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Implementing the

Nurse Navigator Role

Sharon Gentry, RN, MSN, AOCN, CBCN

Breast Nurse Navigator

Derrick L. Davis

Forsyth Regional Cancer Center

336-718-8476

Creating a Patient Navigator

Program

Access Need

Identify Champions/Recruit Supports

Determine Scope of Program

- Collect baseline data

- Navigator responsibilities

Program Planning

- Identify navigator

- Marketing

Step 1:

Assess need for implementation

Step 2:

Enlist internal support

Step 3a:

Evaluate potential obstacles to

implementation; brainstorm

for solutions

Step 3b:

Determine program scope, cost, and

implementation strategy

Step 3c:

Collect baseline data for needs

assessment and evaluation

Step 4:

Implement program and identify

a patient navigator

Step 5:

Assess program effectiveness

Task:

Coordinate program planning

with appropriate departments

Task:

Prepare documents

(eg, posters, brochures,

policies, procedures, forms)

Task:

Track responses, appointments,

and other relevant data

Task:

Implement support systems,

referral processes, outreach

strategies

Implementing a Navigation

Program

HANYS BCDP™. Breast Health Patient Navigator Resource Kit. Rensselaer,

NY: HANYS; 2002.

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Where Should Navigation

Be Implemented?

Organizations providing care within the cancer continuum

– Hospitals

– Clinics

– Screening centers

– Community not-for-profits

– Oncology and radiation therapy offices

Organizations with an underserved population

Organizations wishing to provide a premier cancer

care center delivery model

“Patient navigation in cancer care refers to

individualized assistance offered to

patients, families, and caregivers to help

overcome health care system barriers and

facilitate timely access to quality medical

and psychosocial care from pre-diagnosis

through all phases of the cancer

experience.”

*From a definition created by C-change, May 20, 2005. Permission granted.

ACCC’s Patient Navigation Project

The Patient Navigation Model

Freeman HP et al. Cancer Pract. 1995;3:19-30.

The Cancer Care Continuum

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Rationale

“Cancer programs have a responsibility to assist our patients, their families,

and caregivers to navigate the continuum of care through a navigation program developed by a cancer program or via a partnership with a

community agency that utilizes patient navigators.

Since each cancer program understands its unique patient population and

its community, individual programs or health systems can best create a navigator system that suits its needs.”

ACCC’s “Cancer Program Guidelines”

Specific Patient Navigation Needs

of your Health Care System

Discussion of your specific patient navigation program

Discussion of specific needs

Discussion of specific barriers

Discussion of specific challenges

Ideas that will work for your program

ACCC’s Patient Navigation Project

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Who is a champion?

A champion of patient navigation is a

person who initiates and supports

implementation of the program within a

given organization.

- knowledgeable about health care barriers

- an advocate for addressing gaps in service

- a persuasive speaker on the benefits of patient

navigation

http://www.patientnavigation.com/myhome/program/ ; January 14,

2008

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Identify Champions/Recruit

Supporters

Physician Champion

– May or may not be Medical Director

Leader Support

– CEO, COO of Organization

Department Support

– Case Management

– Inpt Oncology Unit

Community Agencies

– ACS

– Hospice

Making a Patient Navigation

Program Work

Organizational buy-in and support

Dedicated resources

Supportive leadership

An established alliance between the navigator

and highly connected, key decision makers

in the organization, especially those involved

in financial decisions

A patient navigator dedicated to expediting

patient access and improving continuity and coordination

of care

Financial support

Budgetary Considerations for the

Program

Patient navigator selection, salary, benefits, and training

Supplies, materials, and office space with computer access for the navigator

Program promotion for patients and professionals

Outreach incentives to patients to use navigation

Evaluation costs in implementing tracking systems, if not already incorporated into the existing structure

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What have we got?

Oncology nurse with 20 years of inpt experience

Oncology services – dietician, social worker, physical therapy

Hospice care

350 new breast cancer pts / year

Radiology services for staging

Breast Clinic

Cancer Center

4 Oncology Offices

Radiation Therapy 4 Surgical Offices

Community resources

Lymphedema Therapist

2 hospitals

NO PRESSURE!!!!

