Cancer Care Patient Navigationw E a Practical Guide for Community Cancer Centers

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Cancer Care Patient NavigationW E A practical guide for community cancer centers

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W E A Publication of the Association of Community Cancer Centers

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S Cancer Care Patient Navigation A practical guide for community cancer centers

Patient Navigation: A Call to Action S3 by Virginia T. Vaitones, MSW, OSW-C

ACCC’s Cancer Program Guidelines S4 Chapter 4, Section 10: Patient Navigation Services

A Conversation with Dr. Harold P. Freeman S5 An Interview with Amanda Patton, Associate Editor, ACCC

ACCC’s Patient Navigation Program Pre-Assessment Tool S8

Patient Navigation: A Multidisciplinary Team Approach S10 by David Nicewonger, MHA

Patient Navigation at Billings Clinic S15 An NCI Community Cancer Centers Program (NCCCP) pilot site by Karyl Blaseg, RN, MSN, OCN, BC

Growing Your Patient Navigation Program S25 A step-by-step guide for community cancer centers by Joann Zeller, MBA, RTT, CTR

A Regional Navigators’ Network S28 A first-person perspective by Debbie Williams, RN

Thoracic Oncology Patient Navigation S29 Creating a site-specific navigation program by Susan Abbinanti, MS, PA-C

Broward Health’s Breast Cancer Navigation Program S32 Meeting the needs of underserved patients by Pia Delvaille, ARNP, MSN

ACCC’s Patient Navigation Program Outcome S39 Measures Tool

© 2009. Association of Community Cancer Centers. All rights reserved. No part of this Cover photograph and Photograph this publication may be reproduced or transmitted in any form or by any means without written page courtesy of MultiCare Regional permission. Cancer Center, Tacoma, Wash.

ACCC OFFICERS AND TRUSTEES Board of Trustees President Fran Becker, LCSW, OSW-C Luana R. Lamkin, RN, MPH Gabriella Collins, RN, MS, OCN President-Elect Steven L. D’Amato, RPh, BCOP ACCC Editors Al B. Benson III, MD, FACP Becky L. DeKay, MBA Monique J. Marino Treasurer Heidi Floden, PharmD Amanda Patton George Kovach, MD Thomas A. Gallo, MS Guest Editor Secretary Anna M. Hensley, MBA, RT(T) Virginia T. Vaitones, MSW, OSW-C Thomas L. Whittaker, MD, FACP Diane M. Otte, RN, MS, OCN Art Director and Designer Immediate Past-President Virginia T. Vaitones, MSW, OSW-C Constance D. Dillman Ernest R. Anderson, Jr., MS, RPh Alan Weinstein, MD, FACP

ACCC’s Cancer Care Patient Navigation: A Call to Action Patient Navigation: A Call to Action by Virginia T. Vaitones, MSW, OSW-C N

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entral to ACCC’s mission is ensuring timely patient access to W E appropriate cancer care. Over the past decade, patient navigation services have been emerging as an important strategy for Cenhancing patient access to the full continuum of cancer care from screening to detection, diagnosis, treatment, and beyond. SW SE ACCC’s Patient Navigation: A Call to Action project is designed to help

community cancer programs establish or expand patient navigation services. S Included in this supplement is the newly developed Patient Navigation guideline from ACCC’s Cancer Program Guidelines. To view ACCC’s full Cancer Program Guidelines go to www.accc-cancer.org. This supplement is not designed as a “how to” guide. It is a resource for community cancer programs interested in implementing or expanding patient navigation services. We’ve included articles describing five model patient navigation efforts currently underway at ACCC member programs. The range in program design and scope demonstrates that there is no one-size-fits-all template for patient navigation programs. Rather, these services can be designed to dovetail with your program’s specific resources, community needs, and strategic objectives. Included are sample tools from successful navigation programs, such as pre-assessment forms, intake summaries and referral forms, navigation tracking forms and progress notes, patient satisfaction surveys, and outcomes measures. And, we’ve included an interview with Dr. Harold Freeman, who in 1990 first conceived and developed a patient navigator service to help underserved populations access the healthcare system. Dr. Freeman talks about what he believes is essential to any patient navigation program. He also describes the Harold P. Freeman Patient Navigation Institute, founded in 2008, to help define patient navigation, create standards, and develop a certification process for people who were trained in the patient navigation program concept. As the model programs in this supplement demonstrate, patient navigation in community cancer centers can be tailored to meet the unique needs of the community, patients, and caregivers. Patient navigation services can streamline patient access to care, enhance quality care, and increase both patient and provider satisfaction.

With more than 30 years of experience as an oncology social worker, Virginia T. Vaitones, MSW, OSW-C, has also been an active participant and supporter of ACCC, serving on the Association’s Board of Trustees, and ACCC’s Program, Guidelines, and Patient Advocacy Committees.

ACCC’s Cancer Care Patient Navigation: A Call to Action S3 Association of Community Cancer Centers Cancer Program Guidelines Chapter 4: Clinical Management and Supportive Care Services

AssociAtion of community cAncer centers Cancer Program Guidelines population and its community, indi- 2. Cancer programs may choose vidual programs or health systems to partner with an organization can best create a navigator system that employs patient navigators that suits its needs. or uses volunteers. a) The cancer program will Characteristics help determine who will oversee these navigators. A. Patient navigation may include but b) The cancer program will Section 10 is not limited to oncology social develop a contract between worker(s) and nurse(s) who may: the navigator(s) and the pro- Patient Navigation Services 1. Act as a coordinator to ensure gram that clearly outlines the patient, their family mem- the role the navigator(s) Guideline I bers, and caregivers move will have with patients and through the complexities of families. A patient navigation program is the system in a timely fashion c) The cancer program will available for patients, their families, 2. Provide psychosocial services develop an orientation and and caregivers to help “overcome to patients, families, and care- training program that the health care system barriers and givers or refer to oncology navigators must attend. facilitate timely access to quality social worker for psychosocial d) The cancer program will medical and psychosocial care from care provide an ongoing pre-diagnosis through all phases of 3. Link patients, families, and in-service education pro- the cancer experience.” * caregivers with appropriate gram for the navigators. community resources (i.e., 3. The program should provide financial, transportation, transla- adequate space for confidential Rationale tion services, and hospice) interviews and counseling. 4. Provide education to the 4. Navigators should receive train- The diagnosis and treatment of patient, families, and caregivers ing in ethnic, cultural, and reli- cancer and living with the disease throughout the continuum of gious diversity as well as ethics. may be confusing, intimidating, and care 5. Mechanisms exist, when overwhelming for an individual, fam- 5. Link patients, families, and necessary, to review the plans ily member, or caregiver. Cancer caregivers with appropriate and coordinate among team programs have a responsibility to post-treatment follow-up care. members. assist our patients, their families, and B. Trained volunteers and non-clinical 6. Navigators should facilitate caregivers to navigate the continuum paid staff may provide some of communication between of care through a navigation program the navigator activities and func- patient and providers. developed by the cancer program or tions under defined conditions 7. Navigators should educate the via a partnership with a community and with professional oversight. oncology staff about the naviga- agency that utilizes patient naviga- 1. Cancer programs may choose tor program and how it will be tors. Since each cancer program to select, train, and oversee integrated into the oncology understands its unique patient their own volunteers or non- program. clinical paid staff.

*From a definition created by C-Change, May 20, 2005. Permission granted. “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.”

