Sustainability Planning for Patient Navigation: Best Practices

Sustainability is the “degree to which an evidence-based program, policy, or intervention can deliver its intended benefits over an extended period of time.”¹ In other words, sustainability refers to the ability of a program or clinical practice to continue to maintain and strengthen its activities and intended outcomes for the target audience over the long term, even when faced with challenges. While this is the goal of most public health programs and practices, a common question asked by implementation teams is: How and when should you plan for sustainability?

The answer: it is never too early or too late to start planning for sustainability. No matter a program’s age or expertise, sustainability capacity will always be an important element.

Funding Stability is one of the key elements that contribute to sustainability, but there are many other important factors (also known as domains) that are instrumental in positioning programs and practices for long-term success, such as Engaged Staff & Leadership, Workflow Integration, and Monitoring & Evaluation. Here are some tips to get started, based on the best practices developed by Washington University in St. Louis² and the Colorado Cancer Screening Program (CCSP).³

1. Introduce sustainability planning and build buy-in among your internal team and partners. As you begin your sustainability planning and consideration of opportunities to build capacity for your program or practice, participate in several conversations with internal and external partners and leaders to build engagement and buy-in. Engagement and support from the internal team as well as external partners is crucial to ensure that efforts to strengthen sustainability capacity incorporate the priorities and perspectives of changemakers for lasting effects.
2. Define the practice or program of focus for sustainability planning. To effectively plan for sustainability, it is important to define the scope of the program or set of activities being examined. This will ensure all individuals involved in the sustainability planning efforts have a clear understanding of what is being assessed.
3. Assemble a sustainability planning team of at least 3 to 5 individuals. The sustainability planning team should be composed of individuals representing a variety of roles directly involved in the program or practice. For example, program champions, frontline staff, program/organizational leadership, evaluation/financial specialists, and external partners could all contribute valuable and unique perspectives.
4. Identify a framework or sustainability planning tool to guide your efforts. CCSP developed the Patient Navigation Sustainability Assessment Tool (PNSAT) to support patient navigation practices in assessing their current sustainability capacity and developing a sustainability action plan to strengthen capacity. The PNSAT was adapted from the Program Sustainability Assessment Tool and the Clinical Sustainability Assessment Tool developed by the Center for Public Health Systems Science at Washington University in St. Louis. The PNSAT has been used by a variety of partners, including clinic systems participating in CCSP³ and the American Cancer Society National Navigation Roundtable.⁴ Use one of these tools to assess sustainability capacity before developing a sustainability plan.
5. Develop an actionable sustainability plan. We recommend that each member of the sustainability team complete the assessment independently to encourage robust, honest responses, then come together as a group to discuss the findings and develop a time-bound action plan. Some questions to consider include:
   1. What are the program’s/practice’s overall short-term and long-term mission and goals?
   2. What are current domains/areas of strength identified through the assessment?
   3. What are challenges and opportunities for improvement?
   4. Are there elements that the sustainability assessment didn’t capture?
   5. What are 1 to 2 domains/factors that can be feasibly strengthened by our team within the next year? Are there other domains/factors that can be addressed in the long term or by external partners?
   6. What resources are needed to elicit change within the domains of focus?

Next, develop a written plan containing the following components. Make sure to identify how you will document progress, such as a sustainability planning template and routine planning meetings.

1. SMART (Specific, Measurable, Achievable, Relevant, Time-Bound) goal
2. Action steps and timeline
3. Roles and responsibilities
4. Expected outcomes
5. Resources needed and how to obtain them.
6. Begin implementing the plan! Now it’s time for your team to take the plan and put it into action. Regular, transparent communication is key to success. Ensure there are scheduled forums to share updates and brainstorm solutions to barriers, both as a team and with external partners. Then, celebrate successes (big and small) and reassess your sustainability capacity.

Sustainability planning is a nonlinear, ongoing process. On at least an annual basis, consider sharing a recap of progress made, retaking the sustainability capacity assessment, and updating the sustainability plan based on new opportunities for improvement.

Funding Source

The Colorado Cancer Screening Program is funded by the Cancer, Cardiovascular, and Pulmonary Disease Grants Program.

References

1. Kwan BM, Brownson RC, Glasgow RE, et al. Designing for dissemination and sustainability to promote equitable impacts on health. Annu Rev Public Health. 2022;43:331-353.
2. Calhoun A, Mainor A, Moreland-Russell S, et al. Using the Program Sustainability Assessment Tool to assess and plan for sustainability. Prev Chronic Dis. 2014;11:130185.
3. Dwyer AJ, Weltzien ES, Harty NM, et al. What makes for successful patient navigation implementation in cancer prevention and screening programs using an evaluation and sustainability framework. Cancer. 2022;128(suppl 13):2636-2648.
4. Fleisher L, Staples ES, Gentry S, et al. Enhancing sustainability in patient navigation programs: perspectives from the field. Journal of Oncology Navigation & Survivorship. 2025;16(2):46-58.