how patient navigation drives quality and produces profit

How Patient Navigation Drives Quality and Produces Profit

in Health Care

Judy C. Kneece, RN OCNEduCare Inc., Charleston, SC

Learning Objectives

• Define patient navigation

• Describe the benefits of patient navigation on quality-of-care

Financial Disclosure

• Educare Inc., President

– Salary

• Nursenav Oncology, Shareholder

Quality:Organization's efficiency,

outcomes of care and level of patient satisfaction.

- Health Resources Administration

Quality is NEVERan Accident

Quality is ALWAYSthe Result of

Intelligent Planning

American College of Surgeons

• ACS recognized that Patient Navigation was an essential component of quality health care delivery

– 2008: NAPBC included Patient Navigation as an accreditation standard

– 2012: CoC added Patient Navigation as an accreditation standard

Patient Navigation DefinitionCommission on Cancer; C-Change

“Individualized assistance offered to patients, families and caregivers to help overcome healthcare systems barriers

And facilitate timely access to qualitymedical and psychosocial care

From pre-diagnosis through all phases of the cancer experience.”

How Patient Navigation Creates a Culture of

Qualityfor the Patient

is wrapped a patient.

CAUTION:

Handle with care.”

“Around each cancer

Dr. Henry P. Leis

The Patient

A Dedicated Team of Physicians Focus on Quality Care for a Patient’s Cancer

Patient NavigatorFocuses on a Patient’s

Quality of Care

Cancer Care Delivery

• 15% of cancer care is delivered in Comprehensive Cancer Centers with all physicians and support staff located on-site

– Ideal model for patients and physicians

• 85% of cancer care is delivered in Community Cancer Centers with physicians practicing independently at multiple sites that are separated by distance and time

– Creates barriers for patients in navigating their own care

– Creates problems for physicians in delivering collaborative care

Cancer Care Delivery

• Community Cancer Centers face a challenge in delivering the same patient-centered cancer care as Comprehensive Centers

– Challenge: Finding a cost-effective solution to close gaps in care delivery

Making the Case for

Patient Navigation

The

Patient

Experience

Diagnosis:

CANCER

ShockedEmotionally Overwhelmed

Forced to Proceed: No Time for Delay

Patient Faces an

UnknownHealth Care System

Totally Unprepared

Silo Care Delivery

S

U

R

G

E

R

Y

DiagnosticRadiology

PathologyPlastic Surgery

SurgeryMedical

OncologyRadiation Oncology

P

A

T

H

O

L

G

Y

M

E

D

O

N

C

R

A

D

O

N

C

P

L

A

S

T

I

C

S

R

A

D

I

O

L

O

G

Y

Physicians Practice Independently, Separated by Time and Space

Dr. Fitzhugh MullanCancer Diagnosis 1982: Age 32

“I was experiencing medicine from the other end of the stethoscope, coming from a very personal perspective.Various specialists were doing diligent work, but kind of “smokestack” work, each in their own chimney.This was a graphic demonstration of what I think is a major ailment in our system, which causes gross inefficiency.”

Vital Signs: A Young Doctor’s Struggle With Cancer

Dr. Mullan’s writings created widespread

awareness and advocacy for reform

1986: Co-Founded the National Coalition for Cancer Survivorship (NCCS)

Identifying Gross Inefficiencies in Silo Care

Patient Challenges

Health Care Provider Challenges

Patient: Inefficiencies Experienced

S

U

R

G

E

R

Y

DiagnosticRadiology


SurgeryMedical


P

A

T

H

O

L

G

Y

M

E

D

O

N

C

R

A

D

O

N

C

P

L

A

S

T

I

C

S

R

A

D

I

O

L

O

G

Y

Care Fragmented ─ Hard to Navigate on Own

Medical Language Difficult to Understand

Patient’s Emotions are at Highest Level

Barriers to Patient Care Not Addressed

Conflicting Advice Received from Physicians

Lengthy Wait -Time Between Appointments

Healthcare Team: Inefficiencies Experienced

R

A

D

I

0

L

O

G

Y

S

U

R

G

E

R

Y

DiagnosticRadiology

Pathology Plastic Surgery

Surgery Medical Oncology

Radiation Oncology

P

A

T

H

O

L

G

Y

M

E

D

O

N

C

R

A

D

O

N

C

P

L

A

S

T

I

C

S

Time from Diagnosis to Treatment Increases

Communication Between Physicians is Difficult

Uncoordinated Care Decreases Patient SatisfactionTransitions of Care May Increase Error Potential