S4 ACCC’s Cancer Care Patient Navigation: A Call to Action A Conversation with Dr. Harold P. Freeman An Interview with Amanda Patton, Associate Editor, ACCC

Harold P. Freeman, MD, is an internationally recognized authority on the interrelationships between race, poverty, and cancer. In 2007 the Harold P. Freeman Patient Navigation Institute was established to set and ensure standards for patient navigation programs through an emphasis on the navigation model developed by Dr. Freeman. In an interview, Dr. Freeman shares his perspective on why patient navigation remains a critical need in cancer care.

Q. Why do you think the use of fight their way through the system. patient navigators is becoming Often they become disillusioned and more prevalent? give up hope. So if there is a strategy which eliminates barriers for people But I do believe patient navigation A. Patient navigation is an important who don’t have the knowledge or the has a universal benefit for all patients concept. The American healthcare sys- resources or insurance—if there’s a and is even being applied to diseases tem is fragmented. Many Americans, way to create a program which causes other than cancer. especially the poor and uninsured, meet these people to move rapidly through barriers to receiving timely diagnosis the system to earlier diagnosis and full Q. In January 2008 the Harold P. and treatment of cancer. Patient naviga- treatment—then this is the reason Freeman Patient Navigation tion programs are becoming more prev- that patient navigation seems to be Institute was launched. What was alent because patient navigators serve working and catching on. the impetus for the Institute? to eliminate barriers to timely diagnosis and treatment. Q. In 1990 you developed the A. By this time navigation had begun Secondly, I think the larger issue is patient navigation model in an to spread rather rapidly to different that there are an estimated 45 million effort to remove the barriers you’ve sites throughout the country…. First of uninsured in America and an additional just described. Do you see the all starting with the United States gov- 25 million American citizens who are primary mission of navigation still ernment, the NCI has funded 9 patient underinsured and, therefore, may not to be to address these problems? navigation programs starting about 5 be able to pay for treatment. Healthcare years ago, demonstration sites. The is the number one cause of bankruptcy A. I truly believe that navigation Centers for Medicare & Medicaid Ser- in America. may benefit people of all socio-eco- vices (CMS) has funded 6 patient navi- And thirdly, if you look at 32 mil- nomic statuses, but it’s most impor- gation sites, which is very important lion American people on Medicaid, tant for people who don’t have the because CMS oversees Medicaid and a study published just a few months resources and the knowledge [about Medicare. And thirdly, most recently, ago by the American Cancer Society cancer detection and treatment] and HRSA [Health Resources and Services showed that people on Medicaid have that should be the target audience. Administration] has 6 sites. In 2005 no better cancer outcome as measured However, as we learn more, we are the Patient Navigation Act, based on by survival and mortality compared to finding that there are people who the model in Harlem, was signed into people that are uninsured. So when you meet barriers who are insured or who law by President George Bush. put together the 45 million uninsured, do have knowledge [about cancer In the meantime, the number the 25 million underinsured, and add detection and treatment]. I think it’s a of agencies and nonprofits support- the 32 million on Medicaid—just those broader issue that needs to be applied ing patient navigation, such as the categories alone add up to 100 million to the whole population of people American Cancer Society, the Susan G. people who are likely to have severe who either develop cancer or are in Komen Foundation, the Avon Founda- challenges when they attempt to enter the process of being diagnosed for tion, have rapidly increased around the the healthcare system. That’s one-third cancer. I think that the critical part— country. of the American people. and the most effective and the most So while hundreds of patient The problem is very large and necessary part—of navigation is to navigation sites were developed, there the issue is that in communities these target it to populations that are under- were no clear standards or definitions people who have these barriers must served or less educated or uninsured. for what patient navigation is. In other

ACCC’s Cancer Care Patient Navigation: A Call to Action S5 …the navigator’s job is to see the entire movement of the patient across disciplines.

words, the term patient navigation is [patient navigation] database—how A. Yes. We encourage people to being used in many ways. We saw the it’s been formed, and suggestions for apply and they can apply through our need to try to create some standards how participants can create their own website (www.hpfreemanpni.org). The of patient navigation that people could database. course gives the total picture of how at least compare to or with the hun- Part of the training is done with patient navigation developed, and, with dreds of sites that were developing. our navigators at the Ralph Lauren this much experience, we’ve developed And these sites were developing in Center. We have developed a program navigation to a pretty sophisticated level very different ways throughout the in which navigation is carried out at this point. country—sometimes concentrating by four navigators each of whom is One thing to point out is that the on other elements such as diagnosis responsible for a particular phase of concept of navigation has to do with and/or treatment. navigation: addressing the entire continuity and We saw the need for creating 1) Outreach navigator movement of the patient through an institute that could define patient 2) Diagnostic navigator the system from the community to navigation and create standards and a 3) Treatment navigator the healthcare site and ensuring that certification process for people who 4) Financial navigator. patients get the tests they need, such were trained in the patient navigation as a mammogram, to ensure that program concept as it was developed in These navigators are in close commu- any abnormal findings will be rapidly 1990 and which we now have 19 years nication with each other in the manage- resolved. Timeliness is a very critical experience with. And that was the ment of a given patient. part of navigation. And then to assure impetus for the creation of the Patient For the Institute’s training pro- that anyone who has cancer will get Navigation Institute which has been gram, all of these navigators come rapidly treated by all modalities. funded by a leadership grant from the in and talk about their role in patient So navigation encompasses the Amgen Foundation. navigation. The idea is that there is a concept of continuity from the commu- continuity that should take place for nity to the healthcare setting to getting Q. What are the goals of the patients. It begins in the community the test, having the finding, and getting Institute? where they live to get them into the the patient all the way through treat- center where the test is done—that’s ment. Now the navigator in our concept A. There are two goals: One is to set called outreach navigation. Then, at is the only person in the healthcare sys- and ensure standards for patient navi- the point of an abnormal finding, the tem whose job it is to watch and guide gation programs through an emphasis diagnostic navigator takes the patient and assist the patient through this entire on the Patient Navigation Model that through the point of diagnosis and the continuum. In other words, the naviga- I initiated in 1990. A second goal is to finding of cancer or no cancer. At this tor’s job is to see the entire movement help others learn best patient navigation point, we have a treatment navigator of the patient across disciplines. One practices by creating a national data- to work with the patient through all the of the problems in medicine is that base for the collection, analysis, and forms of treatment. And finally, as a we have excellent areas—excellent dissemination of information on best sort of consultant to these navigators surgeons, excellent radiation depart- navigation practices. is a financial navigator whose work is ments—but the patient doesn’t easily to make sure that the patient has pass through one part into another. Q. Can you briefly describe the financial coverage. So we are working across disciplines Institute’s navigation training that have to be bridged through this program? Q. How many navigators have navigation. been trained to date? A. It’s a three-day training course Q. So the training provided at that we give usually once a month. A. Since we started the first the Institute can help bridge these We have developed training mod- Navigation Training Course in January challenges? ules for the course. I generally start 2008, we have trained 181 naviga- off the course with an Introduction tors from 85 institutions in 33 states, A. Yes. We’ve found that the four Module about the origins and evolu- including Alaska and Hawaii. In addi- principal barriers patients face are: tion of patient navigation. Then we tion, some trainees have come from 1. Financial barriers—no insurance have a module on how to create a the Caribbean and parts of Europe. or not enough insurance, or lack of patient navigation program; a mod- ability to pay for transportation, and ule related to cultural sensitivity and Q. And the Institute is still other costs related to cancer care. cultural issues; and a module on the accepting applications? 2. Communication barriers—people

S6 ACCC’s Cancer Care Patient Navigation: A Call to Action …if navigation is going to be cost-effective, part of it can be done by lay navigators who are not clinical professionals.

