Patient Navigation 2.0

Not Applicable

Active, not recruiting

Interventions: Behavioral: One-on-one Patient Navigation (PN)
Behavioral: Patient Navigation (PN) 2.0 Checklist

Brief Summary: This study evaluates whether a "Patient Navigation 2.0 Checklist" intervention is effective in addressing patients' social determinants of health and recommended cancer-related screenings, behavioral counseling, and immunizations.

Detailed Description: Cancer patient navigation (PN) is an effective strategy for resolving patient barriers to care and improving completion and consistency of cancer screening, follow-up of abnormal findings, and treatment initiation. However, as the current standard one-on-one PN model is challenging to scale across cancers and economically difficult to sustain, the investigators propose to convert one-on-one PN into a learning health system "PN 2.0 Checklist" that will help coordinate navigation workflow and integrate clinical team members with community/local resources. This pragmatic, randomized trial tests whether this checklist strategy is as effective as one-on-one PN in addressing patients' social determinants of health and recommended cancer-related screenings, behavioral counseling, and immunizations.

In this study, half of the participants will be navigated using the "PN 2.0 Checklist". The other half will be navigated using the "One-on-One PN". All participants enrolled in the study will be asked to report their utilization of health services and be asked to complete a patient survey at the beginning of the program and every 6 months.

Recruitment & Eligibility

Inclusion Criteria

Age 21 or older
Reside in one of the eight Chicago zip codes corresponding to Chinatown's geographical boundaries: 60605, 60607, 60608, 60609, 60616, 60623, 60632, 60653
Self-identify as Chinese
Not cognitively impaired
Have the ability to participate in verbal survey in Cantonese, English, Mandarin, or Toishanese

Exclusion Criteria

Arm && Interventions

Group	Intervention	Description
Group 1: One-on-One Patient Navigation	One-on-one Patient Navigation (PN)	One-on-one Patient Navigation will be based on a Case Management Model where patients navigators perform appointment scheduling and reminders; facilitate communication between patients and care teams; and identify and reduce patient barriers through education, outreach, and referrals to community, local, and state resources.
Group 2: Patient Navigation 2.0 Checklist	Patient Navigation (PN) 2.0 Checklist	The PN 2.0 Checklist intervention is centered on a learning health system checklist that enumerates a patient's Social Determinants of Health (SDoH) related barriers and tracks completion of services to address SDoH (at community oncology and community social service settings) as well as completion of USPSTF recommended cancer-related screenings, behavioral counseling, and immunizations.

Primary Outcome Measures

Name	Time	Method
Patient Receipt of Clinical Cancer Preventive Services and Resolution of Social Determinants of Health Barriers	through study completion, an average of 18 months	Patient Receipt of Clinical Cancer Preventive Services and Resolution of Social Determinants of Health (SDoH) Barriers is an adjusted, composite proportion of items completed/resolved in 2 domains: (1) USPSTF recommended cancer screenings, behavioral counseling, and immunizations; and (2) SDoH barriers resolved from those identified in the Accountable Health Communities Health-Related Social Needs (AHC HRSN) Screening Tool

Secondary Outcome Measures

Name	Time	Method
Timeliness of diagnostic resolution	through study completion, an average of 18 months	Time from an abnormal screening result to diagnostic resolution
Timeliness of treatment initiation	through study completion, an average of 18 months	Time from diagnostic resolution to initiation of treatment

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