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The Role of a Public-Private Partnership: Translating Science to Improve Cancer Care in the Community/PRACTITIONER APPLICATION [Journal of Healthcare Management]
[February 06, 2014]

The Role of a Public-Private Partnership: Translating Science to Improve Cancer Care in the Community/PRACTITIONER APPLICATION [Journal of Healthcare Management]

(Journal of Healthcare Management Via Acquire Media NewsEdge) Donna A4. O'Brien, FACHE, president and CEO, Strategic Visions in Healthcare EEC, New York, New York, and Arnold D. Kaluzny, PhD, professor emeritus of health policy and management, UNC Gillings School of Global Public Health, and senior research fellow, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill EXECUTIVE SUMMARY Health reform is bringing about changes in the healthcare environment, but an equally significant transformation is occurring in science with the sequencing of the human genome and the increasing role of personalized medicine in the delivery of new cancer therapies. These changes directly affect the ability of hospitals to provide value-based, state-of-the-art care and represent major strategic decisions that must be made by management. In the United States, an estimated 85% of cancer patients receive care in community settings, but patients' outcomes are often not equivalent to those achieved in academic health centers. Care of cancer patients in the community is often fragmented, as most oncologists are in private practice and have limited access to formal mechanisms for coordinating care across specialties or with primary care physicians. Furthermore, genetic analysis, advanced diagnostic tests, and clinical trials are not always available to patients in these settings.

The evolution of cancer care requires a reconfiguration of processes and investment in new services. In response, the National Cancer Institute launched the Community Cancer Centers Program in 2007 as a public-private partnership with 16 community hospitals. This article draws on the results of an external evaluation of the pilot program and assesses the role of such a partnership as a means of facilitating the translation of the developing science to the community setting, with reference to the role of management in the implementation of such partnerships.

INTRODUCTION The biological and clinical sciences are undergoing a major transformation that will have a profound impart on healthcare delivery and policy. The burden of cancer in the United States is significant, as 1.5 million people are diagnosed with cancer and almost 600,000 cancerrelated deaths occur annually (American Cancer Society, 2012; Howlader et al., 2012). As the population ages and becomes more diverse, cancer prevalence will continue to increase. With some estimates projecting the incidence to increase by 45% over the next two decades (Smith, Smith, Hurria, Hortobagyi, & Buchholz, 2009) and recognizing that the vast majority of cancer patients are treated in community hospitals, public-private partnerships offer opportunities for bringing comprehensive, high-quality cancer care to this setting.

Developing science, the emergence of value-based care, and the implementation of the Affordable Care Act require healthcare managers to consider new paradigms for hospitals and their affiliated physicians whereby they collaborate with the larger scientific and clinical community. To meet this challenge, community hospitals need to make significant infrastructure changes, enhance biospecimen collection capabilities, and make new investments in electronic health record systems (EHRs) and bioinformatics processing capabilities. Addressing these issues in the community setting while bringing multispecialty, integrated approaches to care across the cancer continuum requires major strategic decisions involving both the hospital management and the clinical leadership of the institution.

Building on the institutional capacity of community hospitals, their commitment to patient care, and their access to the majority of cancer patients, the National Cancer Institute (NCI) launched the NCI Community Cancer Centers Program (NCCCP) in 2007. As a public-private partnership, the program was designed to explore the best methods to enhance access to careespecially for those who experience healthcare disparities-improve quality, and expand research within a community setting (Johnson, Clauser, Beveridge, & O'Brien, 2009). The program addressed the full cancer continuum, from prevention, detection, diagnosis, treatment, survivorship, and palliative care through end-of-life care. It involved managerial and clinical leadership and relevant clinicians and support personnel within the participating organizations. This article assesses the role of a public-private partnership as a means to facilitate the translation of scientific advances to the community setting and presents management considerations that are important to the implementation of such partnerships.

PROGRAM OVERVIEW In general, community-based cancer care in the United States relies on independent, private practice physicians who work in settings with few formal linkages between them and specialists or across specialties (Katz et al., 2010). This fragmentation has continued to challenge efforts aimed at earlier diagnosis, improved care, cancer surveillance, and the advancement of cancer research. In 2007, NCI selected eight community hospitals and two multihospital systems to participate in the NCCCP, funding a total of 16 sites for a 3-year pilot. The program was managed through NCI's contract with SAIC-Frederick, Inc. (now Leídos Biomedical Research, Inc.)1 and had an annual budget of $5 million.

