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Phase One: Research and Beta Model Development

Research: Environmental Scan & Development Site Visits

Development of the Improving Care Coordination Model began in 2016 with a bibliography and an  environmental scan to better understand the current state of care access and coordination for patients with lung cancer covered by Medicaid, identify barriers and challenges, and review existing studies that included potential strategies to improve care coordination for this patient population.

The scan incorporated a literature review and insights from  members of the project’s interdisciplinary Advisory Committee, a lung cancer survivor and patient advocate, and multidisciplinary health professionals from two ACCC-member cancer programs. Among the scan’s key findings:

  1. The financial and social barriers that Medicaid beneficiaries face in pursuing lung cancer treatment are significant, detrimental to outcomes, and largely unaddressed. These include:

    • Accessing reliable transportation 

    • Taking time off from work/lost incomes 

    • Procuring childcare or other family support 

    • Covering out-of-pocket expenses for services and drugs 

  2. Medicaid beneficiaries have unequal access to high-quality care. Disparities in care access can be attributed to multiple causes, including how patients typically access the healthcare system. 

  3. Increasing patient engagement is critical to improving outcomes but will require a tailored approach given the unique challenges Medicaid beneficiaries face.  

  4. Integration of patient navigators into the care team can promote Medicaid beneficiaries’ access to timely, high-quality care. Both clinical and non-clinical navigators may play a key role in ensuring access to care, coordination of services across providers, education, and follow-up to promote adherence to treatment recommendations. 

  5. Multidisciplinary teams are key to improving care coordination. Opportunities may exist to strengthen and build on the team approach to caring for patients with lung cancer.

  6. Improvement is needed to promote timely access to supportive services for this patient population, including attention to biopsychosocial needs, palliative care needs, survivorship issues, hospice, and end-of-life care. 

Development Site Selection

The Advisory Committee and ACCC staff used results from the environmental scan to develop an application and criteria for the selection of Development Sites that would participate in comprehensive interviews to map out existing care pathways for Medicaid patients with lung cancer.* Over the next several months, the ACCC project team traveled to the five Development Sites. Using a standardized interview protocol, the team completed in-depth interviews with cancer program staff, including both clinical and administrative personnel; patients insured through Medicaid; palliative care and hospice providers; the interdisciplinary care team involved in the diagnosis and treatment of patients with lung cancer; and healthcare staff from referring practices and healthcare facilities. 

Comprehensive reports provide snapshots of each site’s successes and challenges in providing care for patients with lung cancer, with a focus on individuals insured by Medicaid or without healthcare coverage. These reports were published on the ACCC website in late 2016. Below are the five Development Sites and their reports.

*Note: Under the terms of the grant, programs in the following states are excluded from participation in this project: AL, GA, KY, MS, NC, TN, SC, and WV.

AdventHealth Daytona Beach (formerly, Florida Hospital Memorial Medical)


Read a snapshot of successes and challenges in providing care to lung cancer patients covered by Medicaid in this Development Site report.

AdventHealth Daytona Beach (formerly known as Florida Hospital Memorial Medical) is one of six AdventHealth hospitals in Florida's Flagler, Lake and Volusia counties. These comprise facilities comprise the AdventHealth Central Florida Division - North Region. The largest hospital system in the area with 1,208 beds and more than 8,000 team members, the North Region includes facilities in Daytona Beach, DeLand, Orange City, New Smyrna Beach, Palm Coast and Tavares. Formerly known as Florida Hospital, the organization’s parent company changed the name of all wholly-owned entities to AdventHealth in January 2019. Based in Altamonte Springs, AdventHealth is a connected system of care. With more than 80,000 team members, AdventHealth is one of the nation’s largest faith-based healthcare systems with close to 50 hospitals and hundreds of care sites in nearly a dozen states.  

Genesis HealthCare System, Genesis Cancer Care Center


Read a snapshot of successes and challenges in providing care to lung cancer patients on Medicaid in this Development Site report.

