This article is the fifth in a 10-part series highlighting the work of the Alliance for Equity in Cancer Care, a national initiative focused on expanding access to high-quality cancer care for underserved communities.
Each installment will spotlight a different Alliance grantee site, exploring how healthcare teams are partnering with community organizations to break down barriers to care and reimagine what navigation looks like on the ground.
Through these stories, we’ll see how tailored, community-informed solutions are making cancer care more accessible.
Embedded across the care continuum, patient navigators serve as vital connectors guiding individuals throughout their care journey. Thanks to the Promoting Access, Resources, and Treatment through Novel and Equitable Solutions (PARTNERS) for Cancer Care initiative, the handoff between those connectors is being streamlined.
PARTNERS is building a vital safety net of medical and community resources working together across a network of hospitals, clinics, a Federally Qualified Healthcare Center (FQHC), and community groups.
Led by Case Western Reserve University, PARTNERS strives to make care more equitable, efficient, and patient-centered—ensuring no one is left behind. The initiative emphasizes necessary system-level changes and community involvement to develop a sustainable, patient-focused navigation system across multiple organizations while leveraging lessons learned to create a healthcare approach that is both community informed and outcome driven.
Building a sustainable navigation system in cancer care begins with understanding the challenges at every level of the healthcare landscape. The journey for the PARTNERS program started with a comprehensive assessment of the existing system.
To understand strengths and shared challenges across collaborating sites, the team conducted an online Qualtrics survey, site visits, and qualitative interviews with all PARTNERS organizations: 2 units within a large health system, 1 federally qualified health center, and 2 community-based social needs organizations.
Through these assessments, common obstacles were identified: staffing shortages, unreliable communication during care transitions, and data integration complexities. These insights highlighted the need for a targeted focus on patient navigation as a vital component in coordinating care, thereby reducing fragmentation and engaging patients more effectively.
In today’s technology-driven world, one might assume that advancements would seamlessly translate into improved patient care. However, the reality is often different, especially in large, multi-institutional systems where traditional electronic health records can fall short in facilitating efficient data sharing across healthcare institutions. Ongoing communication issues—stemming from incompatible data systems, different workflows, and varying operational priorities—continue to present significant challenges.
Recognizing this shortcoming, the PARTNERS program implemented a low-cost, customized patient-tracking dashboard built on the secure REDCap platform and approved through an institutional review board protocol. This innovative tool enables navigators to monitor patients’ social needs, record resources, and communicate effectively across organizations without encountering interoperability challenges. With this solution, PARTNERS has shown that creativity in using existing technology can dismantle systemic barriers and promote collaboration, ultimately fostering a better environment for patient care. The REDCap tool allows for adaptation by other institutions and has emerged as a viable approach for other organizations seeking interinstitutional coordination.
Shared tools like referral dashboards and patient-tracking platforms now enable real-time information exchange for dozens of patients, ensuring that individuals don’t fall through the cracks as they move through screening, diagnosis, and treatment (Figure).
Recognizing the importance of empowering patient navigators, PARTNERS places significant emphasis on professional development. The program encourages navigators to enhance their skills and confidence through activities like cross-site shadowing, peer mentoring, and participation in study groups. Such initiatives have helped navigators complete professional patient navigator certification through the Patient-Centered Education & Research Institute, ensuring the PARTNERS team is well equipped to guide patients effectively through the continuum of care.
“The [support] I have received through the PARTNERS program has taught me to look at situations for more than what they appear to be and to dig deeper to identify the roots of problems patients face.” —Team Navigator
Biweekly forums for navigators and leadership provide care team members with opportunities to exchange strategies, troubleshoot challenges, and highlight best practices. By fostering a strong community of practice, the PARTNERS initiative elevates individual expertise and strengthens the entire patient navigation network. “The [support] I have received through the PARTNERS program has taught me to look at situations for more than what they appear to be and to dig deeper to identify the roots of problems patients face,” shared a navigator on the team.
