Managing a Navigation Program: Managing a Navigation Program: The Role of Administrators The Role of Administrators

Phyllis A. DeAntonio, RN, MSN, FAAMAAdministrator, Cancer ServicesPitt County Memorial Hospital

University Health Systems of Eastern North CarolinaGreenville, NC

ObjectivesObjectives

• Create strategies for the identification and removal of specific barriers to efficient and effective patient care.

• Discuss the roles of various types of navigators and the ways in which they improve patient care.

• Evaluate best practices regarding patient navigation and survivorship care.

• Understand the processes for implementing and sustaining a successful survivorship program.

• Assess methods for managing the psychosocial needs of patients and caregivers.

Burden of CancerBurden of Cancer

• 2011 U.S. Incidence – 1,596,670 new cases; Deaths - 571,950

• 2011 N.C. Incidence – 48,870 new cases; Deaths - 19,760

• US Cancer Survivorship – over 12 million

• NC Cancer Survivorship – 362,810

Teaching Hospital Cancer Program Accredited by ACoS CoC Teaching Hospital Cancer Program Accredited by ACoS CoC Teaching Hospital Cancer Program Accredited by ACoS CoC Teaching Hospital Cancer Program Accredited by ACoS CoC

Role of Nurse NavigatorRole of Nurse Navigator

• “To provide continuity of care for cancer patients across the continuum. The navigator will be an active member of the cancer care team and provide support as needed.”

Article from Community FocusArticle from Community Focus

Responsibilities of Nurse NavigatorResponsibilities of Nurse Navigator

• Meets the patient/family at the point of a suspicious finding

• Identifies any barriers or potential barriers to care, i.e. medical, psychosocial, emotional, socioeconomic, cultural

• Educates patient/family— diagnosis, treatment— prevention, early detection

• Maintains open communication and provides support to patient/family along the continuum of care

• Advocates for the patient• Links patient/family with appropriate resources/services• Addresses survivorship issues

Goals of Nurse NavigatorGoals of Nurse Navigator

• Improve illness adaptation with better coordination

• Elimination of barriers to care, i.e. financial and economic, transportation, cultural, fear and poor coordination of care

• Timely Delivery of Services

Patient Navigation Criteria for Patient Navigation Criteria for Breast/GYNBreast/GYN

• 40 years of age or younger• High anxiety• Difficulty in understanding disease concepts

and treatment

• Complex socioeconomic situation/issues• Low literacy • Bilateral disease

Outcome MeasuresOutcome Measures Patient Satisfaction Survey - Scale 1-5•How well do you feel your nurse navigator listens to and addresses your concerns?•Helpfulness in providing you with information about your condition and treatment.•Helpfulness in providing you with information about support groups and programs.•If you had side effects of treatment, how effective was your nurse in helping with these problems?•Overall how would you rate your nurse navigator?•Have the services provided by our patient navigator helped you cope better with your disease and treatment?

Question•Do you feel your nurse navigator cares about you and your well-being?

Outcome MeasuresOutcome Measures

• Patient Satisfaction Scale– Excellent (5)– Very Good (4)– Good (3)– Fair (2)– Poor (1)– Does not apply

Outcome MeasuresOutcome Measures• Patient Comments

“This is an excellent program. After being diagnosed, I was in a state of shock! Debra has helped clarify what the doctor’s plan of action and lab reports meant. She has been an excellent liaison, and true help in a very difficult time.”

“Debra did an outstanding job in serving as a resource for both my doctors and me. Her warm compassionate mannerism is to be commended. She has a way of making you feel that you are her only patient. Debra truly cares about her patients. Breast cancer is very scary and the journey is difficult. Debra walks the journey with you – calming your fears and reassuring you there’s HOPE for tomorrow.”

Outcome MeasuresOutcome Measures

Physician Satisfaction Survey - Scale 1-5•Are you utilizing the PCMH RN Navigator, Debra Mascarenhas, for assistance with your patients?

•How would you rate the patient navigator overall?