Forgive me!! Yuk, Yuk

Determining If Patient Navigation Is

Appropriate for Your Organization

Patient demographics

Statistics concerning patient populations

Outcomes

Percentage of patients who complete a

treatment plan to resolution

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Potential Barriers to Receiving Timely Health Care

Barrier Examples

Financial and economic Lack of or inadequate insurance

Transportation Difficulty arranging transportation

Cultural Cultural beliefs regarding treatment

Social support Cultural prohibitions about cancer

Information and education Lack of understandable cancer-related

information

Health care system Fragmentation of care

Bias based on race/culture Patient distrust of the health care

system

Fear Delay or refusal of care

Freeman HP, Reuben SH. Voices of a Broken System. Bethesda, Md: NIH, NCI; 2001.

Barriers That Inhibit Optimal Health

Care Appointments missed per week

Percentage of patients lost to follow-up

Average time from suspicious finding to follow-up

appointment

Average time from suspicious finding to diagnosis

and/or treatment

Lack of coordination between departments

NCCN Clinical Practice

Guidelines in Oncology

Bladder

Breast

Cervical

Colon

Leukemia

Lymphoma

Melanoma

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Collect Baseline Data

For Needs Assessment

– Time Delays

Data for Evaluation

– Outcomes

– Guideline Compliance

– Outmigration

Sample Outcome Measurements

Patient Satisfaction – Patient satisfaction score prior to implementation of navigation services

(baseline score).

– Patient satisfaction score 6-12 months after navigation program has unrolled. Continue to monitor scores on an ongoing basis.

– Number of patients leaving the cancer center for treatment elsewhere prior to implementation of navigation services.

– Number of patients leaving the cancer center for treatment elsewhere 6-12 months after navigation program has unrolled.

– Number of patient referrals prior to implementation of navigation services.

– Number of patient referrals 6-12 months after navigation program has unrolled. Continue to monitor scores on an ongoing basis.

– Patient satisfaction with navigation program. Continue to monitor scores on an ongoing basis.

www.accc-cancer.org or www.hopkinsbreastcenter.org

Sample Outcome Measurements Patient Encounters

– Time to diagnostic mammogram BEFORE and AFTER implementation of navigation services.

– Time to needle biopsy BEFORE and AFTER implementation of navigation services.

– Time to diagnosis BEFORE and AFTER implementation of navigation services.

– BEFORE and AFTER implementation of navigation services, the time to initial treatment from: a) Initial visit, b) diagnostic mammogram, 3) diagnosis.

– BEFORE and AFTER implementation of navigation services, the time from diagnosis to consult with: a) breast surgeon, b) plastic surgeon, c) medical oncologist, d) radiation oncologist, e) genetic counselor.

– Time from OR to chemo/radiation BEFORE and AFTER implementation of navigation services. ( Becoming a Breast Cancer Nurse Navigator)

– Number of referrals to a) navigator, b) genetic counseling, c) nutrition, d) social work.

– Number of underserved BEFORE and AFTER implementation of navigation services.

– Number of unavoidable admissions/ER visits BEFORE and AFTER implementation of navigation services.

– Length of hospital stay BEFORE and AFTER implementation of navigation services.

www.accc-cancer.org

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Sample Outcome Measurements

Programmatic components and performance improvement – Track tumor conference recommendations based on guidelines (e.g., NCCN,

ASCO).

– Create standing order sets by disease site and measure use of tools.

– Track percentage of patient provided with educational materials/information, BEFORE and AFTER patient navigation services.

– Track percentage of patients given information on clinical trials and monitor percentage of patients put on clinical trials.

– Create site-specific navigation programs.

– Establish a Patient and Caregiver Advisory Committee.

– Develop marketing materials and measure physician referrals BEFORE and AFTER implementation of navigation services.

– Establish survivorship program and measure patient satisfaction.

– Develop end-of-treatment celebration and measure satisfaction.

