Abstract
SUMMARY
Delivering effective cancer care increasingly depends on a health system’s ability to anticipate and address social needs that interrupt access, adherence, and continuity. In El Paso, Texas—a U.S.-Mexico border region shaped by geographic distance, rural catchment areas, a large military-connected population, persistent poverty, and concentrated social vulnerability—those needs are routine, not exceptional (ATSDR 2024
;
City-Data 2023
;
City of El Paso 2023
;
Esri Federal Data 2002). Patients commonly face transportation barriers, food insecurity, housing instability, financial toxicity, language discordance, and fragmented pathways across civilian and federal systems. These factors can derail evidence-based treatment as surely as any clinical complication (Jaber 2024
;
Raber et al. 2022). This article presents how the University Medical Center of El Paso, in partnership with Texas Tech Health El Paso, is building a community cancer care ecosystem anchored by the new Fox Cancer Center, while redesigning care delivery to function reliably beyond hospital walls (UMC Cares 2025b
;
Vierra 2025). The approach embeds social needs identification into oncology workflows at predictable pathway points and strengthens the system’s ability to respond through formal partnerships with community-based organizations and clearer accountability for whether needs are actually resolved (AMA 2025). A central workforce strategy is the integration of
promotoras
, culturally concordant navigators who operationalize trust, ease the delays and confusion that arise when patients move from one stage of care to the next, and help patients and families complete complex treatment journeys. The article introduces the THREADS Framework, a practical model for health services leaders comprising Trust, Hub-and-spoke anchoring, Routine screening, Embedded partnerships, Aligned navigation, Data that reflects reality, and Sustainability and stewardship (AMA 2025
;
Jaber 2024).