This study is for patients diagnosed with a solid tumor malignancy of any stage and identified as high risk (having a 6-month mortality estimate). The study is evaluating A-PACT (algorithm-Enables Patients Activated in Cancer Care through Teams). The subjects will be randomized (like flipping a count) to determine if they will receive A-PACT with usual care or usual care alone. The primary purpose of this study is to determine if the A-PACT Program reduces unplanned hospital visits and improves communication between patients and their health care team. Participants in this study can expect to be in this study for 12 months or their withdrawal of consent.

This research study aims to improve care coordination in the context of cancer survivorship care by understanding how primary care providers and cancer specialists share responsibilities. Researchers want to understand how technology can help these teams communicate more clearly and effectively to coordinate care for survivors. The study team will use surveys and conduct interviews and focus groups for interested and eligible participants as methods of data collection to inform the research. Oncologists, primary care physicians, and survivors of breast, prostate, lung, colon and rectal cancer that meet the eligibility criteria will complete surveys and engage in interviews to understand barriers and identify strategies to improve care. Using this information, the team will create an intervention plan called ACT that addresses common barriers, using focus group discussions to refine the intervention. The ultimate goal is to help patients receive better and more coordinated follow‑up care.

This study aims to improve cancer survivorship care work by refining how primary care providers and cancer specialists share responsibilities. Researchers want to understand how technology can help these teams communicate more clearly and effectively to coordinate care for survivors. The study team will use surveys, conduct interviews and organize focus groups for interested and eligible participants as methods of data collection to inform the research. Oncologists, Primary Care Physicians, administrative leads and colon or rectal cancer survivors that meet the eligibility criteria will complete surveys, engage in interviews and group discussions from each perspective to learn strategies to improve care, including who should handle which parts of survivorship care. Using this information, the team will create an intervention plan called PRIMES that outlines strategies to overcome common barriers. The ultimate goal is to help survivors receive better and more coordinated follow‑up care.