equity Report Card for use in community health settings. This project evaluates the feasibility and scalability of the tool, which tracks performance measures and equity practices across four pillars: community engagement, care accessibility/SDOH, addressing implicit bias, and the overall quality and comprehensiveness of care.
• Boston Medical Center (Boston, MA): Boston Medical Center (BMC) has implemented a multilevel systems intervention to help marginalized patients navigate complex cancer care. In collaboration with local and national stakeholders, BMC uses evidence-based patient navigation, real-time patient registries, individualized social and psychological distress screenings, and updated navigation policies to ensure sustainable, equitable care.

Across its sites, the Alliance has significantly expanded the reach of SDOH barrier screening and navigation services, enabling earlier identification of patient needs and more timely intervention. At the same time, the implementation of closed-loop referral systems and real-time tracking has improved the likelihood that patients not only receive referrals but also successfully connect to and benefit from those services. These improvements have contributed to more consistent care delivery, reduced delays, and enhanced patient support throughout the care continuum.

Alliance grantee efforts:

• Provided patient navigation services to 4,007 patients
• Identified 3,476 patients with at least one SDOH concern
• Referred 2,656 patients to SDOH-related support services
• Resulted in 2,296 unique patients using SDOH referrals
• Led to 91.9% total patient treatment adherence across sites

While these numbers provide good evidence that the Alliance’s efforts are working to improve timely care, Dr. Wright stressed a bigger take-away: Evidence that equitable cancer care is not a “unicorn” – it’s feasible, achievable, and can be built into the everyday practice of cancer care.

“The Alliance has demonstrated measurable improvements across participating sites, reflecting meaningful progress in increasing access to services, strengthening care coordination, and improving overall system efficiency,” she said. “These outcomes result from integrating standardized workflows, data-driven decision making, and community-based partnerships into routine care delivery.”

Solving Implementation Challenges Together

According to Dr. Wright, one of the reasons VCU’s Massey Comprehensive Cancer Center and Center for Health Advancement were chosen as the Alliance’s NPO was their national reputation for advancing health equity through community engagement and developing practical, evidence-based solutions that improve access to high-quality cancer care.

“We’ve had a long-term commitment to looking at cancer from bench side, to bedside, to the community,” she said, noting that VCU’s commitment extends beyond its Richmond catchment area to the entire Commonwealth of Virginia. “Our philosophy is that a person’s zip code, race, or background should not determine their outcomes or chances of surviving cancer.”

As the NPO, Dr. Wright’s team acts as the coordinating hub for the Alliance, providing technical assistance, leading cross-site evaluation, and facilitating collaboration among the partners. A big part of the job is identifying and disseminating scalable best practices among the wide variety of partners – from large academic medical centers to small community clinics and even hospitals that did not previously have navigation programs.

Ensuring Sustainable Practices

As the Alliance’s funding expires in 2027, Dr. Wright and grantee sites are focused on ensuring the sustainability of the programs developed under its auspices. For example, some patient navigation positions funded under the Alliance are being transitioned to permanent, health system-funded roles. Work is also underway on an educational training app designed to help grantees move through the Center for Medicare and Medicaid Services (CMS) Principal Illness Navigation (PIN) code program and ensure effective billing for professional navigators.

“We’re working on identifying best practices and driving policy changes to ensure the effective use of patient navigators moving forward,” concluded Dr. Wright. “And we continue to develop implementation tools, publications and presentations to help everyone understand that the work of the Alliance is not just a one-off project. It’s a sustainable effort that can be scaled into the everyday processes and life of any cancer center.”