Potential for Duplication of Services Increases

Malpractice Potential Increases

Major Cause of Inefficiencies in Silo Care Delivery

R

A

D

I

0

L

O

G

Y

S

U

R

G

E

R

Y

DiagnosticRadiology



Radiation Oncology

P

A

T

H

O

L

G

Y

M

E

D

O

N

C

R

A

D

O

N

C

P

L

A

S

T

I

C

S

Gaps of Time Created During Delivery of Care

Examining the Gaps in Silo Care Delivery

R

A

D

I

0

L

O

G

Y

S

U

R

G

E

R

Y

DiagnosticRadiology



Radiation Oncology

P

A

T

H

O

L

G

Y

M

E

D

O

N

C

R

A

D

O

N

C

P

L

A

S

T

I

C

S

White Space:Transition Period Between Service Lines

Where There is NoPatient Ownership or Accountability

White Space in an OrganizationHarvard Business Review

“The large, but mostly unoccupied territory, in every organization where rules are vague, authority is fuzzy,budgets are nonexistent and strategy is unclear — and where, as a consequence, errors occur.”

During Transitions of Care, the Patient is Left to Find Her Own Way

Potential Hazards:Patient Out-Migration or Malpractice

How Can Community Cancer Centers Close Gaps in Care Delivery?

S

U

R

G

E

R

Y

DiagnosticRadiology



Radiation Oncology

P

A

T

H

O

L

G

Y

M

E

D

O

N

C

R

A

D

O

N

C

P

L

A

S

T

I

C

S

R

A

D

I

0

L

O

G

Y

? ? ? ? ?

The Answer

R

A

D

I

0

L

O

G

Y

S

U

R

G

E

R

Y

DiagnosticRadiology



Radiation Oncology

P

A

T

H

O

L

G

Y

M

E

D

O

N

C

R

A

D

O

N

C

P

L

A

S

T

I

C

S

Patient NavigationFull Continuum of Care

Multidisciplinary Care ConferencesPhysicians Review All Patient Cases Weekly

Weekly Multidisciplinary ConferenceCloses White Space Gaps in Physician Communication

Facilitates Collaborative Decision Making

Navigator Serves as a Patient’s Personal GPS

Navigator Provides Emotional Support,

Education, Assessment, Triage,

and Advocacy Throughout the

Continuum of Care

Navigation Closes White Space Gaps During Transitions of Care With Patient Surveillance and Communication

R

A

D

I

0

L

O

G

Y

S

U

R

G

E

R

Y

P

A

T

H

O

L

G

Y

M

E

D

O

N

C

R

A

D

O

N

C

P

L

A

S

T

I

C

S

Multidisciplinary Care ConferencesPhysicians Review All Patient Cases Weekly

Create a VIRTUAL Cancer Center

Combined With

Patient NavigationFull Continuum of Care

How Patient Navigation

ImpactsPatient and Facility

QualityOutcomes

Patient Benefits

S

U

R

G

E

R

Y

DiagnosticRadiology


SurgeryMedical


P

A

T

H

O

L

G

Y

M

E

D

O

N

C

R

A

D

O

N

C

P

L

A

S

T

I

C

S

R

A

D

I

O

L

O

G

Y

Navigates Patient Through All Service Lines

Educates Patient and FamilySupports Patient and Family EmotionallyAddresses and Removes Barriers to Care

