Table 1 Intervention components, functions, and implementations strategies

Patient registry

Capture patients with the following attributes:

• Stages I–III breast or colorectal cancers

• Diagnosed with ≥ 1 of the following chronic conditions: diabetes, hypertension, chronic lung disease, chronic kidney disease, and/or chronic heart disease

• Presenting at medical oncology clinic

Full-time nurse coordinator with competencies in care coordination co-located in oncology and primary care

Coordinate care for patients identified through registry:

• Establish relationships with providers and staff in oncology and primary care

• Facilitate appointment scheduling between primary care and oncology

• Coordinate lab tests and appointment referrals to specialty care

• Track appointments and results

• Assign PCP to patients with cancer presenting through the emergency department

Ensure continuity of care between treatment and survivorship phases

• Notify primary care providers (PCPs) of patient completion of cancer treatment and transition to survivorship phase

• Initiate treatment summary and follow-up guidelines and synthesize patients’ medical and cancer history

Identify champions^a

Identify providers, staff, and other system stakeholders to advocate for interventions, support intervention implementation, and provide ongoing feedback

Change record systems^a

Incorporate patient registry into existing electronic health records system using the EPIC Reporting Workbench

Create new clinical workflows^a

Develop new clinical pathways between primary care and oncology (or emergency department, primary care, and oncology) incorporating the nurse coordinator to improve care coordination and clinical outcomes for patients

Flexibility in implementation

Respond in real time to implementation challenges and/or opportunities based on stakeholder feedback