don’t really understand the medical single group of people arguing that they if it’s cancer, it has to resolve with the information that’s been communi- “own” navigation because that’s simply treatment of cancer. cated to them. not correct. There is room for We’re getting the sense from 3. Complexity of the healthcare sys- all kinds of people to be navigators. And talking to people around the country tem—when people have to move certainly, if navigation is going to be that people are working on segments from a surgeon who says you need cost-effective, part of it can be done by of the navigation problem without the a biopsy to medical clearance and lay navigators who are not clinical pro- full continuum of care in mind. If you then back again, or from surgery to fessionals. We should concentrate on have cancer, it’s not over for you until chemotherapy—they get lost in the what has to be done for the patient as the cancer has been treated. We’re system. opposed to what we want to do in our seeing navigators that do parts of 4. Barriers related to fear and distrust specialty. And if we do that, we soon navigation very effectively, but we are and emotional issues. come to the realization that everybody teaching at the Institute that while it’s has a role in navigation. From the lay okay to do whatever your part is, we Our navigators work with all of these person, the nurse, the social worker— also have an obligation to connect the barriers. While we use lay navigators as all the way through to administration, whole system for the patient. So that’s the principle navigators in our system, it’s a team effort with everyone having a very important navigation concept: to we realize that there’s a role for naviga- their eyes on what has to be done for open the case and to define when your tors who are professionals, especially the patient as opposed to turf issues. navigation begins and to close the case social workers and nurses, to navigate We should embrace the philoso- and define when your navigation ends. people at more complex points. For phy that navigation is a continuum of We believe, in cancer care, navigation example, if the lay navigator finds that actions that need to be carried out for should end at the end of treatment. the person is experiencing social prob- our patients, and that at certain levels And we have to develop survivor- lems…then that navigator will refer the these actions are relatively simple and ship navigation support systems for patient to the social worker. Or when can be done by a lay navigator, but survivors who have recurrent disease of patients with cancer have challenges as cancer treatment becomes more special areas that need to be addressed with respect to understanding the dis- complex in terms of social services through special training. What I see is ease and the options for treatment, the or clinical services, a clinically trained that navigators in various sites around navigator will call in a nurse or an oncol- navigator should step in. It’s important the country are taking on parts of the ogy nurse to navigate those issues. that the navigation system is set up navigation process and not necessar- But we find that the trained lay so that the entire healthcare institution ily connecting to the next action that navigator can eliminate many barriers will embrace this as an idea so that the needs to be done for the patient. And faced, particularly in poor communities. team can really work together rather to use an analogy from surgery, it’s not These barriers include: lack of medical than have conflicts over turf. over until you close the case. insurance, under insurance, and how to obtain various medical and support Q. From your patient navigation Q. Some programs begin services. database do you have any emerging navigation services with a single We believe there should be an best practice information you can disease site, such as breast cancer. interconnection between the lay naviga- share? Is it your sense that this is a good tor and the professionally trained navi- way for programs to begin to work gator, such as a nurse or social worker, A. It’s too early at this point. What with navigation services? and that they should be working we are finding is that in sites around the together to move the patient through country people are concentrating on A. I think that is generally the way it the treatment of cancer. This approach segments of the navigation problem, has been happening. My wish is that is also cost-effective in that highly working with the screening part of navi- navigation programs will cover all can- trained healthcare professionals are gation for example. The concept we’re cers. We would like to encourage insti- not spending time on work that can be teaching is that you have to initiate the tutions to navigate all cancer patients. handled by non-clinical staff members, navigation at some point, whatever It would be better for society if patient such as a lay navigator. your definition is for when that starts, navigation programs were made avail- I know there’s been debate about and then you have got to finish the able to eliminate barriers to diagnosis the use of lay navigators versus the navigation. Close the case. The case and treatment of all cancers, as well use of clinical navigators, but I think we isn’t over until it’s over. In other words if as to other chronic diseases such as need to work together on who should you have an abnormal finding, you have diabetes, heart disease, and psychiatric navigate. I don’t like the idea of any to resolve this through diagnosis. And and neurological conditions. 4

ACCC’s Cancer Care Patient Navigation: A Call to Action S7 Patient Navigation Program Pre-Assessment Tool

This pre-assessment tool can help you assess your organization and consider all aspects of a patient navigation program. This tool can also help you assess your readiness for implementation or identify areas that need to be addressed before rolling out a patient navigation program.

Goals and Challenges 1. Goals for navigation program:

2. Barriers/Challenges to navigation program:

Operations 1. Tumor types to be covered by navigation program:

2. Will each tumor type have its own navigation program or will one navigator cover more than one tumor type?

3. Do you have team(s) to set up program(s) by disease state(s)?

4. Timeline for implementation:

5. How many patients per year will participate in the navigation program?

6. What is your anticipated patient to navigator ratio?

7. How will you identify patients eligible for the program? Pathology reports Inpatients MD referrals Surgical reports Other ______

8. What are the biggest challenges facing the patient that need to be addressed by the navigation program?

9. Where will the navigator(s) be housed?

10. What other space is allocated for the navigation program: Patient library/education space Counseling rooms Other offices Other ______

11. How will program be funded? Grants Patient pays Insurance Other ______

12. Will patients be charged for any part of the service?

13. Which salaries will be supported solely by program budget (navigator, administrative assistant, etc.)?

S8 ACCC’s Cancer Care Patient Navigation: A Call to Action 14. Which salaries will be partially supported by program budget (social work, PT/OT, etc.)?

15. What else will budget be used for (patient education materials, journals, etc.)?

16. Do you have an electronic charting system?

17. How will you communicate between practitioners?

Role of Navigator 18. Who do you see as the navigator in your program? RN Social Worker Lay person/survivor Other ______

19. When would you like the navigator to become involved with the patient? Prior to entering the healthcare system At time of screening At time of suspicious finding At time of diagnosis Other (please specify) ______

20. What are the primary functions you would like the navigator to fulfill? Please rank them with 1 being the most important. _____ Community education _____ Patient education _____ Care coordinator _____ Financial counselor _____ Psychosocial counselor _____ Other (please specify) ______

21. What other activities would you like the navigator to be involved in? Please rank them with 1 being the most important. _____ QI/PI activities _____ Community _____ Educational programs _____ Screenings _____ Staff educational programs _____ Survivorship program _____ Help set up program(s) by disease state(s) _____ Other (please specify) ______

Resources 22. What resources do you currently have in place? Case managers Social workers Registered dietitians Financial assistants Genetic counselors Chaplain Health psychologists PT/OT Speech therapy Home care services Hospice services Palliative care services PT/OT Patient advisory committee Support groups (specify) ______Other (please specify) ______

23. Do you currently have relationships with community patient support agencies such as ACS or local support groups other than hospital-based groups?

Other Considerations 24. Do you have an MD champion for patient navigation program?

