This article is the seventh 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.
Boston Medical Center (BMC) is the largest safety-net hospital in New England. As a beacon institution for all patients who walk through its doors, navigation services are paramount to achieving BMC’s mission of high-quality, accessible, and equitable care.
The Oncology Equity Alliance (OEA) at BMC partners with clinicians, patients, and health system leadership to improve access to evidence-based oncology navigation services and ensure patients are immediately connected with resources that address each element of their unique cancer experience.
Through the Alliance for Equity in Cancer Care, the OEA and BMC Cancer Center designed and implemented a standardized navigator-driven workflow for proactively identifying and addressing health-related social needs with the goal of improving timely access to oncology care.
When Boston City Hospital, the nation’s oldest municipal hospital, merged with Boston University Medical Center in 1996 to create BMC, a commitment to delivering high-quality healthcare for underserved populations in the Greater Boston area was reaffirmed. Consistent with this enduring mission, the majority of BMC patients represent communities that have been historically marginalized in healthcare systems, including low-income families, minoritized racial and ethnic groups, immigrants, older adults, and those who are underinsured or reliant on public programs such as Medicare, Medicaid, and the Health Safety Net.1-3 To ensure these populations can access high-quality healthcare, BMC prioritizes health equity and mitigates health disparities alongside its mission of providing exceptional clinical care, education, and community engagement.
Since 1999, patient navigation at BMC has played a crucial role in bringing these ideals to life. For patients with cancer, the Oncology Patient Navigation Program is an essential resource for accessing evidence-based cancer care. Patient navigators in this program are uniquely trained to address the multifaceted barriers that patients encounter throughout the cancer continuum. Patients connected with the Oncology Patient Navigation Program are given Navigator Cards that include their assigned navigator’s contact information, 3 unique resources identified by their navigator, and BMC’s “Five W’s of Patient Navigation” (Figure) that highlights the core functions of patient navigation and how it supports patients throughout their cancer journey.
Building on the longstanding foundation of patient navigation at BMC,4 the OEA takes a multilevel approach to improve the patient experience and ensure that all individuals with cancer at BMC have access to timely, equitable care. For the OEA, that approach starts with clinicians and care team members. Increasing awareness of patient navigation and evidence-based components of the navigation process across multidisciplinary care teams reduces the likelihood that patients experience gaps in care. At the patient level, coupling evidence-based patient navigation with systematic screening for health-related social needs enables BMC to address barriers to accessing healthcare that can often impede treatment access and completion. New policies and workflows have been integrated at the health system level to ensure long-term sustainability and quality of care.
The OEA has developed resources, such as the Navigator Cards, to help build awareness of the importance of navigation support among patients and providers alike. These materials are also designed with direct input from a broad network of partners. Among these collaborators are an External Advisory Council (EAC) and a Patient Advisory Group (PAG). The EAC is composed of local, regional, and national public health and navigation leaders who provide nuanced insight and advice on activities that advance community priorities. The PAG includes 10 BMC cancer patients who are deeply connected with different communities and resources throughout the Greater Boston area. Through quarterly meetings with both groups, the OEA receives direct feedback on matters related to the patient experience, community engagement, clinical policy development, and workflow implementation. The OEA also recognizes a variety of clinical champions, including staff and leaders from the Oncology Patient Navigation Program and the Cancer Center, as vital allies to more effectively deliver multilevel patient navigation at BMC.
