This article is the tenth 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.
Advancing equitable cancer care requires interdisciplinary care coordination and intentional community engagement to meet the unique needs of vulnerable populations. The Alliance for Equity in Cancer Care (Alliance) brought together 8 grantee sites from diverse healthcare settings to improve timely access to high-quality cancer care for patients from underserved communities.
Since its launch in 2022, the initiative has leveraged community-rooted strategies to address inequities in cancer care driven by social determinants of health (SDOH). Through dynamic implementation models, strong community relations, integrated data systems, and sustainable workforce structures, the Alliance has effectively operationalized equitable care coordination, thus improving patient outcomes and advancing health equity (Figure 1). Moving into its final year, the Alliance is ensuring this work is sustainable while strengthening operational efficiencies among academic medical centers, community oncology programs, professional organizations, and safety-net hospitals.
Across grantees, common challenges centering adequate resource availability to address SDOH include workforce limitations; alignment of data systems, documentation practices, and cross-team communication; and infrastructure needs for systematically identifying, tracking, and addressing equity-focused outcomes.
The Alliance addressed these challenges through a combination of adaptive infrastructure, strengthened partnerships, and system-level standardization. Central to this work was the customization and implementation of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework1 and the development of the Alliance Business Model, 2 complementary systems that together define both what to measure and improve and how to operationalize, finance, and sustain those improvements at scale.
The Alliance has established evidence-based benchmarks to guide equity-focused care coordination across diverse institution types while also addressing a critical gap in the field: the absence of standardized metrics for measuring and operationalizing equitable cancer care. Beyond simply tracking data, the Alliance has defined meaningful strategies that institutions can deploy to evaluate performance, guide quality improvement, and compare progress across settings.
From the perspective of the Alliance, innovative equity-focused models often fail because clinical impact and operational feasibility are evaluated in isolation. To address this challenge, the Alliance intentionally integrated both equitable care practices and operational strategies, creating a more sustainable framework for durable systems-level change.
The RE-AIM framework was designed to improve the translation of evidence-based interventions into real world practice by evaluating not only clinical effectiveness but also the factors that influence broad adoption, implementation quality, and long-term sustainability. The 5 interconnected domains work together to assess whether interventions successfully engage the intended populations, improve meaningful outcomes, are adopted across practice settings, are implemented consistently and feasibly, and can be sustained over time.
The Alliance adapted this framework as a systems-level approach to equitable cancer care across grantee sites. Across partner institutions, the Alliance demonstrated that equity-centered care coordination is achieved when community engagement is supported by leadership and embedded into routine clinical operations rather than treated as separate or mutually exclusive processes. Importantly, community partnership emerged as a foundational driver across all RE-AIM domains by strengthening patient and intervention reach and supporting long-term maintenance within local healthcare ecosystems and community-based organizations (CBOs).
“By integrating rigorous measurement with real-world implementation, the Alliance is turning equity-focused innovation into durable, system-wide impact.” —Marcie S. Wright, PhD, MPH
At the site level, Boston Medical Center and RWJBarnabas Health embedded SDOH screening, referral management, and care coordination into routine clinical workflows, strengthening the systematic identification and management of social barriers to care. These operational changes improved communication across care teams, reduced delays in treatment initiation and follow-up, and established more integrated models of equitable cancer care delivery (Figure 2).
A defining strength of the Alliance has been its ability to balance standardization of workflows with locally tailored community engagement strategies. While shared frameworks enabled consistency in measurement and implementation, individual programs retained the flexibility to tailor interventions to their patient populations, organizational structures, and community contexts. This balance between scalability and local responsiveness will be critical to sustaining equitable cancer care transformation in the years ahead.
While each grantee site employed distinct strategies tailored to meet the needs of their local communities, common themes emerged across the Alliance. Programs that established bidirectional relationships with trusted CBOs demonstrated greater patient engagement, improved referral completion, and stronger sustainability planning.
For example, these partnerships enhanced transportation, food, housing, and care coordination support while improving communication to reduce delays in treatment initiation and follow-up.
Alliance grantees leveraged community partnerships to ensure that interventions reflected local needs and could be sustained over time. Mary Bird Perkins Cancer Center established a community advisory board (CAB) to guide culturally responsive outreach, identify unmet support needs, and strengthen trust within a community disproportionately affected by environmental exposures, poverty, and limited healthcare access. The CAB provided ongoing strategic input, ensuring that program development remained grounded in lived experience. Similarly, the University of Kentucky Markey Cancer Center expanded rural outreach through regional partnerships and digital health technologies designed to address geographic barriers to specialty oncology care and improve access for medically underserved populations.