25. Do MDs support the program? If not, will MDs need convincing of the need for a program?

26. Administration level support/commitment or lack of support/commitment?

27. What percentage of your population has? Private health insurance ______Medicare ______Medicaid ______No insurance ______

28. What percentage of your population is? African American ______Asian ______Caucasian ______Hispanic ______Native American ______Other (please specify) ______

ACCC’s Cancer Care Patient Navigation: A Call to Action S9 Patient Navigation: A Multidisciplinary Team Approach by David Nicewonger, MHA

MultiCare Health System Navigation Team. This team would be first weeks of their cancer treatment. charged with addressing the unmet The team’s motto: “Patients and fami- is a community-based needs identified by patients and their lies should only have to focus on heal- healthcare organization families. By early 2006, patient naviga- ing.” The Team’s goal: to take all of the based in Tacoma, tor job descriptions were developed peripheral worries out of their patients and the first members of the Navigation and families hands. Washington, that Team were hired. One of the Navigation Team’s first includes four hospitals, a MultiCare Regional Cancer Center tasks was to conduct another survey (MRCC) developed the concept and of new patients to obtain a baseline multidiscipline physician structure of its Navigation Team by score measuring how well supported group, and various other drilling into the details of the patient patients felt before the Team started its service lines. MultiCare and staff surveys. The most commonly work (see Figure 1, page S12-13). The identified needs were then bundled into results of that survey became the defin- Regional Cancer Center four categories: ing structure for the Navigation Team’s (MRCC) is a hospital-based 1. Care management and coordination work, and over the course of the first oncology practice consisting 2. Social and psychosocial support year, the survey was repeated for new 3. Financial support and counseling patients entering the program. of five medical oncology 4. Nutritional support and education. By the end of that first year, practices and two radiation MRCC saw significant improvements oncology practices. While multiple needs and issues in all but two areas: assistance making existed within each of these four cat- and/or getting appointments with other egories, these fundamental patient MultiCare departments and transporta- needs drove the decision to create tion issues. Furthermore, physicians in a multidisciplinary Navigation Team the clinic and nurses in the infusion cen- In 2005 MultiCare entered into a versus the traditional pool of case ters reported that the Navigation Team five-year strategic planning pro- managers. By leveraging the focused allowed them to focus on direct patient cess for cancer services. At that skills of each individual on the team, we care rather than struggling with how to Itime the services delivered included believed that cancer patients would be address issues such as transportation basic oncology services with very little better supported and that team mem- or financial coverage. The Navigation structure beyond physician, infusion, bers would be more satisfied with Team also maintained a log of patient and radiation services. Data gathered their work. stories, documenting successful inter- through a survey of patients and fami- The first three members of ventions and the impact on the lives of lies revealed a significant unmet need MRCC’s Navigation Team were an RN patients entering cancer treatment. related to the support patients received navigator, a social worker, and a patient At the end of the first year, hospital throughout their treatments. Likewise, representative who provided financial and cancer center leadership looked at a survey of staff at that time showed assistance. While we initially requested these findings and approved the addi- considerable frustration expressed over a larger Navigation Team, the model tion of three new team members: a a lack of resources to provide patients was untested and hospital leadership second RN navigator, a second patient with much needed support beyond initially approved the smaller three- representative, and a nutritionist. The basic cancer treatment. Based on this person team. This approval came with expanded Patient Navigation Team sup- survey data and as part of the strategic the expectation that Cancer Center ported all patients who received care planning process, we decided that leadership would return in one year to at MRCC’s main campus but another future programs would build on four report on outcomes and conclusions ongoing challenge remained: how could fundamental foundations: regarding continuation or expansion the Navigation Team support staff and 1. Facilities of the navigation program. Specific patients at satellite clinics where patient 2. Providers outcomes measures were identified, volumes were significantly lower but 3. Technology including improved patient satisfaction needs were just as important? 4. Patient support systems. and increased patient volumes for the To help initially address this Cancer Center. challenge, we adopted a model that Putting the Team to Work combined the job functions of the RN The strategic plan ultimately approved Growing the Team navigator with a clinic supervisor. In by MultiCare’s Board of Directors MRCC’s Navigation Team initially small clinical operations, where the included the development of a Patient focused on helping patients through the supervisory demands are less signifi-

S10 ACCC’s Cancer Care Patient Navigation: A Call to Action 9 Ways Patient Navigation Can Benefit Your Cancer Patients

1. Patient navigators become the initial contact point for all patients who come into contact with the healthcare system. They remain an ongoing, consistent point of contact for patients and families through the full continuum of their care. 2. Patient navigators support patients as they move through different points of the healthcare system, including hand-offs between inpatient and outpatient cant, this approach provided some navi- settings, specialty consultations, research, hospice, and/or palliative care. gation support for the patients. Later, an Smoother hand-offs across all phases of care translate into fewer delays in organizational focus on standardization treatment, improved communication between caregivers, and less confu- of care across all care locations led sion for the patient and family. to the approval of an additional social 3. Patient navigators provide valuable education to patients and families on a worker and patient representative in the variety of treatment, nutritional, financial, or social issues. next budget cycle. The expanded eight- 4. Patient navigators can help decrease ER visits associated with complications person Navigation Team was then able in care by identifying complications sooner and directing earlier interventions to service all clinical locations. at the clinical level. 5. Patient navigators link patients and families to community resources such Disease-site-specific Navigators as transportation, housing assistance, financial assistance, and/or support Another component of the original stra- groups. tegic plan was a focus on four primary 6. Patient navigators optimize access to financial resources to assist patients disease groups: 1) thoracic, 2) urologic, and families with treatment-related costs, including drugs. This access is 3) breast, and 4) neurologic. While our particularly critical for indigent, uninsured, and under-insured patients. cancer program treats all cancer types, 7. Patient navigators offer emotional support to patients and families during the decision was made to focus on difficult and stressful times. these primary disease groups with the 8. Patient navigators can help match patients to potential research protocols. eventual goal of becoming a center of 9. Patient navigators can provide a valuable link between the cancer center and excellence in those areas. Over time the community physicians referring into the cancer center. it was acknowledged that this goal would be best achieved by having disease-site-specific navigators. And while the general navigators continued

enter to function in the clinics, these new disease-focused navigators became a key component in MRCC’s strategy ancer C to develop a program of excellence for l C each disease site. iona

g The disease-site-specific naviga- e tors were expected to work not only

are R with the patient and family, but also to C ti serve as a direct liaison between the cancer program and referring physicians f Mul and surgeons. Our expectation was that y o navigator services would be valued by rtes both patients and referring physicians; u therefore, providers would be more likely to direct their patients to a Multi- MultiCare Regional Cancer Center’s multidisciplinary Navigation Team. raph co Care facility. Accordingly, we projected g substantial volume increases in cancer some direct patient care and works using an RN in the same position. With hoto services during our 2008 budget plan- directly with community physicians an ARNP navigator, the level of connec- P ning process. and surgeons to provide support and tion and collaboration with surgeons So, in addition to the two general intervention on cases earlier—often is enhanced. Again, our assumption is RN navigators, our Navigation Team before the patient even enters the that improving those relationships and would now include four disease-site- actual oncology clinics. Some of the making the navigators indispensable to specific navigators. While three of the services performed by our ARNP navi- community surgeons will foster loyalty disease-site-specific navigators would gator, such as office visits for ongoing and increase patient volumes. be RNs with an oncology background, care, are billable. And while the billable we decided to fill the other position charges do not fully support the ARNP A True “Team” Effort with an ARNP who could provide salary, the additional revenue stream is The multidisciplinary Navigation Team service at a different level. Under this enough to make up for the difference model is working well at MRCC. Our model, the ARNP navigator provides between the salary of an ARNP versus model is both cost effective and

ACCC’s Cancer Care Patient Navigation: A Call to Action S11 comprehensive in scope. In other tion of documentation for enrollment in that the program is a success. Look- words, our multidisciplinary Naviga- alternative funding sources, freeing up ing back at our outcome measures, tion Team is more cost effective than the RNs and ARNP to deal with issues we have improved patient satisfaction hiring only one discipline such as RNs. such as coordination of medical care and increased patient volumes. In fact, Likewise, if the team consisted only and patient education. Augmenting the since the inception of the first Naviga- of social workers or volunteers, there team with patient representatives to tion Team in 2006, the volume of cases would be an absence of qualified exper- offer financial assistance has not only across all locations has increased more tise to work through the complex medi- helped our cancer patients, it has also than 30 percent. While it is difficult—if cal issues associated with cancer care. helped the cancer program by decreas- not impossible—to definitively cor- Instead, social workers are available to ing payer denials and improving patient relate these volume increases to the address issues such as assistance with access to funding alternatives. work of the Navigation Team, when transportation, linkages to community While our patient navigation model coupled with the improvement in support groups, or assisting in comple- is still evolving, early indications are continued on page S14

Figure 1. Percentage of Patients Giving a Score of 4 on MRCCs Cancer Patient Survey*

Patients asked to use 1-4 point scoring on all questions with 1= Disagree; 2= Somewhat Disagree; 3= Somewhat Agree; and 4=Completely Agree. 1. A member of our staff informed you of the details of your 5. I was given assistance making appointments and getting insurance coverage prior to the start of treatment. appointments with other departments at MultiCare.

