Reshaping women’s cancer prevention, diagnosis and treatment initiation via an innovative, collaborative and sustainable community-academic care delivery model

Primary care in community health clinics is crucial for population health attainment and sustainability. However, at time points along their lifespan, patients are faced with the need to seek care outside of their local, trusted site of primary care for specialty care. This is the case with cancer care, which although a highly prevalent chronic disease, is often considered very separate from primary care- as opposed to other common chronic conditions including diabetes, hypertension and even HIV. Preliminary data demonstrate that once cancer is diagnosed, care at the primary care medical home is cut off or disjointed and transferred to the site of specialty care. As such, at the point of diagnosis of an abnormal cancer screening test or cancer, patients are often referred off site for further care and treatment. It is at this juncture that primary care becomes vulnerable to gaps and breakdown. Upon return to the primary clinic site, patients and health care provider teams are often left with incomplete care plans uncertain of the appropriate next steps in primary care screening, care and follow-up post cancer diagnosis. There is a clear need to create models and approaches that bolster more connected integration between primary care and specialty care delivery. Our and others’ research consistently demonstrate that community clinic sites lack capacity, and often detailed guideline knowledge beyond general risk populations, to appropriately deliver the required spectrum of care. As a result, there are glaring gaps in patient care in the form of low cancer screening and prevention rates, ineffective screening and diagnostic processes that are arduous for patients and providers, and gaps in survivorship care plan implementation causing a loss to follow up. Building on decades of community engage research, this application aims to improve care delivery in this area in a systemic, sustainable manner that leverages the strengths of our partnership to benefit medically underserved patients and to raise the level of care for all patients. With our well-established community engaged research partnership, we propose to implement an intervention that we have created and piloted to improve care delivery in the Alliance, a large community health center network with a strong footprint in low income, minority communities across Chicago. This model is the 4R Care Delivery Model (4R = Right information and Right Treatment to the Right Patient at the Right Time) and was developed specifically to fill these stated gaps in community nested comprehensive cancer care for low income patients at community primary care practices. In addition, we will apply an innovative methodologic approach, comprehensive dynamic trials, to implement and evaluate this model of care that is rooted in a learning health system approach (whereby data are fed back into improving the system in real time). Importantly, this approach is highly congruent with the principles of community based participatory research (CBPR) to which we will adhere.