THRIVE is BMC’s custom screening questionnaire that assesses a patient’s social needs across domains such as housing, transportation, and food. This tool allows care teams to understand and address unmet needs that may act as barriers to care.5 THRIVE is integrated with Findhelp, an electronic platform that identifies potential resources within and outside BMC. THRIVE is also integrated with BMC electronic health record (EHR) workflows to streamline patient referrals to these vital resources. EHR integration also provides opportunities for clinicians to engage with patients about their social needs and keeps dialogues focused on holistic, patient-centered care during routine clinical visits. If additional assistance is needed, clinicians can connect their patients with social workers or patient navigators who can help address individual patient needs.6
In line with Joint Commission requirements, THRIVE has become BMC’s standard for assessing patients’ health-related social needs and has been successfully implemented into primary care and emergency medicine service lines.5,7 With a focus on improving the evidence-based implementation of patient navigation, the OEA hypothesized that an oncology navigator–driven workflow incorporating universal THRIVE screening could improve patient-related outcomes.
With support from the Alliance, the OEA partnered with the PAG, EAC, Oncology Patient Navigation team, and the Cancer Center to understand the landscape of social needs assessment in oncology care and identify opportunities to augment gold-standard patient navigation services by addressing the most pressing challenges faced by cancer patients. This multistakeholder engagement approach was critical for the OEA to understand patient, clinical, and operational needs across the cancer care continuum and identify opportunities to improve access to oncology navigation services and reduce barriers to timely care. First, input from the PAG highlighted the need for a renewed assessment of health-related social needs at the time of the cancer diagnosis. For many patients, transportation constraints, financial insecurity, language barriers, and mental health concerns are pressing challenges. The OEA subsequently interviewed oncology and patient navigation staff to inform the implementation process and identify existing gaps, opportunities, and optimal integration points for THRIVE within established clinical workflows. Finally, meeting with the EAC and Cancer Center leadership helped shape the THRIVE workflow design and implementation strategy.
While the potential value of assessing and addressing health-related social needs in oncology patient navigation became clear, several implementation challenges emerged. These included department-level staffing turnover and changes in staff capacity, as well as integration of THRIVE into the oncology navigator EHR workflow. The OEA successfully addressed these challenges through regular meetings with key stakeholders to align priorities and refine implementation strategies. This enabled successful standardization of proactive social needs assessment to connect patients with a new cancer diagnosis to community-based resources before their first visit to the BMC oncology department.
Regular, consistent conversations with clinical champions and department leadership provided additional support to put the new processes in place and ensure center-wide adoption.
Overcoming these challenges was made possible by a core value of the OEA: collaboration with stakeholders at all levels. Biweekly meetings with patient navigators and Cancer Center leadership provided key implementation updates and opportunities for feedback on policy updates, patient navigation protocols, and standardization of screening procedures. Regular, consistent conversations with clinical champions and department leadership provided additional support to put the new processes in place and ensure center-wide adoption. Partnership with patient and external advisory councils ensured that implementation aligned with community values and best practices while addressing an unmet need. Updating health system policy documents to reflect the revised workflow and training protocols ensured consistency through staffing changes and laid the groundwork for sustainability.
THRIVE was fully implemented in oncology patient navigation at BMC in November 2024. In the first year, BMC oncology intake patient navigators contacted over 700 new patients and completed nearly 500 social needs assessments across all cancer types. Patient navigators connected 274 patients with identified needs to resources before their first oncology appointment.
Today, screening for health-related social needs is a critical part of BMC’s standard-of-care practice for every patient facing a cancer diagnosis. To build on these successes and ensure long-term sustainability of the navigation workflow, an additional intake patient navigator was hired to conduct screenings for all new oncology patients. Coupled with new patient navigator training on the important role standardized social assessment screening plays in oncology care coordination, OEA’s mission of true multilevel, evidence-based patient navigation has both enhanced the Oncology Patient Navigation Program and supported the Cancer Center’s foundational principle of equitable and accessible state-of-the-art cancer care.
Standardized social needs screening in oncology care produces real-time insight into patient barriers and supports immediate connection to resources. Through implementation of THRIVE, the OEA has shown how patient navigation, evidence-based interventions, and strong partnerships are truly indispensable. Assessment of feedback from patients, navigators, and care teams, as well as quantitative evaluation of effectiveness and impact continue to inform ongoing sustainability of these efforts.
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