2006 37% 2006 89% 2007 65% 2007 85% 0 20 40 60 80 100 0 20 40 60 80 100

2. I was contacted by an oncology clinic staff member prior to my initial physician consult to answer any questions or 6. A dietitian was available to me to discuss nutrition and diet concerns. during my treatment.

2006 50% 2006 37% 2007 80% 2007 50% 0 20 40 60 80 100 0 20 40 60 80 100

3. I was given written information regarding my medications 7. I was provided information about access to community and an opportunity to speak with the pharmacist. support services.

2006 95% 2006 42% 2007 100% 2007 85% 0 20 40 60 80 100 0 20 40 60 80 100

4. My questions about my treatment plan and the potential impact to my life were answered by the nurse. 8. I had no transportation issues during my treatment.

2006 85% 2006 55% 2007 90% 2007 45% 0 20 40 60 80 100 0 20 40 60 80 100

S12 ACCC’s Cancer Care Patient Navigation: A Call to Action Practical Tips for Developing and Growing ■■ Listen to your cancer patients. Keep a log of patient a Patient Navigation Team success stories. These anecdotal accounts provide faces, emotions, and reality to patient navigation benefits that are not easily quantified. These human interest success ■■ Start small. Although your needs may be great, consider stories help gain and sustain support for navigation implementing a smaller navigation program with defined programs and services. boundaries and objectives that can then be used as ■■ Control program growth. Evolving the program benchmarks for success and justification for program structure and scope in small intervals with demonstrated expansion. It’s better to do a few program elements successes through each stage can garner confidence and successfully and use that success to validate expansion support for continued expansion. than to allow the program to struggle with measurable ■■ Expand the navigator role. Asking patient navigators to outcomes due to “scope creep.” liaise with your community referral base—patients and ■■ Use a multidisciplinary model. Bringing together RNs, referring physicians—can help increase patient volumes ARPNs, social workers, nutritionists, financial counselors, and grow your navigation program. and other professionals can provide a depth of expertise ■■ Establish an advisory council. An advisory council of in a cost-effective manner. Clearly define roles for each providers, patients, and family members can help direct discipline on the team. the goals and work of your Navigation Team. ■■ Survey your cancer patients. Conduct a baseline survey ■■ Set up a foundation to help fund the program. A of patient satisfaction administered prior to initiation of the foundation can accept community donations and other navigation program so that success can be measured and funds to pay for supplies, materials, and programs reported to leadership. associated with the work of your navigation team.

Figure 1. Percentage of Patients Giving a Score of 4 on MRCCs Cancer Patient Survey*

9. My pain was monitored and managed during my 13. I understood potential side effects of my treatment and treatment. how to manage them.

2006 67% 2006 89% 2007 100% 2007 95% 0 20 40 60 80 100 0 20 40 60 80 100

10. My family was well supported by the clinic staff. 14. I understand when I need to call my physician.

2006 95% 2006 95% 2007 100% 2007 95% 0 20 40 60 80 100 0 20 40 60 80 100

11. My quality of life was maintained through my treatment. 15. All of my questions were answered understandably.

2006 79% 2006 79% 2007 85% 2007 95% 0 20 40 60 80 100 0 20 40 60 80 100

12. I knew what to expect through each stage of my care. 16. I know who to call when I have problems or questions.

2006 74% 2006 85% 2007 80% 2007 85% 0 20 40 60 80 100 0 20 40 60 80 100

*The 2006 survey established a baseline before the initiation of the Navigation team.

ACCC’s Cancer Care Patient Navigation: A Call to Action S13 Figure 2. Possible Future Directions for Targeted Disease Group Navigation Teams

Medical Oncologists

Research Breast Lung Urology Neurology RN ARNP ARNP ARNP ARNP RN RN Navigator RN Navigator RN

Social Work Patient Representatives/Financial Counselors Nutrition Administrative Support patient satisfaction, it is reasonable to for the Navigation Team to work within. model the RNs, social workers, nutrition- assume that there is some correlation We communicated those boundaries ists, and patient representatives continue between patient volumes and the to physicians and other staff in an effort to play their supportive roles. This model Navigation Team. to keep our Navigation Team focused. is still a concept, but in looking at the For example, preliminary findings Without clearly defined boundaries, unique contributions of the ARNP in our related to our lung cancer patients may “responsibility creep” can easily pull the current thoracic model it seems there support the positive benefits of disease- Navigation Team in so many directions are advantages in patient care and care site-specific navigation. The ARNP has that team members cannot be effective delivery economies in moving toward only been in the position for six months; in their supportive roles and there will this next iteration. however, in that time there has been be no measurable success points that Reflecting back over the evolution a sudden and definite increase in lung can then be used to help justify of the Navigation Team, several key cancer patients entering the program. expansion of the team. Even today, actions contributed to the team’s Preliminary data for the past four months with the expanded Navigation Team, success, including: show a 20 percent rise in referrals for the definition of boundaries is crucial to ■■ Starting small lung cancer, and the ARNP has had early sustain focus and experience success. ■■ Using a multidisciplinary model success developing close relationships Another important step taken ■■ Surveying patients and listening to with the leading pulmonology and in the program’s early stages was what they had to say cardiothoracic practices in the area. conducting the baseline survey of ■■ Controlling program growth Today, our Navigation Team con- patient satisfaction in key areas, and ■■ Expanding the navigator role sists of six navigators (five RNs and then focusing the Navigation Team on ■■ Establishing a patient advisory coun- one ARNP). Four of these navigators improving those specific indicators. cil and listening to their experiences are disease-site-specific and two are As success benchmarks are achieved and advice in setting priorities and generalists who provide care manage- through patient satisfaction scores identifying unmet support needs ment support for those patients whose or increased patient volumes and the ■■ Establishing a foundation to help cancer does not fall into one of the team is expanded, the boundaries can fund some of the resources of the four focused disease sites. The team likewise be expanded. program. also includes two social workers, a Our model is still evolving and being nutritionist, and three patient represen- refined. The structure of MRCC’s Navi- For more information, see “Practical tatives. Our plan is to add an additional gation Team is defined based on suc- Tips for Developing and Growing a nutritionist and an additional patient cess and continued unmet need as the Patient Navigation Team” on page S13. representative in the next 12 months. next iteration is taking shape. Figure 2 As 2007 survey results show, Collectively this multidisciplinary team illustrates the direction that our program MRCC’s Patient Navigation Team supports all cancer patients at five appears to be taking. In addition to meet- has clearly benefited our patients clinic locations. ing the support needs of patients and and our cancer center. Today, we call driving patient volumes, another impor- the navigation program at MultiCare Lessons Learned tant factor that comes into play is the Regional Cancer a successful “work in We are still working to understand the increasing shortage of oncology physi- progress.” Our hope is that other com- appropriate workload for the Navigation cians. With this new model, the disease- munity cancer centers can learn from Team and the right mix of disciplines. site-specific ARNPs will continue to our program as we continue to evolve In addition, the Navigation Team’s work liaise with referring physicians, but they to meet the needs of our patients, fami- continues to evolve; as one segment will also start to become responsible lies, physicians, staff, and community. 4 of identified needs is addressed, more for routine follow-up care of patients, needs are identified. freeing the oncologist to focus his or David Nicewonger, MHA, is Administra- One critical decision made early in her expertise on initial consultations and tor, Cancer Services Careline, MultiCare the process was to define boundaries management of complex cases. In this Health Systems in Tacoma, Wash.