– Create support groups and other educational programs and evaluate. www.accc-cancer.org

Moving Toward Implementation

Patient Navigation’s Guiding

Principles

The guiding principles of patient navigation are to ensure

that quality, confidentiality, and professionalism are

threaded throughout all aspects of care and programming. Inherent in the process is continuous quality care for

patients from screening through diagnosis and treatment,

based on the following tenets:

– Culturally competent care

– Confidentiality

– Respect

– Compassion

– Patient safety

Freeman HP. Oncol Issues. September/October 2004;19:44-46.

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Characteristics of a Navigator

Preferably selected from the community of patients

being served

Compassionate with a sincere desire to help people

Understands the issues of financial, cultural, educational,

and social barriers to information and care in the patient community

Can communicate effectively with patients, their families, and health care providers

Is organized and can demonstrate creative problem-solving solutions

Is highly resourceful and able to research resources

for patients

Freeman HP. Oncol Issues. 2004;5:44-46.

Long Island College Hospital. Breast Health Navigator Program. Rensselaer, NY: HANYS; 2002.

Responsibilities of a Navigator

Meet with patients at point of suspicious finding

Identify any barriers or potential barriers to care

Streamline appointments and paperwork

Maintain open communication with health care providers, caregivers, and patients

Assist in increasing access to culturally appropriate, supportive care when and where possible

Link patients, caregivers, and families with appropriate follow-up services

Maintain personal contact with patients throughout the health care continuum and follow their progress

HANYS BCDP®. Breast Health Patient Navigator Program Resource Kit. Rensselaer,

NY: HANYS; 2002.

Long Island College Hospital. Breast Health Navigator Program. Rensselaer, NY: HANYS; 2002.

Non-Clinical Volunteer

Can connect patients to information and community resources

No cost to the institution; can assist clinical navigators

High risk of position turnover; negatively impact care due to schedule

ACS Navigator

Trained by ACS and host, specific role, standardized information

Low cost due to ACS funding

Restricted in ability to provide clinical information and interventions

Lay/Survivor

Can connect patients to information and community resources

Low cost; can assist clinical navigators

Lack medical knowledge outside of experience; Restricted in ability to provide clinical information and interventions

The Advisory Board Company 2008: www.cancer.org

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Clinical Navigators Social Worker

Individual assessment and address of psychosocial barriers; counseling

Less costly of clinical group and has some clinical knowledge: great knowledge of community resources

Restricted in medical knowledge and ability to address treatment and symptom concerns

Nurse

Medically knowledgeable resources; trained for nursing assessment

Play a larger clinical role; refer patients to support as needed

More costly than social work and non-clinical; may lack community resource awareness

Advance Practice Nurse

Can bill for services; larger clinical role beyond RN capabilities; refer patients to support as needed

Some institutions do not bill services; additional cost compared to RN may be difficult to justify

Oncology nurse vs Nurse Navigator * key is limited vs expanded clinical role

Oncology nurse

Basic oncology nursing education

CHEMOTHERAPY & BIOTHERAPY/SAFE HANDLING

SYMPTOM MANAGEMENT

RADIATION

GENETICS

PHARMACOLOGY

DISEASE MANAGEMENT

BREAST

LUNG

HEMATOLOGIC DISORDERS

HEAD & NECK

TREATMENT

NURSING-SENSITIVE PATIENT OUTCOMES/EBP

CLINICAL TRIALS

CANCER ESSENTIALS

PATIENT EDUCATION

Certification – OCN, CPON, CBCN,

AOCN, AOCNS

www.ons.org, www.oncc.org

Oncology Nurse Navigator

Oncology Certified Nurses with at least 4 years oncology experience

Clinical Nurse Specialist Navigators hold a Masters Degree in Oncology Nursing in addition to having Advanced Oncology Certification All navigators exemplify role model behavior and are committed to providing quality care

Frelick, et al, 2006

Care Management knowledge

Healthcare System knowledge Diversity Training

High organizational skills Leadership skills Team buliding skills

Patient advocacy skills

Seek and Hogle, 2007

Familiarity with internal and community resources

Liasion skills Site specific certification- -www.breastcare.org

Clinical Trials Nurse

Healthcare System

clinical trial

availability

Screening

Navigation

Treatment

Navigation

Survivorship

Navigation

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Navigator Types

RN – 55%

APN – 20%

SW – 7%

Non-clinical – 13%

Other – 5%

The Advisory Board Company. Elevating the patient experience: building successful patient navigation, multidisciplinary care, and survivorship programs. Oncology Roundtable 2008. Washington, DC.