Genesis HealthCare System is an integrated healthcare delivery system based in Zanesville, Ohio. The system includes Genesis Hospital, a non-for-profit facility located in Zanesville, and an extensive network of more than 300 physicians and multiple outpatient care centers throughout the region. Genesis is the largest healthcare provider in a six-county region of southeastern Ohio, including Muskingum, Moran, Perry, Coshocton, Noble, and Guernsey Counties. The health system’s mission is “to provide compassion, quality health care.” The Genesis cancer physicians’ group was among the first practices in Ohio to receive American Society of Clinical Oncology (ASCO) Quality Oncology Practice Initiative (QOPI) certification. Genesis offers convenient, comprehensive cancer care services.

MaineGeneral Health


Read a snapshot of successes and challenges in providing care to lung cancer patients on Medicaid in this Development Site report.

MaineGeneral Health is a comprehensive non-profit health system with the mission of enhancing, every day, the health of the people of the greater Maine's Kennebec Valley. MaineGeneral’s Harold Alfond Center for Cancer Care (HACCC) in Augusta is accredited by the Commission on Cancer (CoC) and the American College of Radiology (ACR). HACCC provides care for approximately 12 percent of Maine’s cancer population. The cancer center sees more than 7,000 individuals with a cancer diagnosis annually, including nearly 1,000 newly diagnosed cases. In 2010, the HACCC became one of the first 16 cancer practices in the United States — and the first site in Maine — to be recognized by the American Society of Clinical Oncology’s Quality Oncology Practice Initiative (QOPI) certification program and achieved recertification in 2019. 

Mary Bird Perkins - Our Lady of the Lake Cancer Center


Read a snapshot of successes and challenges in providing care to lung cancer patients on Medicaid in this Development Site report.

Mary Bird Perkins – Our Lady of the Lake Cancer Center is a leading cancer care organization in Louisiana. Mary Bird Perkins and its partners work together to provide state-of-the-art treatments and collaborative, comprehensive cancer services. More than 3,500 new cancer patients turn to the cancer center each year and receive the benefit of more than 100 oncology specialists working together to provide high quality care. The cancer center provides comprehensive care at every stage of the cancer journey, including early detection and education, advanced treatment options, disease site-specific multidisciplinary care teams, a robust clinical research program and extensive supportive care services.

Sidney Kimmel Cancer Center at Thomas Jefferson University


Read a snapshot of successes and challenges in providing care to lung cancer patients on Medicaid in this Development Site report.

Jefferson Health encompasses Jefferson University Hospitals and Thomas Jefferson University—partners in providing excellent clinical and compassionate care for patients in the Philadelphia region. With five primary locations, taken together Thomas Jefferson University Hospitals have 908 licensed acute care beds. Located in south Philadelphia, Jefferson’s Methodist Hospital has a long history of providing the highest level of compassionate care to its community.

The Sidney Kimmel Cancer Center (SKCC) at Thomas Jefferson University has been a National Cancer Institute (NCI) designated cancer center since 1996. SKCC is committed to delivering the most advanced, personalized cancer care, made possible through their scientific discoveries and breakthroughs in detecting and treating cancer. SKCC provides access to advanced clinical trials and novel treatment strategies throughout the Greater Delaware Valley, The center provides oncology research, patient care, education, and health information services for Thomas Jefferson University, the University Hospital, Methodist Hospital, and the Sidney Kimmel Cancer Center Network with 29 hospital and practice partners.

Beta Model Development

Informed by the environmental scan and the Development Site reports, the project’s expert Advisory Committee convened an in-person meeting in November 2016 to discuss key findings in the context of model development. Ultimately, consensus developed around the concept of a beta Care Coordination Model built directly upon the Multidisciplinary Care (MDC) Assessment Tool created by the National Cancer Institute (NCI) Community Cancer Centers Program (NCCCP), a project funded by NCI from 2007-2014.

The NCCCP pilot, which eventually engaged 30 participating hospitals and health systems across the country, sought to build a community-based research platform to support a wide range of basic, clinical, and population-based research on cancer prevention, screening, diagnosis, treatment, survivorship, and palliative care at community hospitals—contributing to enhanced quality of care for patients and advancing cancer research. Learn more.

To enrich Model development, ACCC formed a Technical Expert Panel (TEP). All members of the TEP were former NCCCP pilot participants. The TEP collaborated with the Advisory Committee and the ACCC project team to draft a beta version of the Care Coordination Model. The beta Model consisted of 13 assessment areas. Each assessment area had five levels—level 1 represented the most basic provision of care and level 5 represented optimal best practice for care coordination.