CHER Associate Director Samantha Sabo Co-Leads National Grant to Enhance Cancer Care Coordination for Native Patients
Northern Arizona Healthcare, Inc. (NAH) has received a $248,500 competitive grant from the American Cancer Society and Pfizer, Inc. to improve cancer care coordination for Native American patients in northern Arizona and the Colorado Plateau.
The project, called Connected Care, focuses on strengthening coordination for Native patients receiving radiation therapy at the Cancer Centers of NAH. Northern Arizona University’s Center for Community Health and Engaged Research (CHER) serves as the systems-bridging and implementation partner for Connected Care. Nearly one in three patients receiving radiation therapy at NAH are Native American and many travel long distances for care. Radiation treatment typically requires daily visits for five to six weeks, creating significant transportation, lodging, and food access challenges for patients and families.
Samantha Sabo, DrPH, MPH Associate Director of CHER and professor of public health, is co-leading the project alongside Matthew Greer, MD, and Stephanie Rice, MD, of the Cancer Centers of NAH.
“In Northern Arizona, rural American Indian patients often move between Tribal, Indian Health Service, and Urban Indian health systems and specialty oncology care at the Northern Arizona Healthcare (NAH) Cancer Center—systems that were not designed to operate seamlessly together. CHER’s role is to strengthen the connection from the community to the clinic. We focus on supporting frontline public health professionals—especially Community Health Representatives and Tribal-based patient navigators—so they have clear, consistent linkages to patient navigators and oncology teams at NAH” said Sabo.
Drawing on longstanding partnerships with Tribal health departments and Community Health Representative program leadership, CHER is co-developing referral pathways, communication protocols, and a regional learning collaborative that centers frontline workforce voices in cancer support services. Through technical assistance and implementation guidance, CHER will support strengthening bidirectional communication to ensure culturally grounded follow-up in patients’ home communities during radiation and cancer treatment. Using community-engaged implementation science approaches, CHER monitors treatment completion, identifies cross-system barriers, and generates policy-relevant evidence to sustain and scale a community-to-clinic model of coordinated cancer care.
The Connected Care project will allow NAH to establish a Native American Advisory Board to guide the project and cross-train an oncology patient navigator to support rural Native patients while they undergo radiation treatment away from home. The navigator will assist with transportation, lodging, and food access and will coordinate closely with Tribally based patient navigators and Community Health Representatives in patients’ home communities to support follow-up care and continuity once treatment ends.
“Connected Care extends the work of NAU’s American Cancer Society funded Center for Native American Cancer Health Equity (C-NACHE) and National Cancer Institute funded Partnership for Native American Cancer Prevention (NACP) by strengthening the frontline Tribal public health workforce and creating intentional community-to-clinic linkages that directly address persistent cancer health disparities in Native communities through improved coordination, cultural responsiveness, and continuity of oncology care,” said CHER Associate Director Nicky Teufel-Shone. Teufel-Shone is also a professor of public health and directs the Community Engagement Core of the Native American Cancer Partnership (NACP).
For CHER, integrating Community Health Workers into care coordination reflects years of partnership with Native nations and Community Health Representative programs across the region. In fact, anyone can access and use CHER’s Building teams together: A 5-step guide to integrate CHRs into care coordination, which is being used to guide the Connected Care Project. This toolkit – led by Louisa O’Meara, MPH CHER research coordinator senior and co-designed with Tribal leaders involved in the Connected Care project – serves as a foundation for our collaborative work.
NAH was one of only seven organizations nationwide selected for this award. The proposal was jointly developed by NAH’s Office of Philanthropy and NAU.
The initiative brings together a regional network of partners, including:
- Native Americans for Community Action (NACA)
- Hopi Health Department Community Health Representative and Cancer Support Services Programs
- Hualapai Tribe Elder Services Program
- Navajo Nation Department of Health Community Health Representative Program
- Tuba City Regional Health Care Corporation Cancer Support Services
- Indian Health Service National Community Health Representative Program
CHER will lead evaluation and provide technical assistance throughout the two-year project period, working alongside clinical and community partners to document outcomes, strengthen coordination practices, and support sustainability beyond the grant.
Through collaborative leadership and long-standing community partnerships, CHER hopes the Connected Care project will advance coordinated cancer care grounded in the priorities and strengths of Native communities across northern Arizona.
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