Clinicians monitor individual patient treatment progression but lack a system for analyzing it across all patients

Data around treatment progression milestones is sometimes available but may not be easily accessible or real time

Organization has a system that shows real time when treatment milestones are missed to allow for follow-up

Clinicians have access to some outcomes data, but it is not consistently broken down along equity lines

Clinicians have access to outcomes data that is broken down along equity lines; data is not in an easily accessible or usable format

Clinicians have easy access to frequently updated outcomes data broken down to specifically examine inequities

Clinicians or other staff may be aware of patient SDoH but do not track these needs in a standard way

All patients are screened for SDoH factors, but there may not be a robust follow-up process when needs are identified

All patients are screened for SDoH, and the organization has dedicated staff time to connect patient to relevant resources

Clinicians keep up-to-date on clinical best practices on their own as new research and guidelines are published

The organization offers clinicians some resources for keeping up with advances, but still relies primarily on clinician initiative

The organization provides clinicians with resources like conferences, trainings, and protected time to stay updated on clinical best practices

When patients present with comorbidities, clinicians refer care for areas outside their specialty

Clinicians collaborate informally with other specialties as needed to ensure aligned treatment across comorbidities

Systems or forums exist (e.g., multi-specialty forums) to consistently discuss treatment plans, comorbidities, and patient progress when appropriate

Clinician is responsible for identifying potential drug interactions during patient consultations

Organizations have standardized protocols or tools to monitor potential drug interactions (e.g., EHR warnings or checklists)

The organization has dedicated staff (e.g., clinical pharmacists) to help monitor for drug interactions and advise on treatment protocols

Biomarker testing completed inconsistently, no standardized process for timely result integration and treatment

Biomarker testing performed consistently, but results may be inconsistently used due to delays, accessibility issues, or incorrect referrals

Biomarker testing is consistently performed; results are easily accessed by clinicians and used for timely treatment when applicable

Patients see a generalist or specialist based on factors like chance and geography, not clinical appropriateness

Specialists and generalists informally collaborate to ensure precision medicine cases get the right specialist input

There is a referral system or direct communication avenue to ensure access to precision medicine and specialist care

Organization refers or enrolls eligible patients in clinical trials when the opportunity presents

Clinical trial enrollment is actively sought for all eligible patients, but the organization does not provide outreach or additional support

Organization invests staff time (e.g., a research coordinator) to foster patient confidence in clinical trials and enrolls all eligible patients

Clinicians educate patients and build relationships with patients during appointments, as time allows

Organization has scaled resources (written or digital) with accessible language to ensure patients understand their treatment

Organization has members of the clinical team (e.g., clinic nurses or nurse navigators) who explain treatments, answer questions, and provide support to patients outside of appointments

Patients usually manage their own care journey, including making appointments, getting referrals, and consulting their clinicians about needs

Staff in other patient-facing roles (e.g., nurses, social workers, or administrative personnel) may assist patients in navigating the healthcare system as needed

Trained staff help patients by coordinating appointments, providing education, connecting to resources, and offering emotional support

Patient visits are scheduled in a timely manner where there are openings; time and location flexibility is limited

Efforts made to schedule visits promptly and consider patient convenience (e.g., grouping appointments), but flexibility in time and location is limited

Intentional efforts are made to schedule patients conveniently, (e.g., same-day imaging and consults) when possible

Organization has identified community resources that meet non-clinical needs (e.g.,, housing, food, transportation); patients are given contact information when needed

Organization is building partnerships with community organizations and frequently refer patients when risk factors are identified

Organization has strong partnerships with community organizations and has staff members (e.g., social workers or nurse navigators) to assist patients in making those connections

Basic financial navigation and guidance may be offered to patients, including general information about costs and insurance coverage

Financial navigators help patients understand their insurance and treatment cost estimates

Financial navigators help patients understand insurance and costs, work to obtain insurance coverage, and apply for financial or pharmaceutical assistance programs