S14 ACCC’s Cancer Care Patient Navigation: A Call to Action Patient Navigation at Billings Clinic an NCI Community Cancer Centers Program (NCCCP) Pilot Site by Karyl Blaseg, RN, MSN, OCN, BC

A cancer diagnosis often produces an overwhelming navigation to assist them as they emotional response, including feelings of shock, denial, fear, move through the cancer treatment continuum (see Figure 1). Over the last anxiety, anger, grief, and/or depression. Because a multitude six years, the navigation program has of medical tests and consultations typically are needed to grown in an organized, phased manner into today’s team of eight navigators determine a definitive diagnosis and course of treatment, a (see Figure 2). This phased approach cancer patient’s path through the healthcare system can be allowed Billings Clinic to build upon incremental successes, expanding the complicated and confusing. Even worse, some patients may scope of the program with a focus on not fully comprehend the importance of prompt evaluation navigating a majority of patients served in our vast geographic service area (see and treatment of their disease. To address these challenges, “Serving, the Underserved in the Last more and more cancer programs are looking to assist patients Frontier, page S22). The overall goal of our navigation program is to ensure through this process. Here’s how Billings Clinic embarked on seamless and coordinated care among its journey to create a care navigation program to meet the the physicians, the diagnostic tests, and unique needs of the people it serves. the cancer treatments, while offering education, support, and guidance to help patients and families cope with their challenges. All of our patient navigators are hen medical the many successes and contributions registered nurses with oncology experi- oncologist navigation brought to comprehensive ence. The navigator’s primary focus: to Thomas cancer care and was successful in provide one-on-one support and coor- WPurcell, MD, joined Billings Clinic in championing the initiation of a patient dination of services for cancer patients 2003, his vision was to create a regional navigation program at Billings Clinic by and their families as they move through comprehensive cancer center designed engaging senior leadership’s support the care pathway. Specifically, Billings to be a premier destination facility char- and relating program benefits to poten- Clinic patient navigators: acterized by an interdisciplinary team tial effects on existing market share. ■■ Assess for clinical, emotional, approach to cancer treatment. Based spiritual, psychosocial, financial, and on his previous experience with patient Our Navigation Model other patient needs navigation at the Sidney Kimmel Com- Billings Clinic launched its patient ■■ Coordinate the timely scheduling of prehensive Cancer Center at Johns navigation program in 2003 with one tests, procedures, appointments, Hopkins, patient navigation was central navigator. The model put patients at the and treatments to this vision. Dr. Purcell had witnessed center of decision making; with patient ■■ Help eliminate barriers to obtaining a definitive diagnosis ■■ Ensure patients receive a treatment plan that is understandable and feasible inic ■■ Reinforce patient education and s Cl g direct patients and families to avail- in able resources and supportive ll i services f B ■■ y o Facilitate access to clinical trials. rtes u Phase I—2003 As stated above, our program started with a 1.0 FTE patient navigator who raph co g received referrals for patients requir- ing complex coordination of care after hoto P The Billings Clinic disease-site-specific patient navigation program employs diagnosis and upon treatment initia- eight RN navigators. tion. At the outset, the navigation

ACCC’s Cancer Care Patient Navigation: A Call to Action S15 We found that the mere presence of a patient navigator on a consistent basis within these departments enhanced communication, trust, and provider referrals for navigation services.

program focused on two primary standardized educational and support tion to the team, as well as a clearer areas. The first goal: to establish an materials for patients. focus on site-specific navigation. We understanding of navigation within assigned each navigator two of the the Cancer Center among the medi- Phase II—2004 most common cancer types—breast cal oncologists, staff, and support Phase II of the program brought a and colorectal cancers and lung and services. The second goal: to develop second 1.0 FTE patient navigation posi- prostate cancers. At this point, it

Figure 1. Billings Clinic Patient Navigation Model* Cancer Care Navigation

COMMUNITY PROGRAMS

Regional Outreach Network Clinics SUPPORT DEPARTMENTS

Wellness Pulmonology Urology Screening Center SITE-SPECIFIC PROGRAMS Programs

CORE SERVICES Medical Radiation Thoracic Oncology Oncology Gynecologic Stem Cell Surgical Transplant Patient Oncology Pathology and Radiology Infusion Family Cancer Guest Hematologic Center Research Breast Cancer Suites Library Tumor Tumor Registry Boards Cancer OB/Gyn ENT Dermatology Wellness Center Genitourinary

Gastrointestinal

Neurosurgery Dermatology Cancer Quality of Life Control Trials Program General Surgery

Community Forums

*This figure depicts patients as the center of decisions with patient navigation to assist them as they move through the cancer treatment continuum rather than responsibility for coordination and communication between multiple disciplines and specialists being left to the patient alone. ©Billings Clinic

S16 ACCC’s Cancer Care Patient Navigation: A Call to Action Current Scope of Navigation Services

Some of the most common roles and well as connecting patients with responsibilities of patient navigators community resources) at Billings Clinic include: ■■ Coordinating diagnostics, pro- ■■ Acting as the single point of cedures, and specialist appoint- contact for patients and families, ments including telephone triage regard- ■■ Providing patient education ing symptom management ■■ Collaborating with physicians and ■■ Accompanying patients to initial following up on multidisciplinary became important for navigators to appointments during diagnosis tumor conference recommenda- collaborate with other departments and treatment planning period tions within Billings Clinic, including Gastro- ■■ Assessing patients’ physical, ■■ Contributing to multidisciplinary enterology, Pathology, Primary Care, emotional, psychosocial, spiritual, program development, such as Pulmonology, Radiology, Surgery, and and financial needs education materials, clinical Urology. This ongoing collaboration ■■ Initiating referrals (both internal as pathways, and quality studies. allowed us to: ■■ Promote a better understanding of patient navigation Current ■■ Simplify referral and care processes Referrals Navigation ■■ Identify system impediments to Assignments timely and optimal cancer care. All navigated patients receive automatic refer- We found that the mere presence of a rals to the dietitian, social worker, financial ■■ Breast (cancer) patient navigator on a consistent basis counselor, and multidisciplinary tumor confer- ■■ Breast (diagnostic) within these departments enhanced ence. As appropriate, patients navigated will be ■■ Gastrointestinal communication, trust, and provider referred to: ■■ Genitourinary, Head referrals for navigation services. ■■ Medication assistance programs and Neck, Sarcoma, ■■ Subsidized programs Skin Phase III—2005 ■■ Support groups ■■ Gynecologic Two additional 1.0 FTE patient navigator ■■ Integrative medicine ■■ Hematological positions were added during phase III. ■■ Genetic counseling ■■ Lung, Neurological, Each of the patient navigators assumed ■■ Cancer research Unknown Primary primary responsibility for one major ■■ Home health and/or hospice ■■ Regional cancer site (breast, colorectal, lung, and ■■ Lymphedema program. prostate), with hematological cancers distributed among three of the navigators due to the intense needs of these patients. Major goals during phase III included: Figure 2: Evolution of patient navigation positions using ■■ An increased focus on processes to a phased approach clarify role expectations ■■ The development of a variety of flowcharts and fishbone diagrams A Historical Perspective (see Figures 3 and 4) ■■ A navigator orientation manual to ensure consistency among the 2003 2004 2005 2006 2007 2008 patient navigators.

