(Not) Lost in Transition—Enhancing Patient-Reported Care Coordination by Bridging Oncology and Primary Care for Breast and Colorectal Cancer Survivors

PURPOSE Over 70% of cancer survivors also have chronic conditions requiring coordinated care throughout survivorship. Few intervention studies have focused on improving care coordination between oncology and primary care during active treatment, specifically among under- and uninsured survivors. This study evaluated the effectiveness of Project CONNECT, a system-level intervention using an EHR-based registry and an oncology nurse coordinator, in improving patient-reported care coordination among breast and colorectal cancer survivors with at least one chronic condition seen in a large, urban, safety-net health system. METHODS Using a pre-post quasi-experimental design, 294 patients diagnosed with stage I to III breast or colorectal cancer and ≥1 chronic condition were administered a telephone survey before intervention and 6 and 12 months after intervention to measure patient-reported care coordination. Summary statistics described patient characteristics, and generalized estimating equation assessed adjusted population-average changes in care coordination. RESULTS The mean age of eligible patients was 56 years (standard deviation = 9.54). The majority of the survivors were women (78.6%). Race/ethnicity distribution of the sample represented the patient population of the safety-net health system with 45% White, 34% Black, and 51% Hispanic. Nearly 80% had ≥1 chronic conditions. After the intervention, patient-reported care coordination scores demonstrated significant improvement (β = –.05, P = .016). Notably, the proportion of survivors reporting never or rarely receiving confusing or differing information about their health or treatments decreased by 11% after the intervention. CONCLUSION An EHR-based registry of cancer survivors with chronic conditions supported by an oncology nurse coordinator assisting survivors to establish or maintain primary care during active cancer treatment is a promising strategy to bridge the transition between oncology and primary care for cancer survivors receiving care in a safety-net heath system.