PROJECT SUMMARY Oncology financial navigation is an evidence-based intervention to combat cancer-related financial hardship by helping patients prepare for out-of-pocket treatment costs, optimizing health insurance, and accessing financial resources. Though research-based integration of oncology financial navigators has been proven beneficial for patients in controlled settings, little is known about how to implement oncology financial navigation into routinely-delivered oncologic care, especially for systems serving patients experiencing large inequities in financial hardship. To address this knowledge gap, we propose a pragmatic, hybrid effectivenessimplementation study to assess outcomes of oncology financial navigation delivered as routine cancer care at the University of Alabama at Birmingham. This study will build upon my existing skills in quantitative research methods, which has provided foundational work to better understand cancer-related financial hardship, and allow for the development of new skills in implementation science, pragmatic trials, and qualitative methods to address financial hardship. We hypothesize the proposed assessment will identify potential areas to improve implementation of oncology financial navigation, which will result in better financial and clinical outcomes for patients with cancer. Outcomes will be assessed overall and for inequities by race, residence, and insurance status using three specific aims. In Aim 1, we will track oncology financial navigation implementation strategies and their effect on implementation outcomes, including reach, adoption, implementation fidelity, and maintenance. In Aim 2, we will use routinely collected, patient-reported data to evaluate change in patientreported measures of financial distress, financial difficulties, quality of life, and psychological distress for patients receiving oncology financial navigation compared to historical controls ("usual care"). In Aim 3, we will use qualitative interviews to assess how oncology financial navigation implementation strategies were leveraged to address implementation barriers identified from patient, provider, and health system perspectives. Through the evaluation of real-world oncology financial navigation implementation, this innovative project will create opportunities for immediate scalability and sustainability within value-based payment models. The proposed research is significant because it will provide foundational data on the utility of oncology financial navigation implementation strategies and their effect on implementation and patient outcomes in clinical settings serving a diverse, real-world pool of patients with cancer. Results from this study will inform a larger study testing implementation and integration of oncology financial navigators into routine cancer care delivery at multiple institutions nationally. Furthermore, it will provide the training and mentorship necessary to develop my independent research program and eventually achieve my ultimate career goal of developing and testing evidence-based interventions that target financial hardship in real-world settings to improve affordable, accessible, and equitable care for all patients with cancer.

PROJECT NARRATIVE The proposed research is relevant to public health because it will provide foundational data on the utility of oncology financial navigation implementation strategies and their effect on implementation and patient outcomes in a real-world clinical setting serving a diverse pool of patients with cancer. This research will significantly advance scientific knowledge regarding how and why specific oncology financial navigation implementation strategies were effective and their impact on patient financial hardship for larger-scale implementation at institutions nationwide. While expected to benefit all patients with cancer, this intervention will particularly impact patients with cancer experiencing high and inequitable levels of financial hardship, making the proposed research particularly relevant to the NIH's mission to enhance health, lengthen life, and reduce illness and disability.