Marketing and public relations promo- tions continued to increase community awareness of the program. In addition, we designed and carried out a patient satisfaction survey to obtain feedback on the effectiveness of our navigation program (see Figure 5).

Phase IV—2006 Phase IV of our patient navigation program involved the largest expansion yet—three additional 1.0 FTE patient navigator positions. One navigator was assigned to hematological malignan-

ACCC’s Cancer Care Patient Navigation: A Call to Action S17 Figure 3: Care Navigation Referral Process

Referral Sources Referral Intake Patient Contact Suspense File Follow-up Discharge

Physicians - Primary Care - Specialty Care CN - Oncologist gathers patient Attend Documentation Call to CN schedules the data via appointment — and all other CN via patient Assemble Cerner Provide education follow-up is Patient discharged phone appointment in Guidebook or Mysis and assess for completed for 2-6 or pager their calendar (appointments, other needs months as needed Other Staff diagnosis, No - Office Staff other) - Infusion Staff - Case Managers - Research Staff Yes

Patient requires CN referral to Social Work, monitors Dietary, or other? activities No on Receive Physician Cerner computer referral? approves CN - Pathology several visit? Reports times a Yes - Hospital Lists day

No Consult completed Patient is placed on active list and note is Referred to placed on CN calendar Cerner patient? - Physician for follow-up with physician Schedules Yes

Yes

CN monitors Patient is placed appointments Continue to on the “patient in Mysis and Patient has future monitor No suspense list” — CN attempts to appointment? patient as to watch for future decipher type needed activity of appointment

©Billings Clinic cies, another to gynecologic cancers, tion and support during procedures led by physician leaders in collaboration and the third focused on breast diag- ■■ Notifying patients promptly of diag- with the site-specific navigators for nostic navigation. Our program was nostic results. breast, gastrointestinal, genitourinary, now seven navigators strong, with one gynecologic, hematological, and lung navigator assigned to the organization’s Patients with a cancer diagnosis are cancers. Breast Center rather than the Cancer then transferred to the breast cancer Expanding to seven navigators Center. The breast diagnostic navigator navigator who further coordinates ser- allowed us to focus on establishing guides patients from abnormal mam- vices related to treatment and survivor- meaningful program metrics. In addi- mogram through diagnosis: ship. tion, our physicians expressed a strong ■■ Ensuring timely scheduling of diag- Major program efforts during desire to have a designated navigator nostic procedures phase IV included the development and for all patients undergoing multimodal- ■■ Providing appropriate patient educa- advancement of multidisciplinary teams ity treatment. With this request, work

S18 ACCC’s Cancer Care Patient Navigation: A Call to Action Referral Sources Referral Intake Patient Contact Suspense File Follow-up Discharge

No Consult completed Patient is placed on active list and note is Referred to placed on CN calendar Cerner patient? - Physician for follow-up with physician Schedules Yes

Yes

began on establishing a patient acuity ous tumor sites based on volume alone by acuity level = estimated workload). system whereby navigation assign- was unrealistic. Instead, we completed While the acuity system was not scien- ments could be determined based on a workload analysis and defined seven tifically validated, it served as an effec- estimated workload rather than mere different acuity levels (see Figure 6). tive mechanism to distribute the various navigator-to-patient ratios. One lesson Next, we evaluated the previous tumor sites so that all patients undergo- learned throughout the previous three year’s cancer registry data, including ing multimodality treatment could be phases of program implementation number of cancer cases by type and assigned a patient navigator. was that patients’ needs varied widely stage. In consultation with the patient based on tumor site, stage at diagnosis, navigators, we matched defined acuity Phase V—2007 treatment(s) chosen, and existing sup- levels with the various stages of dis- In 2007 Billings Clinic was one of port systems. Because of these vari- ease by tumor site. Then an acuity cal- ten organizations across the United ables, we felt that distributing the vari- culation was created (volume multiplied States chosen to participate in the

ACCC’s Cancer Care Patient Navigation: A Call to Action S19 Figure 4: Multidiscplinary Cancer Patient Care

Social Worker

Placement (LTC, Assisted Living, Temporary Intake Assessment Housing) Other Financial Counselor (Financial Screening, Physicians Social Support, Emotional State, Community Resources) Support Groups Assess/Order Financial (General, IP, Manage Patient Care Assessment Hope for Payment Tomorrow) Schedule & Follow-up Counseling Financial Evaluation Counseling (Refer as needed) Well cared for and

Single Patient satisfied cancer patient Room Contact for Therapeutic Patients Ca Patient Entire Tx Course Physician Counseling Schedule Education Medication Ca Patient Treatment Telephone Refill Delivery Triage Education Clinic Flow (Symptom Office Management, Communication Schedule Complex Care) Coordinate Tests Phone Specialist Triage Communication/ Appointments Licensed Counselor Treatment Nurses Outreach Resource Office LPN Refer Patient to Tumor Board

Multidisciplinary Program Development (Pathways, Education, Follow-up on Quality Studies) Tumor Board Recommendations

Care Navigator

©Billings Clinic

National Cancer Institute’s (NCI’s) portion of the regional navigator’s time also helps connect patients with local Community Cancer Centers Program involves traveling and relationship- resources and collaborates with com- (NCCCP) three-year pilot project. As building through face-to-face interac- munity-health offices and tribal leaders part of this pilot, Billings Clinic Cancer tions with community physicians, to promote community education and Center added a regional navigator to agencies, and organizations. As a increase prevention awareness and assess the rural and frontier regions result of this networking, the regional early-detection screening programs served through the extensive oncol- navigator has hosted two navigator (e.g., mammograms, Pap smears, ogy outreach program. This navigator training programs for individuals who fecal immunohistochemical testing, advocates for the individuals in those recently assumed patient navigator and prostate specific antigen screen- regions and identifies the needs of roles within their own organizations ing) in the rural and frontier regions. To those cancer patients. A significant in the region. The regional navigator date, seven Cancer 101 programs have

S20 ACCC’s Cancer Care Patient Navigation: A Call to Action Social Worker

Placement (LTC, Assisted Living, Temporary ■■ Developing an electronic version Intake Assessment Housing) of the patient navigation intake Other Financial Counselor (Financial Screening, Physicians Social Support, worksheet Emotional State, ■■ Refining existing electronic docu- Community Resources) Support Groups Assess/Order mentation templates Financial (General, IP, Manage Patient Care ■■ Successfully launching a multidisci- Assessment Hope for plinary lung clinic coordinated by the Payment Tomorrow) lung patient navigator in collabora- Schedule & Follow-up Counseling tion with pulmonologists, thoracic Financial Evaluation surgeons, medical oncologists, and Counseling (Refer as radiation oncologists needed) ■■ Planning for two additional multidisciplinary clinics (rectal and prostate). Well cared for and The success of the program has led Single Patient satisfied cancer patient Room other clinical departments to request Contact for Therapeutic Patients Ca Patient Entire Tx Course Physician information regarding the development Counseling Schedule of patient navigation programs for other Education Medication Ca Patient chronic diseases. Treatment Telephone Refill Delivery Triage Education Clinic Flow (Symptom Office Management, Communication Schedule Complex Care) Coordinate Tests Phone Specialist Triage …we began to Communication/ Appointments Licensed Counselor Treatment Nurses Outreach evaluate additional Resource Office LPN Refer Patient to data related to Tumor Board timeliness of care… Multidisciplinary Program and appropriateness Development of care… (Pathways, Education, Follow-up on Quality Studies) Tumor Board Recommendations