•How would you rate the patient navigator on the following? - Eliminating barriers to care - Helping patients to understand and cope better with their disease - Linking patients with appropriate resources to meet their needs

Question•Do you feel the patient navigator has been a benefit to your patients?

Outcome MeasuresOutcome Measures

• Physician Satisfaction Scale– Excellent (5)– Very Good (4)– Good (3)– Fair (2)– Poor (1)

Outcome MeasuresOutcome Measures

• Physician Comments “Increased comfort level of patients thus improving oncology compliance and other treatment outcomes. Improved communications related to procedures enhancing patients’ care.”

“Has made it much easier for patients to get through the system of multidisciplinary care and provide physical and psychological support during difficult times for our patients.”

“Debra develops trusting relationships with the patients prior to their visit in the outpatient setting, thus developing a lesser means of patient adaptation to the outpatient setting. She is a mediator between patient/MD, her additional educational opportunities help the patients greatly.”

Outcome MeasuresOutcome Measures

• Patient Volume

78

173

253

417

0 100 200 300 400 500

2008

2009

2010

2011

Number of Patients

Outcome MeasuresOutcome Measures

• Referrals to PCMH/ECU Program because of Nurse Navigator

– 2010 - 8 patients chose or selected to have their care in Greenville due to the Navigation Program

– 2011 - 11 patients chose or selected to have their care in Greenville

Outcome MeasuresOutcome Measures

• Uninsured/underinsured linked to programs for treatment coverage– Breast and Cervical Cancer Control Program– Medicaid– North Carolina Cancer Fund– Medicare

Patient Navigation MarketingPatient Navigation Marketing

Patient Navigation MarketingPatient Navigation MarketingPatient Health Navigation Cancer Services began its patient navigation program in Fall 2007. This program guides newly

diagnosed patients and their family members to various services and resources they need for receiving the best cancer treatment. Patient navigation programs are part of a growing trend in

our country that involves the development of special services to help patients through the maze of appointments, treatments and follow-up that are necessary components of cancer care. Here at PCMH, referrals come from private practice physicians and Leo W. Jenkins Cancer Center. Pitt County Memorial Hospital has a registered nurse, Debra Mascarenhas, dedicated to

helping patients find answers and support for their health care. Ms. Mascarenhas, who monitors gynecological and breast cancer cases, first meets a patient at the time of her diagnosis and is present when the physician explains the phases of treatment. Ms. Mascarenhas facilitates support services and helps patients find financial, transportation and other resources Most patients referred are under the age of 40 and are dealing with the emotions that accompany a cancer diagnosis. Oftentimes patients have problems understanding the disease or have difficulty coming to terms with their conditions and treatments. A navigator can: provide education on various support programs that help patients cope with their cancer experiences help patients desiring a link to other survivors locate local support groups for patients living outside the Greenville area to reduce the difficulty of travel.

Types of Navigators / Navigation Types of Navigators / Navigation ResourcesResources

• RNs• Social Workers• Advanced Practice RNs / PAs• Lay People / Community Advocates

Issues for Cancer SurvivorsIssues for Cancer Survivors

• Physical• Psychological• Social• Spiritual• Economic

Survivorship – Program DevelopmentSurvivorship – Program Development

• Program Start• Staff selection• Staff Training• Existing Services• Funding

IOM’s focus for health professions, education IOM’s focus for health professions, education and improved workforce performance.and improved workforce performance.

• Patient-centered care• Work in interdisciplinary teams• Employ evidence-based practice• Apply quality improvement• Utilize informatics

CoC Standards - NewCoC Standards - New

• Standard 3.1 Patient Navigation Process– A patient navigation process, driven by a community

needs assessment, is established to address health care disparities and barriers to care for patients. Resources to address identified barriers may be provided either on-site or by referral to community-based or national organizations. The navigation process is evaluated, documented and reported to the cancer committee annually. The patient navigation process is modified or enhanced each year to address additional barriers identified by the community needs assessment.

CoC Standards - NewCoC Standards - New

• Standard 3.3 Survivorship Care Plan– The Cancer Committee develops and implements

a process to disseminate a comprehensive care summary and follow-up plan to patients with cancer who are completing cancer treatment. The process is monitored, evaluated, and presented at least annually to the cancer committee and documented in minutes.