Teaches Self-Care Skills

Monitors Phycological and Physical Status

Serves as Patient Advocate to Care Team

PathologySurgery

Facility Benefits

R

A

D

I

0

L

O

G

Y

S

U

R

G

E

R

Y

DiagnosticRadiology



Radiation Oncology

P

A

T

H

O

L

G

Y

M

E

D

O

N

C

R

A

D

O

N

C

P

L

A

S

T

I

C

S

Decreases Time from Diagnosis to Treatment

Facilitates Communication Between Physicians

Decreases Hospital Readmissions

Decreases Duplication of Services

Decreases Inappropriate Access to Care

Manages Patient Transitions of Care

Patient NavigationHas Succeeded InClosing The Gaps

in Community Cancer Care Delivery

How Patient Navigation

Translates into Creating Facility Profit

Presenting the Evidence of How Patient Navigation

Increases Financial Profitability

How Navigation Increases Facility Financial Profitability

Reduces Patient Out-MigrationHenrico Doctors’ Hospital, Richmond, Virginia

Increases Patient SatisfactionFroedtert & The Medical College of Wisconsin Cancer Center

Reduces No-Show AppointmentsAccenture-MetroHealth, Cleveland, Ohio

# 1

Case Study

# 2

Case Study

# 3

Case Study

Patient Navigation Impact on Patient Satisfaction

Froedtert & The Medical College of Wisconsin Cancer Center

# 1

Case Study

Patient Satisfaction Study

3 Year Study

Patient Navigation

Impact on Satisfaction


Patient Evaluations: Quality of Care

100908070605040 302010

0

2002 2003 2005

91%

57%

97%

70% IncreaseFroedtert & The Medical College of Wisconsin Cancer Center

Overall Score: Patient Satisfaction


100908070605040 302010

0

2002 2003 2005

High50s

Low30s

93%

210% Increase

“Research confirms a definite link between a patient’s perceptions

of quality to the profit margins for healthcare facilities.”

Press Ganey:

Return on Investment: Increasing Profitability by Improving Patient Satisfaction 2013

Patient Satisfaction

Translates into Financial Profit

Patient Navigator:

A Guardian of Patient Satisfaction

Throughout Full Continuum of Patient Care

How Patient Navigation Reduced Out-Migration

Henrico Doctors’ HospitalRichmond, Virginia

# 2

Case Study

Understanding the High Cost of

Patient Out-Migration

For Cancer Programs

Patient Out-Migration

Out-Migration is a Loss of

Downstream Revenue for a Cancer Program

and All Practicing Physicians

It is Not Just ONE Patient Leaving

Understanding Downstream Revenue

Breast Cancer

Screening Mammogram

Diagnostic Mammogram

Minimally Invasive Biopsy

Surgical Biopsy

Cancer SurgeryCancer Treatment

$ Radiology Charges$ Radiologist Fee


$ Radiology Charges$ Radiologist Fee$ Pathology Lab$ Pathologist Fee

$ Lab/EKG$ Operating Room$ Central Supply$ Pharmacy

$ Pathology Lab$ Pathologist Fee$ Surgeon Fee$ Radiology

(specimen)$ Lab/EKG$ Operating Room$ Central Supply$ Pharmacy

$ Pathology Lab$ Pathologist Fee$ Surgeon Fee$ Hospital Stay$ Radiology (specimen )

$ Nuclear Medicine$ Plastic Surgeon

(numerous surgical charges)

$ Medical Oncologist Fee$ Lab Fees$ Infusion Center$ Pharmacy Fees

$ Radiation Oncologist$ Radiation Therapy$ Physical Therapy$ Occupational Therapy$ Psychological Services

$ Genetic Evaluation Fees$ Complementary Therapies

Spin-Off Revenue

Cancer Surveillance

Downstream Revenue:

