Abstract A036: Cross-system care coordination to reduce structural barriers in cancer care for American Indian patients: Early outcomes from a Tribal-academic pilot (C-3PO)
Abstract
First American (FA) patients with cancer often navigate fragmented care across tribal, specialty, and tertiary referral systems, facing barriers from geographic distance, payer complexity, and limited familiarity among specialty providers with tribal health system requirements. This report describes early outcomes of a pilot initiative, Care Coordination and Communication Program in Oncology for Tribal Health Systems (C-3PO), developed to strengthen care coordination collaboration between an academic cancer center and tribal health partners in the South-Central Plains region. Methods: The C-3PO pilot connected an academic cancer center with a tribal health partner through interdisciplinary care coordination meetings (CCMs), bringing together tribal case navigators, Registered Nurses serving as care collaboration coordinators (CCCs), and oncology providers to review cases monthly. CCCs served as liaisons between systems. To date, the initiative has supported 10 FA patients receiving oncology care across both settings. Results: Across these cases, coordination efforts addressed recurring cross-system barriers in several broad areas: care coordination, including aligning treatment plans with tribal coverage and referral requirements to prevent unanticipated financial burden; cross-communication among consultants, ensuring oncology, primary care, and other specialty providers across systems shared relevant clinical and coverage information; and patient empowerment, equipping patients with the knowledge and language to raise system-specific coverage or logistical concerns directly with their oncology team. These recurring issues also informed development of provider-facing education on tribal health system referral processes and clinic-specific requirements. Coordination activities were associated with reduced care fragmentation and averted instances of avoidable patient billing across the cohort. Conclusion: A structured model that integrates tribal case navigators with academic oncology teams engaging in CCMs can identify and mitigate cross-system barriers affecting cost, communication, and patient engagement for FA patients with cancer. Early experience across this initial patient cohort suggests this approach is generalizable and may inform standardized coordination protocols, navigator training, and provider education in tribal-academic oncology partnerships. Katy Fisher-Cunningham, Vanessa Wright, Sheryl Buckner, Tara Matthews, Casey Brown, Lauren Bristow, Shondra McCage, Chris Tall Bear, Justin D. Dvorak, Junying (June) Zhao, Amber Anderson-Buettner, Katie Keyser, Sabrina Hawkins, Mariah Daley, Zsolt J. Nagykaldi, Ryan Nipp, Amanda Janitz, Mark P. Doescher, Dorothy A. Rhoades. Cross-system care coordination to reduce structural barriers in cancer care for American Indian patients: Early outcomes from a Tribal-academic pilot (C-3PO) [abstract]. In: Proceedings of the 19th AACR Conference on the Science of Cancer Health Disparities; 2026 Oct 18-21; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2026;35(10 Suppl):Abstract nr A036.