Nationwide Free Sources of Nationwide Free Sources of Patient/Family Information Patient/Family Information

• American Cancer Society (ACS)• American Institute of Cancer Research (AICR)• Lance Armstrong Foundation• National Cancer Institute (NCI)• National Coalition for Cancer Survivorship• Susan G. Koman for the Cure

Nationwide Free Sources of Nationwide Free Sources of Patient/Family Information (cont.) Patient/Family Information (cont.)

• FertileHope• Needy Meds• Shop Well With You• Women’s Cancer Network• Support for People with Head & Neck Cancer• National Prostate Cancer Coalition• The Oral Cancer Foundation

Survivorship 101 ResultsSurvivorship 101 Results

• Patients in active treatment showed a greater improvement than those in post-treatment.

• 17/23 survivors showed weight reduction• 10/23 survivors had improved BMI • 15/23 survivors reduced waist size• 17/23 survivors reduced hip size• 11/23 survivors reduced body fat %• Four participants have enrolled at a fitness

center.

Survivor quotesSurvivor quotes

“Survivorship means being given a second chance at life.”

“Survivorship is being here to share stories with other people who are just starting.”

“Survivorship has given me the chance to teach my kids how to live.”

“Survivorship is the ultimate understanding of one’s purpose in life.”

“Survivorship is about acceptance, determination, and attitude.”

“Survivorship is far more than living through cancer treatment – it’s who I am.”

ReferencesReferences

American Cancer Society, (2011) Cancer Facts and Figures 2011. Retrieved from http://www.cancer.org/research/cancerfactsfigures/cancer-facts-figures-2011.

Case, M. (2011). Oncology Nurse Navigation: Ensuring Safe Passage. Clinical Journal of Oncology Nursing, 15(1), 33-40.

Center for Disease Control and Prevention and Lance Armstrong Foundation. A National Action Plan for Cancer Survivorship Advancing Public Health Strategies. (2004). Atlanta, GA: U.S. Government.

Grant, M., Economou, D., and Ferrell, B. (2010). Oncology Nurse Participation in Survivorship Care. Clinical Journal of Oncology Nursing, 14(6), 709-715.

Institute of Medicine. (2008). Cancer Care for the Whole Patient. Washington, DC: National Academies Press.

Koh, C., Nelson, J., and Cook, P. (2011). Evaluation of a Patient Navigation Program. Clinical Journal of Oncology Nursing, 15(1), 41-48.

Lagrosa, D. (2010). Launching the Navigation Program that is Best for You – Part 1: Defining Your Program. Journal of Oncology Navigation and Survivorship, 1(3), 1-3.

Lagrosa, D. (2010). Launching the Navigation Program that is Best for You – Part 2: Justifying Your Program. Journal of Oncology Navigation and Survivorship, 1(5), 1-3.

QuestionsQuestions

Evaluation and Measurement of Evaluation and Measurement of a Patient Navigation Programa Patient Navigation Program

Marie S. DeStefano, RN, MSN, FAAMAAdministrative Director of OncologyCrozer-Keystone Health System, PA

Burden of CancerBurden of Cancer

• 2011 U.S. Incidence – 1,596,670 new cases; Deaths - 571,950

• 2011 PA. Incidence – 78,030 new cases; Deaths – 28,560

• US Cancer Survivorship – over 12 million

Crozer Keystone Health SystemCrozer Keystone Health System

• Full spectrum of health care — from wellness and prevention to acute and tertiary care.

• CKHS is a not-for-profit integrated health system (501C3 status), established in 1990

• Committed to improving health and quality of life of nearly 1 million people in service area

• two-thirds of citizens of Delaware County.

• Largest employer (6,800) and health care provider in Delaware County. Health system employs more than 300 primary care and specialty physicians.