Breast Cancer

Breast Cancer Survivor Years of Surveillance

89%Survive

63%Survive

78%Survive

83%Survive

5 Years 20 Years15 Years10 Years

American Cancer Society 2016

63% Remain in Long-Term SurveillanceContinued Source of Downstream Revenue

20 Years

Spin-Off Revenue

Cancer Surveillance

$ Medical Oncologist Fee$ Lab Fees$ Radiology Imaging$ Radiologist Fees$ Nuclear Medicine$ Numerous Miscellaneous

Recurrence

$ Medical Oncologist Fee$ Lab Fees$ Radiology/Radiologist Fees$ Interventional Biopsy ?$ Nuclear Medicine ?$ Surgeon ?$ Operating Room ?$ Lab Fees ?$ Hospital Charges ?$ Pathology ?$ Pathologist Fees ?$ Infusion Center ?$ Pharmacy Fees ?$ Radiation Oncologist?$ Radiation Therapy? $ Physical Therapy ?$ Home Health ?$ Hospice ?

Screening Mammogram

Diagnostic Mammogram

Minimally Invasive Biopsy

Surgical Biopsy

Cancer SurgeryCancer Treatment



$ Radiology Charges$ Radiologist Fee$ Pathology Lab$ Pathologist Fee

$ Lab/EKG$ Operating Room$ Central Supply$ Pharmacy

$ Pathology Lab$ Pathologist Fee$ Surgeon Fee$ Radiology

(specimen)$ Lab/EKG$ Operating Room$ Central Supply$ Pharmacy

$ Pathology Lab$ Pathologist Fee$ Surgeon Fee$ Hospital Stay$ Radiology (specimen )

$ Nuclear Medicine$ Plastic Surgeon

(numerous surgical charges)

$ Medical Oncologist Fee$ Lab Fees$ Infusion Center$ Pharmacy Fees

$ Radiation Oncologist$ Radiation Therapy$ Physical Therapy$ Occupational Therapy$ Psychological Services

$ Genetic Evaluation Fees$ Complementary Therapies

Spin-Off Revenue

Cancer Surveillance

$ Medical Oncologist Fee$ Lab Fees$ Radiology Imaging$ Radiologist Fees$ Nuclear Medicine$ Numerous Miscellaneous

Recurrence

$ Medical Oncologist Fee$ Lab Fees$ Radiology/Radiologist Fees$ Interventional Biopsy ?$ Nuclear Medicine ?$ Surgeon ?$ Operating Room ?$ Lab Fees ?$ Hospital Charges ?$ Pathology ?$ Pathologist Fees ?$ Infusion Center ?$ Pharmacy Fees ?$ Radiation Oncologist?$ Radiation Therapy? $ Physical Therapy ?$ Home Health ?$ Hospice ?

Henrico Doctors’ Hospital

Out-Migration Study Results

Oncology Issues: Making The Case For the Nurse Navigator, 2011

Conducted 4-Year Study

Downstream Revenue

Analyzed Patient Out-Migration

After Mammography Screening Callbacks

240 Patients Exited Care Previous Year

Breast Center Navigator Hired

Interventions:• Contacted call-back patients within 24

hours • Explained why additional studies were

needed• Answered patient questions• Offered expedited appointment for

additional views/tests

Out-Migration 1 Year Later

1 Year Before Navigator240 Call-Back Patients Exited Care

1 Year After Navigator Hired28 Call-Back Patients Exited Care

88% Reduction in Out-Migration

28 Patients

240Patients 212 Patients

Retained

Henrico Doctors’ Hospital

Revenue* Gained: 212 Saved Patients

1 Year 212 Patients

315Imaging Procedures

$125,000.00

Diagnostic Imaging Procedures

*Quantified by data analysis of billable services of cancer and non-cancer patient