Action Plan:

Demonstrate Program Success

Data should be gathered at the start of the program and

tracked throughout to:

– Identify system changes that need to be made

– Determine resources that are lacking

– Track success of interventions

– Assure that the intended audience is being served

Choice and complexity of evaluation measurements:

– Should be determined based on the resources available

– Will vary from program to program

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Action Plan:

Promote Awareness of the Program

Identify other departments involved in overseeing

care (eg, radiology, radiation oncology, patient

billing, social work)

Formulate outreach

and educational strategies

Work with the public relations department

to promote and publicize program, both

internally and externally

Program Execution

Coordinate with appropriate departments and

community agencies

Determine what policies and procedures will be needed

Determine referral process

Create brochures and letters for patients and physicians

Market and promote program

Determine monitoring and evaluation process

Outcome Measures - 2006

Measures Patient

Satisfaction

Very Helpful

Patient

contacts

Community

Outreach

Number

Reached

Outmigration

Capture

Breast

Navigators

Very Helpful

85%

Newly

Diagnosed

466

Total Contacts

9,736

Presentations

Health Fairs

19,695

35 cases

$487,817.00

(does not include

outpt. Chemo)

Lung

Navigators

Very Helpful

82%

Newly

Diagnosed

336

Outreach

Activities

Est. 8,000

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Breast Health Navigator 2001

Develop this program

Let us know what you

need

The Navigator Team

2008

Navigators

Care

Coordinator

Adm.

Specialist

Clinical

Trials

Health and

Wellness/

Dietician

Chaplain

Support

Coordinator

Outcomes

Analyst

Navigator Team Programs – Gentle Yoga

– Muscles in Motion (patient exercise program)

– Healthy Eating After Treatment

– Caregivers

– Food for Body and Soul

– Survive and Thrive

– Feel Good Friday

– Pink Broomstick

– Lung

– Colon

– Us Too

– Ovarian

– Leukemia and Lymphoma

– CLIMB (Children Lives Include Moments Bravery)

– LITE ( Losing Inches Through Education)

– Grief Support

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Evaluation

•Increase access to breast cancer services for all patients

•Reduce obstacles to breast cancer care for low income

patients •Increase cancer survivorship skills

•Diminish patient anxiety - increase coping

•Rapid turn around times from diagnosis to treatment

•Stronger linkage of community breast health and breast

cancer services

Navigator Foundation

One Community Center Example

Community Contributions

Annual Simstein Event

– Super Bowl Sunday

– Chocolate Delights

Annual Tennis Benefit

– Smash Cancer

Patient and Family Benefits of

Patient Navigation Programs

Provide emotional support

Help prepare patients for the cancer journey

Ease the referral process with health care

professionals

Help coordinate appointments

Assist with logistics in getting care

Help find resources (eg, transportation,

medications, supplies)

Refer patients to community resources Cancer Patient Navigation Evaluation Findings, Summary Report. March 2004. Cancer Care Nova Scotia; 2004.

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Health Care System Benefits of

Patient Navigation Programs

Better patient preparedness

Greater support for patients

Improved collaboration among the health care

professionals

More efficient clinical involvement with patients

Identification of service gaps

Increased patient satisfaction

Enhanced relationships with the community

Cancer Patient Navigation Evaluation Findings, Summary Report. March 2004. Cancer Care Nova Scotia; 2004.

???QUESTIONS???

The “navigator”...

an

advocate and a companion

above all else