Each of the 10 awarded organizations received approximately $500,000 per year. The organizations were required to provide a reasonable level of cost sharing and to document how they planned to use NCI funds. The multihospital system awards had to be distributed across participating hospital sites, and thus their coinvestment ratio was significantly greater than the other single hospital sites. The funds were to be used for capacity building to meet subcontract deliverables for six program components-disparities, clinical trials, biospecimens, information technology, quality of care, and survivorship and palliative care-with 40% dedicated to initiatives to decrease health disparities. The remainder of the funds was generally allocated as follows: 20% to clinical trials, 20% to biospecimen collection, and 20% to information technology. The subcontract mechanism did not provide program funds for a per-patient reimbursement for accrual to clinical trials, equipment, or indirect costs.

As seen in Figure 1, the hospitals selected to participate in the NCCCP covered a range of geographic locations. All served at least 1,000 new cancer patients annually, with the average volume falling between 1,200 and 1,500 cases. A few facilities saw between 2,500 and 2,800 new cancer patients annually. The hospitals accrued at least 25 patients to clinical trials per year and were required to meet other requirements that established a common baseline for program activities across sites. All hospitals were required to fulfill the same subcontract deliverables; award amounts were based on the work to be completed, not the cancer program size or community location.

NCI has supported various initiatives over the years to expand research and deliver the latest scientific advances to patients in their communities, perhaps best illustrated by the Community Clinical Oncology Program (McAlearney, Reiter, Weiner, Minasian, & Song, 2013; Kaluzny & Warnecke and Associates, 1996; Minasian et al" 2010). Yet patients treated in community settings continue to have a higher mortality rate and are less likely to receive evidencebased, coordinated care than those who obtain care in academic health centers and NCI-designated cancer centers (FCCC, 2011; Katz et al" 2010). Disparities persist for racial and ethnic minorities in cancer morbidity and mortality (American Cancer Society, 2009; Robbins, Siegel, & Jemal, 2012), and clinical trial enrollments experience significantly lower representation from these groups (Murthy, Krumholz, & Gross, 2004).

NCI understood that enabling community hospitals to provide advanced, value-based care and meet the potential of expanding science would involve strategic realignment and reallocation of resources within the hospitals. The participation of top-level management, working in collaboration with key clinical personnel and affiliated private practice physicians, was required. The hospitals found themselves in a new learning environment as they began to interact with staff with relevant expertise from NCI; the other NCCCP hospitals; and the larger oncologic community, including organizations such as the American College of Surgeons Commission on Cancer (CoC), the American Society of Clinical Oncologists (ASCO), and the NCI-designated cancer centers.

A distinctive aspect of the NCCCP public-private partnership was the network whereby the participating hospitals functioned as a learning collaborative and were committed to sharing data, working together on network-wide quality improvement projects, and sharing best practices.

Goals for the NCCCP Building on the underlying principles of collaboration, the program sought to achieve three overarching goals: * Enhance access to care * Improve quality of care * Expand research To support these goals, participating organizations needed a minimum set of organizational and cancer program features, including accreditation from The Joint Commission, CoC, and the College of American Pathologists; a dedicated cancer center with medical, surgical, and radiation oncology in one location; a physician director; a dedicated cancer medical staff; plans for an EHR; at least one ongoing, cancer disease-specific, multidisciplinary team conference (e.g" breast cancer); and planned or existing research affiliations with NCI-designated cancer centers or academic research institutions. The hospitals were also required to have a policy in place whereby all patients screened for cancer would be offered treatment, regardless of ability to pay. They agreed to allocate 40% of the funding to reducing cancer healthcare disparities and promoting the integration of these efforts across all program areas. The hospitals were expected to work together to develop innovative approaches and thus shape the way their organizations (and potentially others) would transform care delivery and research infrastructures; partnering with other organizations also helped to support these goals.

The NCCCP hospitals, through their program selection subcontract awards, committed to a common set of deliverables (i.e., requirements), thus ensuring that all network sites would address the program components and support the achievement of program goals. Figure 2 presents an overview of the requirements for each program component.

