The objective of this study was to explore the implementation of a payment and delivery system innovation to improve coordination and communication between primary care and oncology. We employed a qualitative case study approach, conducting interviews ( n = 18), and reviewing archival materials. Chronic care coordinators and the cancer center social worker acted as boundary spanners. The chronic care coordinator role built on medical home infrastructure, applying the chronic care model to cancer care. Coordination from primary care to oncology became more routinized, with information sharing prompted by specific events. These new boundary spanner roles enabled greater coordination around uncertain and interdependent tasks. Recommendations for scaling up include the following: establish systematic approaches to learning from implementation, leverage existing capacity for scalability, and attend to the content and purpose of information sharing.
