University of Kentucky Markey Cancer Center

Leveraging Navigation through the Comprehensive Connected Cancer Program

The University of Kentucky Markey Cancer Center (UKMCC) serves the entire state of Kentucky with a population of nearly 4.5 million–many of whom face substantial socioeconomic challenges, including transportation access, food insecurity, housing instability, and insurance coverage. Of Kentucky’s 120 counties, 39 are designated as areas of persistent poverty. Around one-quarter of patients are enrolled in Medicaid, and 54% reside in Appalachian counties. As a result, Kentucky has a substantial cancer burden, and is home to some of the highest rates of cancer incidence and mortality in the country.

Through the Alliance

UKMCC established the Comprehensive Connected Cancer Care (C4) Project in 2022 through its work as part of the Alliance. C4 is a collaboration between UKMCC and two community-based oncology programs–Appalachian Regional Healthcare in Hazard and Med Center Health in Bowling Green–and is designed to enhance existing patient navigation services through digital tools and data tracking. 

The C4 Program developed MyPath KY, a patient mobile application and staff navigator dashboard, that facilitates psychosocial/distress screenings, personalized resource recommendations within the patient’s community, communication with a patient navigator, and access to supportive educational materials. Supporting implementation of Commission on Cancer standards, C4 is addressing social drivers of health (SDOH) barriers that contribute to the significant disparities in cancer outcomes in Kentucky. The most common SDOH barriers reported by patients enrolled in the MyPath KY app, include financial strain (48%), transportation access (39%) and housing instability/utility maintenance (30%).

Patients enrolled in MyPath KY are oriented to the app and encouraged to complete regular check-ins. During each check-in, patients complete the NCCN Distress Thermometer as an SDOH/psychosocial distress screening. When concerns are selected, the app immediately provides personalized referrals to community, statewide and national resources. The navigation staff use the dashboard to monitor patient check-in responses and requests for assistance, the status of referrals, and to send patients new referrals and resource recommendations. 

Program Impact (As of November 2026)

For Patients:

• Developed and made ongoing enhancements to the MyPath KY app and navigation dashboard to help patients get immediate assistance and resources delivered directly to their phone or tablet. To date, the app has been used by 53 patients, who conducted 110 SDOH/psychosocial distress screenings and received 1,170 personalized referrals to resources.
• Involved a Patient Advocate Committee of 9 patients, caregivers, and community partners in the co-design process. The committee has been instrumental in ensuring the digital tools are patient-centered. Staff navigators are used to document patient-reported challenges with using the app and suggest improvements. 
• Added subcategories in the NCCN Distress Thermometer within the MyPath KY app based on feedback from patients. This provides patients with more detailed options for describing their barriers and the assistance they need. 

For Providers & Care Teams:

• Involved 264 patients and caregivers, community organizations, healthcare providers and staff in the C4 Project study through co-design studios, user testing interviews, stakeholder committees, or enrolling as study participants.
• Included 7 providers and staff in the co-design process to inform development and refinements of the patient app and staff dashboard. 
• Created a Clinical Collaborator Committee at each site composed of medical oncologists, nurses and navigators–a total of 36 members. The committees provide specific feedback on using the technology to support patient’s unique needs at each site. 
• Created a protocol for navigators to monitor patient needs in the dashboard to enhance communication with participants, provide additional assistance when needed, and document the referral lifecycle from beginning to end.
• Delineated the responsibilities of non-clinical patient navigators and oncology social work navigators, so concerns are directed to staff with the appropriate expertise.

Drivers of Success

• Engage Stakeholders Early On: Engaging stakeholders continuously throughout the co-design process has helped the team consider practical issues that might otherwise limit adoption of the tools, including how patients are introduced to the application, how reported concerns are reviewed, and who handles follow-up. 
• Clearly Define Roles: The MyPath KY app highlights the importance of clearly defining the roles of non-clinical patient navigators, oncology social worker navigators, and cancer care teams in supporting patients throughout their journey, ensuring patient needs and staff roles are well aligned.
• Lean on Automation: Designing automated tools and workflows and adding concern subcategories allows for quicker, more personalized resource connection and tracking of the status of referrals. This process complements existing workflows and navigator-patient encounters to deliver immediate referrals, thus eliminating the delay between submission of SDOH/psychosocial distress screening and provision of referrals.

Meet the Team

Timothy Mullett, MD, MBA, FACS
UK Co-Project Director, Alliance for Equity in Cancer Care
Medical Director, Markey Research & Affiliate Networks
Professor, Thoracic Surgery

 

 

 

Pamela Hull, PhD
UK Co-Project Director, Alliance for Equity in Cancer Care
Associate Professor, Behavioral Science, William Stamps Farish Endowed Chair in Cancer Research
Associate Director of Population Science Community Impact, Markey

 

 

 

Ming Chih, PhD, ACHIP, FAMIA
UK Co-Project Director, Alliance for Equity in Cancer Care
Associate Professor, UK College of Health Sciences

 

 

 

Joan Scales, MSSW, LCSW, Quality Improvement Research Manager

Joseph Alexander, MHA, MS, PMP, Clinical Research Project Manager