Table 1 Hypotheses, design (sample), data collection time points, & outcome measures

System-level primary hypothesis:

A higher proportion of complex cancer survivors will meet quality of care guidelines for their chronic conditions and for cancer follow-up care 12 months post-implementation

Repeated cross-sections of distinct samples of patients at each time point (n~ 500)

• 12 and 24 months pre-implementation (historical controls)

• 12, 24 and 36 months during implementation

Primary outcome: Composite care quality score (EHR)

Chronic disease score

- % patients receiving guideline-appropriate services (process measures) and meeting guideline-recommended targets (intermediate outcomes)

Cancer follow-up care score

- % patients receiving NCCN guideline-appropriate cancer surveillance

Patient-level hypothesis:

Patient-reported care coordination scores will significantly improve over time among complex cancer survivors 12 months post-implementation

Repeated measures on same patients

(n = 402)

• Baseline

• 6 and 12 months post- baseline

Care coordination using patient perception of care scale [65] (patient surveys)

- Coordination of care – overall and at visit

- Specialty care access

- Education/information

- Preferences, social support, health literacy

- Health-related quality of life