The hospitals faced significant hurdles to accommodate the demands of the program, both within their institution and through their network collaborations. Issues included managing data requirements, allocating sufficient staff, and involving time-stressed private practice clinicians. One principal investigator (PI) noted: We thought we knew a lot about the program, but after being selected and reviewing all the expectations, it was overwhelming. We were not organized to support and coordinate all the program components.

The expectation to work as a collaborative network presented other challenges. Concerns about proprietary information along with a wellestablished culture of institutional autonomy required the development of trust among the institutions and confidence in the ongoing engagement with NCI. Despite these concerns and potential barriers, the program moved forward, meeting its goals as described in the next section.

PROGRAM ACCOMPLISHMENTS In 2007, NCI awarded an external contract to RTI International to conduct a multiyear evaluation of the pilot program (Clauser et al" 2009). Findings from the evaluation reports show that the NCCCP made significant strides from the time of its implementation in 2007 through the end of the pilot period (Holden et al" 2012; Association of Community Cancer Centers, 2012; NCCCP, 2012). As participants in a public-private partnership, the hospitals invested $3.74 for every NCI dollar, which exceeded expectations that the hospitals' commitment to "reasonable cost sharing" might translate to 1:1 investments (Dalton, Holden, Wright, Kane, & Allaire, 2012). This level of support required management commitment and a fundamental belief in the underlying rationale that participation in the program would improve care, both within their institution and for other hospitals around the United States.

Enhancing Access With the support of their executive management, the hospitals launched or expanded a number of access-related initiatives, including community and research partnerships focused on addressing healthcare inequities for underserved populations; community outreach activities and screening events; patient navigation, especially for underserved populations; and standardized tracking of race and ethnicity data (Holden et al" 2012). Specific areas of progress included quality-of-care improvements for underserved groups and expanding community partnerships to increase prevention and screening activities.

Quality-of-Care Improvements for Underserved Groups Data from the CoC Rapid Quality Reporting System (RQRS) demonstrated that concordance with evidence-based measures for breast and colon cancer increased from baseline for various underserved groups (Halpern et al" 2011). In the case of breast cancer, the percentage of Medicaid patients who received radiation therapy following breast-conserving surgery in concordance with National Quality Forum (NQF) measures increased from a mean of 59.5% in 2006-2007 to a mean of 84.8% (p < .01) in the 2008-2010 time frame. For stage II or III hormone receptor-positive breast cancer patients, hormonal therapy concordance rates for all races increased. For example, the rate for black patients increased from 49.3% to 78.7% (p < .01). In addition, concordance rates among uninsured patients increased from 47.5% in 2006-2007 to 81% in 2008-2010 (p < .01).

Community Partnership Development for Prevention and Screening Reaching underserved populations required the development of linkages with community organizations that had access to the medically underserved individuals and areas. At the end of the pilot, the hospitals reported 195 partnerships targeted to underserved populations, more than doubling the number in place at the time of program launch (Holden et al" 2012).

Improving Quality The NCCCP pursued an approach that involved benchmarking and establishing network-level partnerships with national cancer quality organizations (CoC, ASCO Quality Oncology Practice Initiative [QOPI]), thus providing standardized metrics and data collection, access to relevant expertise, and the benefit of a collaborative learning network (Halpem et al., 2013; Siegel, Clauser, & Lynn, 2009). This data-sharing quality consortium required significant effort and resource commitment on the part of the participating hospitals, the NCI staff, and the CoC and ASCO staffs. It also provided an empirical base for facilitating change within the participating sites. As measured through RQRS, NCCCP hospitals increased concordance with the RQRS quality measures for breast and colon cancer. As one example, for radiation therapy following breast cancer surgery, women less than 50 years of age had an increase in concordance from 68.8% to 87.4% (p < .01) (Halpern et al., 2011).

Organizational changes to care processes were equally important to improving the quality of care. Patient navigation and the use of multidisciplinary care conferences (MDCs) were often cited as contributing factors. The 16 hospitals reported an increase in the number of MDCs from 47 diseasespecific conferences to 83 at the end of the pilot. The percentage of MDCs that reviewed the diagnosis and treatment plan before treatment also increased.

This prospective review approach is the model in leading academic cancer centers, yet it is hard to accomplish in the community setting with private practice physicians. Navigators were an integral part of these efforts, with 12 sites reporting an increased number of navigators (Holden et al" 2012).

