Northwestern University Feinberg School of Medicine, Chicago, IL

Closing Gaps in Cancer Care for Underserved Communities in Chicago

As a member of the Alliance, Northwestern University Feinberg School of Medicine (Feinberg) will work with its community partner AllianceChicago to address gaps and disruptions in care for patients who require treatment for cancer and primary or chronic diseases, such as diabetes or high blood pressure. These gaps may occur because of the lack of coordination between the cancer care centers and the AllianceChicago primary care clinics.

Together, Feinberg and AllianceChicago will introduce an intervention at the patient, health care provider, and health system levels in a number of AllianceChicago’s health centers in the Chicago area. Through the intervention, Feinberg and AllianceChicago aim to build the capacity of AllianceChicago’s providers to help their patients with cancer receive the highest quality comprehensive care. The team will also study patient outcomes to determine the multi-level benefits of implementing this intervention on a broad scale.

The AllianceChicago network of health centers has a strong presence in vulnerable communities across Chicago and nationally, including Latino, African American, LGBTQ, homeless, and immigrant and refugee populations. Low income, minority individuals are more likely to be diagnosed with cancer at later stages and experience more advanced (or aggressive) disease. This cancer disparity is compounded by financial challenges and the lack of social support. ¹ The potential lack of coordination between the cancer care team and the primary/chronic care team is especially challenging for underserved and vulnerable communities that may lack information and resources needed to plan and manage their cancer care across multiple care providers.


Establish the capacity to develop, implement and monitor integrated cancer care plans at community primary care sites

  • Conduct a baseline assessment with providers and other health center staff to determine the capacity and readiness of each community primary care site to coordinate cancer care
  • Incorporate the 4R integrated cancer care plan as the routine standard of care for AllianceChicago patients facing cancer
    • Implement the 4R Model for Care Planning and Delivery at 15 community primary care sites across the AllianceChicago network
    • Provide 4R care plans to patients and their caregivers as cancer care begins; to help patients understand and manage important care events (such as cancer and non-cancer treatment, preventive care, support services, self-care and lifestyle choices)
    • Use the 4R care plans to clearly identify provider responsibilities for various events in the patient care plan
  • Designate a panel of stakeholders to review data about patient needs, system performance and outcomes; and propose ways to improve the 4R model

Examine the processes for care planning and coordination across AllianceChicago sites

  • Identify gaps in care and determine the degree to which setting plays a role in overcoming these gaps
  • Identify effective or useful practices by site to determine whether these practices can be applied more widely
  • Provide local primary care providers at AllianceChicago clinics with feedback on patient experiences with care to incorporate lessons learned and refine the 4R intervention
4R stands for Right Information and Right Care for the Right Patient at the Right Time. The 4R model is a novel approach, developed by Northwestern University and the Center for Business Models in Healthcare, that personalizes cancer care planning and helps cancer patients better understand and manage their care. It also supports clinical teams’ efforts to deliver cancer care in a timely and coordinated fashion. 2,3
Feinberg, in partnership with AllianceChicago, plans to evaluate the effectiveness of its program in improving the delivery of cancer care to vulnerable and underserved populations in the Chicago area. In addition, the Alliance will create a learning collaborative among program partners to share insights from the programs and help identify and promote best practices in patient-centered cancer care that can improve patient outcomes and reduce disparities in care.

Program Profile Video


Melissa Andrea Simon, M.D., M.P.H.
George H. Gardner Professor of Clinical Gynecology
Vice Chair of Clinical Research
Departments of Obstetrics and Gynecology,
Preventive Medicine and Medical Social Sciences
Robert H. Lurie Comprehensive Cancer Center
Northwestern University Feinberg School of Medicine
  1. National Cancer Institute. Cancer Health Disparities. 2008. Available at: Accessed August 4, 2017.
  2. Trosman, J.R.; Carlos, R.C.; Simon, M.A.; et al. Care for a Patient With Cancer As a Project: Management of Complex Task Interdependence in Cancer Care Delivery. J Oncol Pract. 2016 Aug 30. pii: JOPR013573.
  3. Weldon, C.B.; Friedewald, S.M.; Kulkarni, S.A.; Simon, M.A.; Carlos, R.C.; Strauss, J.B.; Bunce, M.M.; Small, A.; Trosman, J.R. Radiology as the Point of Cancer Patient and Care Team Engagement: Applying the 4R Model at a Patient’s Breast Cancer Care Initiation. J Am Coll Radiol. 2016 Dec;13(12 Pt B):1579-1589.
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