Patient Navigation in Improving Patient-Centered Care for Newly Diagnosed Cancer Patients

PRIMARY OBJECTIVES:

I. To identify vulnerable patients newly diagnosed with cancer who experience multiple barriers to care from the four Massachusetts General Hospital (MGH) community health centers and surrounding communities using population-based technology system.

II. To develop and implement a patient navigation (PN) program to navigate these newly diagnosed vulnerable patients from the four MGH community health centers and surrounding communities to receive timely, patient-centered care at the MGH Cancer Center and/or its affiliate the MGH North Shore Cancer Center.

III. To evaluate the impact of the PN Program on adherence to treatment by randomizing eligible patients to receive either in-person navigation or enhanced usual care at a ratio of 1:2 and comparing two groups.

IV. To improve coordination between primary and specialty care using integrated electronic health records.

V. To strengthen patient-provider communication and empower vulnerable patients to be engaged in treatment decisions including participation in clinical trials.

VI. To integrate psychosocial support and palliative care for this vulnerable population.

OUTLINE: Patients are randomized into 1 of 2 arms.

ARM A: Patients receive in-person navigation of cancer care services at time of diagnosis including education, appointment reminders, help with insurance, transportation, navigating the Cancer Center, assisting in finding appropriate child care, interpreting, connecting the patient to psychosocial and/or palliative care teams, and physically escorting the patient to appointments.

ARM B: Patients receive enhanced usual care at time of diagnosis consisting of phone call reminders about upcoming appointments at the MGH Cancer Center and/or its affiliate the MGH North Shore Cancer Center.