At Memorial Sloan Kettering Cancer Center (MSKCC), community engagement was operationalized through a multidisciplinary steering committee that informed program implementation, while partnerships with community organizations supported universal SDOH screening, referral optimization, and patient engagement strategies designed to strengthen continuity of care.
MSKCC enhanced the referral coordination and patient engagement systems through multiple initiatives, including consistent community steering committee meetings that guide progress, improve referral workflows, universal SDOH screening, and automatic referrals. These work together to improve continuity of care, while the NCCN and ASCO advanced standardized navigation practices and evidence-based implementation tools adaptable across healthcare settings. Case Comprehensive Cancer Center further expanded screening outreach and survivorship support through partnerships serving medically underserved communities. Collectively, these initiatives demonstrated that successful community partnerships are co-developed, operationally integrated, continuously evaluated, and designed to address real-time patient barriers rather than functioning as static or transactional referral networks.
Institutional policy and workflow changes were essential in operationalizing these approaches. By implementing key strategies into existing clinical workflows—such as routine distress screening and SDOH assessment, integration of social needs data into electronic health records, and automation of referral pathways—grantees have demonstrated measurable system-level impact including benefits to patient care. Based on site-specific data, grantees have reported increased adherence to treatment since the beginning of the program, increasing from 87.6% to 97.1%.
Many sites redesigned care coordination models to reduce fragmentation across oncology, primary care, and community-based services, while automation and enhanced data infrastructure improved the efficiency and scalability of navigation through streamlined patient identification, referral management, and longitudinal outcomes tracking. Institutions also implemented proactive workflows to identify patients with high social and clinical complexity earlier in the care continuum, enabling more strategic deployment of navigation resources.
Collectively, programs integrating real-time SDOH data, closed-loop referral systems, and multidisciplinary care coordination demonstrated improvements in timeliness of care, treatment adherence, patient engagement, and organizational capacity to address health inequities at scale.
“The Alliance has created a sustainable, scalable, and replicable infrastructure by integrating the RE-AIM framework for standardized measurement and continuous improvement with a Business Model that operationalizes workflows, technology, partnerships, and financing to embed equitable care into routine practice.” —Robert A. Winn, MD
The Alliance Business Model provides a complementary financial and operational framework to sustain these outcomes long-term. Whereas the RE-AIM model defined how to measure implementation and impact, the Business Model focuses on infrastructure needs, workforce alignment, organizational capabilities, value propositions, and long-term scalability.
The Alliance found that sustainability requires a clear correlation between equity-focused interventions and financial value. Historically, many health equity initiatives have struggled to persist because they lacked clear operational adoption or demonstrable return on investment. The Alliance addressed this gap by helping partner institutions connect navigation and care coordination efforts to reimbursement opportunities, cost savings, improved utilization patterns, and broader value-based care priorities.
In developing the Business Model, the Alliance recognized the importance of showing the value of equitable cancer care at both the patient and financial levels. Traditional navigation staffing models often fail to account for the intensity of addressing SDOH-related barriers, longitudinal care coordination demands, and variability in patient acuity. As such, an emerging area of focus across the Alliance involves optimizing navigator caseload models to better reflect the complexity of patient needs.
The evidence generated across participating institutions reinforces a clear call to action for healthcare systems. Findings from the Alliance demonstrate that sustainable impact requires integrated workforce models, standardized measurement frameworks, embedded SDOH and navigation workflows, robust community partnerships, and financing strategies aligned with value-based care. Future efforts prioritizing more precise navigator caseload models that account for social and clinical complexity, expand system- and policy-level interventions that incentivize equity, and strengthen data infrastructure capable of measuring both patient outcomes and broader organizational transformation are essential.
By integrating the RE-AIM framework with an operational business model that aligns workflows, technology, partnerships, and financing, the Alliance has established an evidence-based, scalable, and replicable infrastructure that health systems can adopt to embed equitable cancer care into routine practice and sustain impact beyond grant-supported funding.
Keep up to date with the latest news from us via social networks:
To sign up for our print publication or e-newsletter, please enter your contact information below.