This collective growth in knowledge and skill is pivotal for creating an effective and sustainable navigation system across institutions, proven true by the recent hiring of a full-time patient navigator within the University Hospitals Seidman Cancer Center. The navigator is fully supported through the clinic’s operating budget, thanks to leadership buy-in and institutional support. The navigator is a part of the diagnostic clinic team, with continued PARTNERS support to refine workflows and document processes related to navigation and social needs.
While systemic changes are critical, they alone are insufficient to achieve equitable health outcomes. Patient care must also be informed by the communities it serves. Engaging directly with the community not only provides valuable insights but also builds the trust necessary for successful interventions. The PARTNERS initiative recognizes that inclusive representation is key to driving equitable healthcare outcomes.
To this end, the program actively seeks engagement from diverse groups, including African American, Hispanic, and low socioeconomic communities, through its Community Advisory Council (CAC), which was established in 2023. In Cleveland, 47% of the population is African American or Black, and in Lorain County, where one of the PARTNER organizations provides services, 11% of the county is Hispanic. The city of Cleveland is reported to be the second poorest urban center in the country, with a 31.2% poverty rate disproportionately affecting non-Hispanic Black or African American residents. By prioritizing community involvement, PARTNERS elevates the voices of those most affected by healthcare disparities.
The CAC brings together local leaders, healthcare providers, and individuals with lived experiences in the healthcare system, ensuring community members play an integral role in shaping the program’s initiatives. The insights gained from CAC engagement have helped pave the way for improved healthcare outcomes. From strengthening patient–provider communication to fully integrating navigators into both community and healthcare settings, the CAC has helped inform strategies that address the real needs and barriers patients face. CAC members were instrumental in providing navigators feedback on the patient engagement experience through roleplaying exercises and mock patient scenarios.
The exercise shed light on the importance of navigators knowing when to listen—and when to offer support—a critical balancing act that builds both trust and engagement. CAC members also emphasized that successful navigation relies heavily on strong connections and awareness of services, reiterating the importance of open communication channels within healthcare systems as well as among clinical and community partners.
For patients and families navigating the complexities of cancer, the promise of support, understanding, and advocacy is becoming a reality. PARTNERS’ collaborative approach proves that a more connected healthcare landscape is possible, one where everyone has access to the care they need. As part of the Alliance for Equity in Cancer Care, these efforts have led to critical lessons learned for the PARTNERS team, many of which they are now well positioned to overcome.
First and foremost, the team recognized that communication is essential—clear, timely, and transparent communication remains vital to coordinated, cross-institutional patient care. Effective information sharing prevents delays, supports problem-solving, and ensures that no patient is lost in transition between systems.
Secondly, that relationships drive success: while technology can facilitate information sharing, it cannot replace human connection. Trust and collaboration among navigators, clinical staff, and community partners are foundational to effective navigation.
Lastly, the PARTNERS team found power in knowledge transferability. Without exchangeable, scalable knowledge, there is no progress. The key to continued success is the ability to gain insights from one organization to the other and apply findings broadly across similar settings.
Transformation in cancer care doesn’t happen overnight, but with dedicated patient navigators, a focus on community engagement, and strategic partnerships among healthcare institutions, significant advancements can be achieved. The PARTNERS initiative is a testament to what is possible when those systems come together with a shared vision of equitable, patient-centric care. Collaboration among hospitals, clinics, FQHCs, and community organizations is a powerful model for addressing disparities and improving cancer outcomes.
The project has begun developing a navigation “playbook” to capture processes, lessons, and tools essential for capacity building across various organization types. This comprehensive resource will serve as a practical guide for those seeking to build or strengthen their own patient navigation programs, offering adaptable frameworks for integration across various care settings.
As the program continues to evolve, there are still challenges to confront. Ensuring consistent funding, improving data sharing, and maintaining robust community engagement remain paramount as the initiative expands. However, the foundation laid by the PARTNERS program offers hope and inspiration for a brighter future in cancer care.
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