• Key stats; 131,500 ER visits, 43,400 admissions, 21,800 surgeries and 3,750 births (FY ’08)

WHAT WE DO

Crozer-Keystone Health SystemCrozer-Keystone Health System

Crozer-Keystone Cancer CentersCrozer-Keystone Cancer Centers

• Partnership with Fox Chase Cancer Center

• Accredited by the American College of Surgeons Commission on Cancer

• Philadelphia Cyber Knife• 2,200 new cases yearly• 381 breast cases• Healthy Woman Provider• Susan G. Komen Grantee

Patient Navigator Outreach and Chronic Patient Navigator Outreach and Chronic Disease Prevention Act of 2005Disease Prevention Act of 2005

• Signed into law in June of 2005• Authorizes $25 million in grants over 5 years• Grants are to recruit, assign, train and

employ patient navigators• Emphasis on addressing health disparities

Patient Navigator Outreach and Chronic Patient Navigator Outreach and Chronic Disease Prevention Act of 2005Disease Prevention Act of 2005

• Navigators should:– Anticipate, identify, and help patients to

overcome barriers within healthcare system– Assist in coordination of health care services &

referrals– Facilitate involvement of community

organizations in assisting individuals at risk for or who have cancer or other chronic diseases

• Complexity of Healthcare Systems• Disease specific needs• Patients “slip through the cracks”• Barriers to care• Health Disparities• Local competition with out migration• Ongoing gap analysis

Why do we need Patient Navigation?Why do we need Patient Navigation?

Navigation OpportunitiesNavigation Opportunities

Freeman, H. (2009). Patient navigation across the healthcare continuum. Retrieved March 20, 2010 from http://www.hpfreemanpni.org/patient-navigation/

Outreach/Screening Diagnosis Treatment Survivorship

Does your facility have a Patient Does your facility have a Patient Navigation Program?Navigation Program?

1. Yes2. No

Job DescriptionJob Description

• Little agreement to definitions of key elements pertaining to nurse navigation– What should be included in job description?– What kind of educational background should a

navigator have?– What is the best navigation model?– Who should navigator report to?– How should navigator interact with other

members of the team?

Do you know your job description?Do you know your job description?

1. Does is describe what you do?2. Did you have input?3. Is it realistic?4. Are you measured by goals achieved?

Multidisciplinary TeamMultidisciplinary TeamSocial

Services

Radiologist

Oncology Nurses

Navigator

Plastic Surgeon

Supportive Services

Radiation Oncology

Medical Oncology

Radiologist

Pathologist

GeneticCounselor

Surgeon PCP/GYN

PATIENT

What disease sites are part of the What disease sites are part of the Navigation Program?Navigation Program?

1. Breast 2. GI 3. Thoracic4. Head and Neck5. All6. Other

NavigationNavigation

• Finding the “niche”• Establishing goals• Getting physician's buy in• Skating in new territories• Selling our service• Reports to Administrator Oncology Services• Reports to Cancer Committee• “I am here to compliment your practice”

History of Navigation CKHSHistory of Navigation CKHS

• DCMH: 2005 First Patient Navigator-Breast• CKHS: Financial Navigator/Komen/Healthy

Women• Decreased in patient out migration 18% to 1%• Decrease in timeliness to care• Increase in Patient Satisfaction• Increase in Physician Satisfaction• 2006 Breast Patient Navigator hired at CCMC

Breast Program at CKHS FY10Breast Program at CKHS FY10

• Breast Imaging Center of Excellence by ACR• NABPC 2009-National Accreditation Breast

Program Center-ACOS• 22,142 Screening mammograms • 8,163 Diagnostic Mammograms• 1746 Breast procedures • 362 Cases of Breast Cancer

Breast Program at CKHS FY11Breast Program at CKHS FY11

• Joint Commission Disease Specific Accreditation

• 22,390 Screening mammograms • 8,533 Diagnostic Mammograms• 1,712 Breast procedures • 381 Cases of Breast Cancer • 2.19% increase from FY10

Virtual Model of NavigationVirtual Model of Navigation

• Coordinating Multidisciplinary care from time of initial imaging abnormality

• Women’s Diagnostic Center• Bi-Rad 4 or 5• Percutaneous Biopsy• FNA• 1-866-965-HOPE• webrequest@crozer.org

