# Care Coordination and Communication Program in Oncology for Tribal Health Systems

> **NIH NIH U19** · UNIVERSITY OF OKLAHOMA HLTH SCIENCES CTR · 2024 · $590,338

## Abstract

PROJECT 3: C3PO CARE COORDINATION: PROJECT SUMMARY
Despite significant improvements in their overall health, AI/AN populations continue to face marked disparities
in cancer outcomes. While reasons for this are multifactorial, suboptimal coordination of care contributes to
fragmented care, less comprehensive supportive services, and delayed access to cancer treatment.
Coordination of care between the AI/AN health care system and cancer care systems is particularly
challenging due to the need to coordinate health services for patients across multiple agencies, levels of
government, and the private sector. The AI/AN health care system comprises the federally operated Indian
Health Service, tribally operated health services, and Urban Indian Health Clinics, collectively known as the
ITU system. ITUs must generally refer their patients with cancer to non-ITU specialists, who may not
understand the nuances of the ITU referral processes, nor understand locally relevant Indigenous Knowledge
and values. These barriers lead to decreased access to cancer care services and delays in treatment. The
Care Coordination and Communication Program in Oncology for Tribal Health Systems (C3PO)
proposes to improve cancer outcomes for AI/AN patients by implementing a novel, navigation-based,
collaborative care model grounded in Indigenous Knowledge and centered on telehealth care coordination
meetings, or “Huddles,” between an NCI designated cancer center and ITU facilities. C3PO will test the
implementation and effectiveness of this patient-centered intervention comprising clinical and supportive staff
from the Stephenson Cancer Center and partnering ITU facilities in Oklahoma. This project features a hybrid
effectiveness-implementation type I randomized controlled trial (RCT) involving AI/AN patients to assess
C3PO's impact on patient-reported and clinical outcomes. Specific aims include: (1) Explore the unique needs
of AI/AN persons with cancer to inform C3PO's approaches to addressing these needs from the perspectives
of AI/AN patients, caregivers, referring ITU clinicians, and SCC clinicians; (2) Assess the impact of C3PO on
patient-reported and clinical outcomes in an RCT, hypothesizing that participants assigned to C3PO will have
higher patient-reported satisfaction, fewer missed visits, treatment initiation, and fewer treatment interruptions
compared with participants assigned to usual care; and (3) Identify facilitators and barriers for C3PO
implementation, adoption, and maintenance using the PRISM RE-AIM framework and cost of the
implementation and maintenance to assess sustainability. By bridging communication gaps between ITUs and
a large cancer center, C3PO seeks to improve cancer outcomes for AI/AN patients with cancer through a novel
and scalable collaborative care coordination to address the clinical, financial, social, and cultural needs of
AI/AN cancer patients.

## Key facts

- **NIH application ID:** 11161062
- **Project number:** 1U19MD020537-01
- **Recipient organization:** UNIVERSITY OF OKLAHOMA HLTH SCIENCES CTR
- **Principal Investigator:** Dorothy Alison Rhoades
- **Activity code:** U19 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2024
- **Award amount:** $590,338
- **Award type:** 1
- **Project period:** 2024-09-17 → 2029-06-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/11161062

## Citation

> US National Institutes of Health, RePORTER application 11161062, Care Coordination and Communication Program in Oncology for Tribal Health Systems (1U19MD020537-01). Retrieved via AI Analytics 2026-05-25 from https://api.ai-analytics.org/grant/nih/11161062. Licensed CC0.

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