212Saved Out-Migration Patients

Oncology Issues: Making The Case For the Nurse Navigator, 2011

29*Positive Breast Cancers

Diagnosed

* 13.7 Percent

Revenue Gained: 212 Patients

29Positive

Breast Cancers

1 Year29 Diagnosed Positive Breast Cancers

Cancer and Non-Cancer Downstream Revenue

$225,000.00

Total Revenue Gained

1 Year

$225,000.00

$125,000.00 Imaging Revenue

$350,000.00Total Revenue

Cancer Revenue

4 Years Later: Our Migration

10 Patients or Less Exited

Screening Mammography Call-Backs

4 Years Later

240 Mammography Call-Back Patients Left

1 Year Before Navigator

10 Patients or Less Exited Yearly AfterNavigator Added

95.8% Reduction240 Yearly

< 10

Out-Migration Reduction After Nurse Navigator

Value of One Nurse Navigator

$225,000.00 X 4 Years = $ 900,000.00

$125,000.00 X 4 Years = $ 600,000.00

$1,500,000.004 Years

Imaging Revenue

4 Year Estimated Revenue*

Cancer Treatment

No-Show Appointments: Navigator Impact

Accenture-MetroHealthCleveland, Ohio

# 3

Case Study

Cost of No-Show Appointments Cancer Treatment

Accenture-MetroHealth; Cleveland, Ohio

$1,500 Per Appointment

Navigators Implementation: 6 Month Study

• Navigators reduced no-show and cancellation rates by 3%

• Reduction generated enough revenue in 3.5 months to pay annual salaries of 2 full-time Navigators


No-Show Appointment Reductions: Financial Impact

End of 1st YearEach full-time

Navigator position generated

$150,000 revenue


“Extrapolating these results, two FT navigators across 7 high-cost priority areas in

cancer care delivery could yield $2.1 million dollars a year.”


Harvard Business Review: David Balderson, Kaveh Safavi, MD

Three EssentialKeys

For A Successful Patient Navigation

Program

#1Written

Clinical Navigation Guidelines

Navigation Program

Navigation Process

• Written navigation guidelines are essential• Center needs to develop own guidelines which

incorporate the needs of their stakeholders for every navigation process throughout the continuum of care– What needs to be done– When it needs to be done– Who needs to the perform task

Clinical Oncology Advisor: June 2017

“Clinical pathways are a critical structural element in the effort to reduce variability in healthcare and to make costsand outcomes more measurable, predictable and accountable. As value-based reimbursement models become more common, reliable care coordination and clinical pathways are essential to reducing cost and variability of oncology care and improving outcomes.”

Patient Navigation Guidelines

Screening Diagnostic Period Diagnosis Treatment

Sample of Navigation Process Needed for Breast Navigator

Patient Navigation Guidelines

Sample of Navigation Process Needed

Survivorship Surveillance

• Clinical navigation guideline development can start with examples provided by:

– NICE (NIH Health and Care Excellence)

– NCCN (National Comprehensive Caner Network)

– Blue Cross/Blue Shield Michigan (shown to improve clinical outcomes while increasing profit)

Navigation Clinical Pathway Development

• Necessary to customize your clinical pathways with your stakeholder’s input and expressed needs– Builds consensus and compliance

• Written clinical pathways should be shared with all stakeholders after development– Clearly outlines and defines expectations for providers– Ensures quality standards are understood

Navigation Clinical Pathway Development

#2Evaluation of Every Navigation Process

for Effectiveness and Efficiency

Navigation Program

Navigation Process Evaluation

• Essential to evaluate every process for:– Right Job

• Done at the Right Time• Performed using the most cost-

effective and outcome-efficientmethod

Evaluate Every Process For Efficiency

• Is this task necessary?– Is it a required standard-of-care or

law?

• Look at every piece of paper– Can it be eliminated or can the process

computerized?

• Is an education process repeated?– Yes: Requires written instructions or

patient teaching materials

Evaluate Every Process

• Is the right skill-level employee performing the task?

Navigator: Common Financial Drain

• Nurse Navigator becomes high-paid clerical employee – Spends large amount of time entering

data and performing non-nursing tasks

• For program to be profitable, Nurse Navigators must spend time facilitating nursing tasks

Can a Navigator Task Be Delegated?