Expanding Research The NCCCP is evidence that, by engaging management and key physicians, community hospitals can contribute to the emerging science through clinical trials, high-quality biospecimen collection, and quality improvement research relevant to the entire cancer care continuum.

Increasing Patient Participation in Clinical Trials Although some of the NCCCP hospitals found it difficult to improve accruals, most were generally able to broaden their clinical trials portfolio, increase memberships in NCI-sponsored cooperative groups (research), and increase the number of local physicians accruing patients to clinical trials. The hospitals made significant infrastructure investments beyond their NCCCP awards to expand their clinical trials research capacity.

Access to research for underserved populations remains a challenge for NCI. However, the NCCCP's focus on disparities and the investment in clinical trials infrastructure allowed for the overall accrual of minority patients to clinical trials across the participating sites to almost double, from 82 patients at baseline to 151 at the end of the pilot. Similarly, accrual of older patients (aged 65 or older) increased from 200 at baseline to 641 at the end of the pilot, which compared favorably to national trends (Abemethy & Locke, 2012).

Promoting High-Quality Biospecimen Collection The limited ability of community hospitals to participate in biospedmen initiatives for cancer research posed a critical challenge from the outset of the project. By the pilot's end, many NCCCP hospitals were collecting biospedmens using standardized collection and storage procedures; this activity helped build a community-based research platform where patient data and high-quality blood and tissue samples could be used to support genomically informed medidne. At the end of the pilot three sites were contributing biospedmens and dinical data to The Cancer Genome Atlas (TCGA) program and five sites were contributing biospedmens to the Moffitt Cancer Center Total Cancer Care longitudinal molecular characterization study. The technical assistance provided by NCI, the role of the learning collaborative among pathologists, and funding support from hospital executive management contributed to these accomplishments (Dalton et al" 2012).

Expanding Information Technology to Support Research Due to the longitudinal nature of cancer care, oncology-specific EHRs are important for research as well as for quality of care. The NCCCP hospitals made significant progress in this area. By the end of the pilot, all 16 sites had EHRs with oncology-specific modules either implemented or in deployment. Sites noted that their participation with the NCCCP network enabled them to recognize the importance of data for their cancer program and draw attention to informatics needs. In many cases, this new focus led to increased budget and executive management engagement, making IT for these hospitals' cancer programs a higher priority.

Role of the Network With common subcontract deliverables, the hospitals were highly engaged with NCI program advisers. Eight subcommittees and several ad hoc working groups met monthly. Although this effort required significant time and resources from the hospitals, all sites were committed to overcoming the challenges and complexities inherent in many of the program's multisite projects. The recurring meetings provided a venue for a free-flowing exchange of information on best practices, challenges, and solutions. As noted by one NCCCP hospital cancer program administrator during a site visit evaluation interview (Holden et al" 2012, p. 15-3): That's been a real advantage of [the] NCCCP: that connection to another program that is similar to ours in terms of the challenges they face. . . . NCCCP has helped facilitate that communication.

Building on the trust developed among the sites, the hospitals supported coordinated efforts to advance programmatic objectives. These included site visits across the network, a project with ASCO to inform IT vendor product development (Ambinder, 2009) and improve and share IT solutions and code (NCCCP, 2012), and collaborations on several publications. For example, a series of white papers about each program focus area was published in Oncology Issues and subsequently compiled into a monograph (Association of Community Cancer Centers, 2012).

MANAGEMENT DECISION POINTS FOR PARTNERSHIP INITIATIVES New technologies and scientific discoveries, combined with the complex and changing healthcare delivery and financing environment, require that management of community hospitals reconfigure care processes and intraand interorganizational relationships to increase access to care, improve quality, and expand research capability. The NCCCP experience suggests that planning and sustaining future public-private partnership initiatives for healthcare delivery and research involve several critical factors, discussed in the following paragraphs.

Aligning partnership goals for success and sustainability. Optimal results can be achieved when the program aligns with the mission, business, and quality goals of the participating organizations and recognizes that organizations function within competitive environments. The NCCCP hospitals assumed a high level of cost sharing during program implementation, which suggests that hospitals are willing to provide significant financial and other organizational support for an initiative when management perceives value for the investment. For example, NCCCP hospital management viewed program participation as an opportunity to achieve greater alignment with physicians, increase grant funding or philanthropy, explore new research opportunities, increase community engagement, and enhance their hospital's reputation.