BenignBenign

Percutaneous BiopsyPercutaneous Biopsy

SurgeonSurgeon

Abnormal

Malignant

Abnormal

Malignant

6 month

f/u imaging

6 month

f/u imaging

Palpable not see

on imaging

Palpable not see

on imaging

Not a candidate for

Percutaneous biopsy

Not a candidate for

Percutaneous biopsy

Abnormal imagingAbnormal imaging

BHCBHC

Breast Panel ReviewBreast Panel Review

Medical

Oncology

Medical

Oncology

Radiation

Oncology

Radiation

Oncology

Reconstructive

Surgeon

Reconstructive

SurgeonGenetic

Counselor

Genetic

Counselor

Definitive Treatment PlanDefinitive Treatment Plan

Supportive ServicesSupportive Services

Is it Working? Is it Working?

• How do we capture?– Monthly reports to administrator– Number of patients seen/contacted– Number of Bi-Rad 4 & 5– Number Staying in system– Number out migration– Number newly diagnosed

Breast Health Breast Health Coordinator STATS July Coordinator STATS July 20102010

CCMCCCMC SpringfieldSpringfield MediaMedia Brinton Brinton LakeLake

Total 24 5 0 1

Seen or Contacted 24 5 0 1

Stayed in System 21 5 0 1

Out migrated 3* 0 0 0

Patient Contacts = 59Total New Bi-Rad 4 or 5 = 30Total New malignancy

New Breast Cancer Staying in System = 6

*Reason for OutmigrationPt referred by Dr. Vakil, preferred surgical biopsy with him

Pt biopsy here- benign- to Jeff

Pt referred to Lankenau by Dr Tirado

Lung Cancer NavigatorLung Cancer Navigator

• Total number of lung - 341• How to capture patients

– Screenings– Incidental findings– Pathology reports– Direct referrals– Physician referrals

• What to report for ROI to administration– # of the diagnostic procedures– # of therapeutic procedures– # of radiation patients, including CyberKnife– # of patients contacted, those staying in system, those out

migrating and why

Colon Cancer NavigatorColon Cancer Navigator• Total number of Digestive System Cancers – 343• Total number of Colorectal cancers - 202• How to capture patients

– Screenings– GI suite– Pathology reports– Direct referrals– Physician referrals

• What to report for ROI to administration– # of the diagnostic procedures– # of therapeutic procedures– # of radiation patients– # of patients contacted, those staying in system, those out

migrating and why

Outmigration Statistics 2006-2010Outmigration Statistics 2006-2010

0

2

4

6

8

10

12

14

Outmigration

2006 beforenavigator2010 afternavigator

We Think So!We Think So!

• 98.86%

• of newly diagnosed breast cancer patients stayed in our

system for care

What Administration Wants: ROIWhat Administration Wants: ROI

Referrals From

Patients

Referrals forSupportive

care

AdditionalRadiographic

Imaging

Medical Oncology/

Chemo RadiationTherapy

Surgery

Surgical Consult

Percutaneous biopsy

Ultrasound

Diagnostic mammogram

Screening mammogram

• Number of patients• Demographics of each• Stage at diagnosis• Appointments

kept/missed/why• Patients accepting not

accepting navigation/reasons

• Timeliness of care

• Education information provided

• Barriers/Resolution• Resources

(internal/external)• Clinical Trial

opportunities/accrual• Outmigration• Downstream revenue

Qualitative/Quantitative MeasuresQualitative/Quantitative Measures

Additional BenefitsAdditional Benefits

• Increased patient Satisfaction• Quality Improvement opportunities• Partnerships with Community• Identifying high risk patients for PARCA program• Screening for Clinical Trials• Identifying Gaps and weakness in services• Sustained Volume, Decrease in out migration:

expansion of Navigation Program • 2010 Lung & Colorectal Navigator at CCMC & DCMH

Final ThoughtsFinal Thoughts

• Team approach• Identify gaps• Set goals• Make contacts • Find point of contact with patients• Evaluate process• Be Flexible!

One Size Does Not Fit AllOne Size Does Not Fit All