Med Tech NurseSocial Worker

$ $$$$ $$

Clerical

• To be financially profitable, care needs to be delivered by a team of professionals, not just a Nurse Navigator

Effective Navigation Program

Clerical Med Tech NurseSocial Work

#3Provide Navigator Tools Needed for

Efficiency

Navigation Program

Most Common Navigator Challenge

“How Can I Get It All Done?”• Barriers to Care• Patient Navigation• Distress Assessment• Survivorship Care Plan

Finding Leverage

Navigators Need Tools to Leverage Efficiency

Key: Electronic Medical Records

Cancer Navigation Software

2006


• Decreases time constraints required for data entry and data retrieval

• Provides work-flow and navigation processes– Serves as a “tutor” for successful

implementation of facility clinical paths


• Calendar linked to patient’s record creates reminders and task lists – Decreases potential for patient task to

be overlooked


• Patient portal allows secure communication between patient and navigator


• Records data from all interventions: – Barriers Assessment – Distress Assessment – Referrals and outcomes for identified

barriers/distress– Educational materials provided to patient– Ancillary/community support referrals


• Automatically builds Treatment Summary for Survivorship Care Plan required at end of treatment– Reduces hours of time manually compiling

treatment summary and history into a task of only minutes

– Decreases errors from manual extraction of data from patient record to compile Survivorship Treatment Summary

Administration Benefits

• Provides complete administrative overview of all navigation processes

• Captures key data elements for benchmarking

• Captures downstream revenue

• Captures patient demographics

Administration Benefits

• Tracks referrals in and out of a program

• Tracks designated quality measures

• Generates patient progress reports for physicians

Navigation Software Selection

• Select software that navigates all cancers and is not cancer-specific

• Web-based software preferred – Access from anywhere, allows

Navigators to be more productive– Automatic software updates

• Ability to compile Survivorship Treatment Summary

Patient Navigation: The New Pathway to

Deliver Quality Care and Ensure

Financial Profitability

American Cancer Society

“Economic evaluation of the patient navigator program suggests that such programs can be a cost-effective use of limited resources and yield a net financial benefit for providers.”

Cancer: 2012

Navigation Financial BenefitsJAMA Oncology: June 2017

“Costs among the navigated patients declined a mean of $781.29 more per patient per quarter than among the non-navigated patients, which could be estimated as a $475,024 reduction in cost annually for a navigator managing 152 patients throughout the year. For a navigator with an annual salary investment of $48,448 (salary and fringe benefits), we estimated a return on investment of 1:10.”

Resource Use and Medicare Costs During Lay Navigation for Geriatric Patients With Cancer: JAMA Oncology

Medicare Recognizes Value of Navigation

• April 2017: Centers for Medicare and Medicaid Services (CMS.gov) announced oncology providers’ financial incentives– Oncology Care Model (OCM) offers oncology providers

reimbursement according to performance and outcomes

– Oncology providers must commit to:• Offer patients enhanced services including care

coordination and patient navigation • Follow national treatment guidelines CMS April 2017: Press Release

Medicare Recognizes: Financial Value of Patient Navigation that Follows

Clinical Pathways on Increasing

Patient Outcomes While Decreasing Cost

Creating a Culture of Patient Quality

Patient Navigation has proven value directly linked to closing inefficiency gaps in healthcare delivery while:

Increasing Patient Satisfaction

Creating and Maintaining Quality Outcomes

Producing Financial Profits

Truth Stages

All truth passes through three stages: • First, it is ridiculed• Second, it is violently opposed• Third, it is accepted as being

self-evident

Patient Navigation Now Has a History of

Self-Evidence Arthur Schopenhauer

Patient Navigation Has Proven to Benefit Both:

Patients and Health care Facilities

Creating a Culture of Quality

While Ensuring Financial Benefits

REQUIRESPatient Navigation

Thank You!

Judy Kneece

how patient navigation drives quality and produces profit

Documents