Sustainability requires a realistic assessment of payoff and a sense of ownership. As described by a hospital executive in an evaluation interview (Dalton et al., 2012, p. 5-20): We did not expect [a positive shortterm return], and I am not sure there could be ... and that didn't deter us because we view additional benefits besides the short-term ones. We view the opportunity or benefit for the longer-term strategic positioning of the hospital to be more valuable to us than anything demonstrated in the shortterm business case.

Defining and assessing the performance capacity and expectations. To fulfill partnership goals in a multisite initiative, requirements for the participating organizations need to be specific and clearly defined. They should reflect the infrastructure and commitments needed to support the partnership's goals. Examples include committed physician support clearly defined by activity, proven access to underserved populations with race and ethnicity tracking for all relevant data systems, prospective MDCs, availability of genetic counseling and testing, commitment to timelines and resource support for submitting data to RQRS, QOPI, or other standardized quality improvement programs, electronic data sharing across their providers, a research infrastructure, an electronic tissue management system, or participation in monthly meetings. For the sponsor-in this case, NCI-the requirements could include providing program access to dedicated staff for mentoring (e.g., high-quality biospecimen collection); offering expertise in data management, disparities research, or research design; and supporting access to early-phase clinical trials. The NCCCP demonstrated that specific data sharing and data standardization commitments and the availability of IT support from the NCI and the sites are critical for any multisite initiative. The complexity of data standardization and data sharing was not always appreciated or anticipated, resulting in some delay of network projects.

Promoting a culture of multilevel collaboration. The NCCCP demonstrated that collaborative relationships with private practice physicians, NCI, the hospitals in the network, and other organizations (e.g., local community organizations, regional or national research partners) contributed to achieving program goals. To the extent possible, relevant partnerships or collaborations should be formalized and in place at the outset of an initiative so that any commitment of resources and project completion timelines, including data-reporting requirements and the rationale for those requirements, are clear at all levels of the organization.

Collaboration across hospitals provides an opportunity for comparing and adapting approaches to achieve common goals. Critical to the success of collaboration is an infrastructure to support benchmarking across sites and the sharing of insights and mutual learning to the collective benefit of all the sites. Systems for communication, data collection, and analysis for program monitoring should be planned, funded, and supported by dedicated staff resources. Optimally, these network collaborations also require sustained engagement and commitment by all participants.

Matching research projects with organizational capacity. Specific projects should be manageable within the scope and capability of the participating hospitals and should be designed with input from community providers so that the assessment of capacity and the relevance of the study or project to a community setting are realistic. To the extent that initiatives can promote the use of standardized performance metrics managed by national organizations (e.g., the CoC's RQRS), project resources can be used more efficiently and simultaneously contribute to expansion of benchmarking to increase standardization across the delivery system.

Multisite efforts to support research projects in a community-based setting are challenging due to the variation in capacity and expertise, the discrete data systems and definitions, local institutional review boards, and limited research experience. The NCCCP pilot has shown that projects should have the benefit of technical guidance and be sequenced to increase in complexity, so that hospitals can refine their expertise and build on accomplishments in conducting research or to use for quality improvement studies-that is, the theory of small wins (Weick, 1984).

Accessing relevant expertise to address disparities. Addressing healthcare disparities is a particular challenge given all the demands facing community hospitals. The NCCCP pilot demonstrated that hospitals have the ability to reduce cancer healthcare disparities by linking with organizations that have relevant expertise to promote the development of creative and sustainable approaches. Additionally, focused efforts on specific underserved populations and an integrated program across the full cancer care continuum, including the promotion of clinical trial opportunities, helped to address disparities. The expertise offered to NCCCP pilot sites by NCI and other organizations allowed the community hospitals to test and adapt approaches, creating synergies that led to measurable progress. For strategies to be effective, management support is required to ( 1 ) draw on disparities or health services research expertise to design initiatives, (2) implement IT system changes and train staff to track underserved populations across all data systems, (3) measure progress by tracking patient outcomes using standardized and comparative data, and (4) improve community engagement to increase access to underserved groups through formal partnerships and informal alliances with community organizations.

CONCLUSION As demonstrated by the NCCCP, science can be translated to practice to improve cancer care and potentially other service lines within a community setting. Future efforts need to consider the underlying principles that guided the NCCCP implementation and performance as a public-private partnership. As described by an NCCCP hospital CEO, "Healthcare is a parochial business, and the NCCCP [as a public-private partnership] offers a breakthrough opportunity to transform care for cancer and other diseases." NOTE 1. Day-to-day project management for the request-for-proposal acquisition and procurement process and the resulting subcontracts awarded to the sites was managed by Science Applications International Corporation-Frederick (SAIC-F), Inc. (now Leidos Biomedical Research, Inc.), the current prime contractor that operates the government-authorized NCI Federally Funded Research and Development Center, the Frederick National Laboratory for Cancer Research. SAIC-F provided a communications infrastructure and worked with NCI and the NCCCP sites to support all aspects of network activities and projects.

ACKNOWLEDGMENTS This project has been funded in whole or in part with federal funds from the National Cancer Institute, National Institutes of Health, under Contract No. HHSN261200800001E. The content of this publication does not necessarily reflect the views or policies of the U.S. Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. government.

The authors wish to acknowledge the hard work and dedication of many individuals who contributed to the success of the NCCCP pilot, in particular all staff who supported the program at each of the 16 hospitals; the SAIC-F project management team, led by Joy Beveridge, with thanks to Kathleen Igo for her editorial assistance; the NCCCP Program Advisory Committee; and the leadership provided by Drs. John Niederhuber, Maureen Johnson, and Steve Clauser throughout the project. The authors also acknowledge the team at RTI International and their evaluation reports, which were used for the preparation of this article.

For more information about the concepts in this article, contact Ms. O'Brien at

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PRACTITIONER APPLICATION Robert H. Houlihan, DHA, FACHE, CCRP, CRA, director, Research Administration and Operations, Virginia Commonwealth University Massey Cancer Center, Richmond, Virginia As a leader of Massey Cancer Center, a National Cancer Institute (NCI)-designated cancer center, I can attest that the goals of the NCI Community Cancer Centers Program (NCCCP), as outlined in this article, are closely aligned with the mission and long-standing practices of Massey. Among other noteworthy accomplishments, Massey has consistently maintained its NCI designation, one of only 68 to do so among more than 1,500 cancer centers in the United States, since its first award in 1974. Over the past five years, Massey has dedicated considerable resources to building a statewide clinical trials network, partnering with community hospitals and local oncology practices to offer clinical trials that are not otherwise available as treatment options before they are available to the general patient population.

The NCCCP and NCI-designated cancer centers have many similarities. For example, community hospitals partnering with NCI-designated cancer centers have access to the expertise of faculty engaged in work at the top 4% of cancer centers in the country and to leaders in shaping the fight against cancer in the United States. NCIdesignated cancer centers are expected to make a meaningful impact on the populations served in their catchment area, including minority and underserved populations, to decrease cancer incidence and mortality. Through a related program, the NCI Center to Reduce Health Disparities aims to strengthen the integration of National Outreach Network-funded community health educators as part of NCI's cancer disparities outreach and research programs within the minority and underserved communities reached by these programs. Many NCI-designated cancer centers actively participate in this program, and natural partners to accomplish this goal are community hospitals. Expanding research and increasing participation in clinical trials, especially for minority and underserved populations, is a mutually shared goal of both NCI-designated cancer centers and the NCCCP. To be successful, cancer centers need to capitalize on public-private partnerships to expand their influence in making innovative clinical trials available for patients seen at community hospitals and oncology practice sites.

As the healthcare environment continues to evolve, innovative federal programs such as the NCCCP provide needed catalysts and seed funding to pilot models to meet the shifting population dynamics while addressing the needs of an increasingly diverse nation. As noted in the article, financial constraints are affecting healthcare providers' ability to provide value-based, state-of-the-art care. The majority of oncology patient services provided are community based, and as cited in the article, studies consistently show that patient outcomes are often not as optimal for those seen in community settings as they are for those in academic medical centers. Natural partnerships are ripe for the forging between NCCCP-participating hospitals and NCI-designated cancer centers that offer the potential to strengthen the results achieved by the program to date.

(c) 2014 Health Administration Press

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