Care Navigator

Future Directions Upcoming endeavors for patient been offered to Native American com- finding to diagnosis and time from navigation at Billings Clinic include the munities in Montana and Wyoming. diagnosis to treatment initiation) and implementation of two additional multi- During this phase, patient naviga- appropriateness of care (compliance disciplinary clinics (rectal and prostate), tors looked again at program quality with clinical pathways). which will be coordinated by the site- metrics. Previously metrics had focused specific navigators in collaboration with largely on patient satisfaction and pro- Phase VI—2008 involved physician specialties. In addi- gram volume, including the number of For the first time since we initiated tion, each multidisciplinary program new patients navigated by cancer type the patient navigation program, no will establish ongoing quality measures and referrals initiated. Now, we began additional positions were added during that span the continuum of care for to evaluate additional data related to 2008. However, program enhance- breast, colorectal, lung, prostate, timeliness of care (time from abnormal ments throughout the year included: continued on page S24

ACCC’s Cancer Care Patient Navigation: A Call to Action S21 Serving the Underserved in the Last Frontier

Significant healthcare disparities exist in the region served diagnosis—an important predictor of the outcome of by Billings Clinic Cancer Center, a vast geographic area of treatment. Between 2002 and 2006, less than half of all 207,000 square miles encompassing the state of Mon- cancers (48 percent) in Montana were diagnosed at the tana, the northern half of Wyoming, and the western edge local stage. Twenty percent of all cancers diagnosed were of North Dakota. This service area is 33 percent larger than regional and 22 percent were diagnosed at a distant, or the entire state of California, with a population of approxi- metastasized, stage.1 mately 1.25 million people (compared to over 33 million in Regionally, Billings Clinic has long been dedicated California). A lack of access to primary care physicians is a to working collaboratively with communities to address well-known characteristic of the region with approximately healthcare disparities in remote and frontier areas. Each 87 percent of Montana counties (some as large as entire month, the Billings Clinic Cancer Center provides 21 states) designated as Health Professional Shortage Areas, outreach clinics in 9 rural communities (see map below). Medically Underserved Areas, and/or Physician Scarcity Areas. References Cancer rates are driven by a complex set of social, 1Montana Central Tumor Registry. (2008). Cancer in Montana economic, cultural, and health system factors. The lack of 2002-2006: Montana Central Tumor Registry Annual Report. local medical care, including cancer prevention information (Montana Department of Public Health and Human Services). and screening, affects the stage at the time of cancer Helena, MT.

S22 ACCC’s Cancer Care Patient Navigation: A Call to Action Figure 5: Billings Clinic Cancer Center Care Navigation Survey

Patient Name: ______Navigator Name: ______Gender: Male Female Cancer Type: Bladder Myeloma Breast Ovarian/Primary Age: < 35 Cervical Peritoneal 35-44 CNS Pancreatic 45-54 Colon & Rectum Prostate 55-64 Esophageal Renal 65-74 Head & Neck Sarcoma > 75 Leukemia Testicular Lymphoma Uterine Lung & Bronchus Other: ______Melanoma/Skin ______

Care Navigator Feedback Section Directions: In the section below, Care Navigators will enter scores based on their perceptions Yes No N/A of the service quality offered during this treatment plan. Patient had quick, seamless access to cancer services. I was allowed an appropriate level of involvement in patient care. The identified clinical plan of care (clinical guidelines) was initiated and followed.

Patient Feedback Section Special Notes: Directions: In the section below, scores will be reported by patients during telephone follow-up. Phone number: ______Hello. My name is ______with Billings Clinic. Is ______available? I am calling on behalf of the Cancer Center and would like to ask a few brief questions with regard to the care you received. Is this a good time for you? I have 5 statements and I would like you to respond to each statement with a number indicating your agreement. A low number would indicate you disagree with the statement I have read, whereas a high number indicates your agreement. I will begin if you are ready.

1 2 3 4 5 6 7 8 9 10 My cancer care was provided in a timely fashion. My care navigator helped me develop my unique treatment plan. My care navigator was important in ensuring seamless care between different areas of the clinic. My care navigator coordinated my care to meet my unique needs. My care navigator answered my questions in a manner I could easily understand.

Was there any additional information or education that would have been beneficial for your care navigator to give you?

Do you have any comments you would like to make?

Thank you for taking the time to respond to these questions. Your input is very important so that we can offer the best possible care. Have a nice day!

Date/Time of All Attempts Staff Signature

1. ______

2. ______

3. ______©Billings Clinic

ACCC’s Cancer Care Patient Navigation: A Call to Action S23 [Patient navigation] has become the link that integrates every aspect of patient care…

Figure 6: Patient Navigation Acuity Scale

Acuity Scale Description

0 No navigation

0.5 Meet patient if referral received; Initial guidance/education/coordination as needed; Typically no follow-up required

1 Meet patients upon diagnosis; Initial guidance/education/coordination; Typically no follow-up required

1.5 Meet patient upon diagnosis; Coordination of multi-modality treatment; Typically ongoing guidance/education for 3-4 months;

2 Meet patients upon diagnosis; Coordination of multi-modality treatment; Moderate intensity of needs; Typically ongoing guidance/education for 5-6 months or more

2.5 Meet patients upon diagnosis; Coordination of multi-modality treatment; High intensity of needs, often inpatient hospitalizations associated with care Typically ongoing guidance/education for 6-12 months or more

4 Meets patient upon diagnosis; Coordination of multi-modality treatment; High intensity of needs, often associated with care coordination outside of facility; Typically ongoing guidance/education for 6-12 months or more ©Billings Clinic hematological, and gynecologic can- surprising if patient navigation programs aspect of patient care through the facili- cers. The navigators will monitor and for other chronic diseases emerged tation of timely communication, seam- report on the measures quarterly by over the next year. less patient flow, and optimal clinical using a clinical quality dashboard. Lastly, In summary, patient navigation outcomes. 4 given the success of patient navigation is integral to the interdisciplinary team within the Cancer Center at Billings approach to cancer treatment that Karyl Blaseg, RN, MSN, OCN, BC, is Clinic and the recent interest expressed Billings Clinic proudly endorses. It has manager of cancer programs at the by other service lines, it would not be become the link that integrates every Billings Clinic in Billings, Montana.

S24 ACCC’s Cancer Care Patient Navigation: A Call to Action Growing Your Patient Navigation Program A step-by-step guide for community cancer centers

by Joann Zeller, MBA, RTT, CTR

Good Samaritan Hospital is a tive “guides” to 232-bed community hospital help patients move through the complexi- serving a 15-county area in ties of the healthcare both Indiana and Illinois. We system. While that opened our new Cancer is exactly what we wanted for our Pavilion in April 2008. patients, we did not have the luxury of a hospital-funded FTE to devote to the project. Our first thought state-of-the-art was to write a grant, facility designed but our experience to bring all of our has shown us that Acancer patient services under one roof, you have better suc- the completion of the Cancer Pavilion cess being funded Traci Hill, RN, (left) is one of two certified breast health

. fulfilled the “bricks and mortar” portion when you have a navigators at Good Samaritan Hospital’s Breast Care nd

, I of our strategic plan. Next we focused well-defined program Center. on expanding our existing patient sup- prior to submitting port services. These included social a grant. Our solu- incennes services, dietary counseling, patient tion was to implement a scaled-down Even in a limited capacity, if applied to l, V support groups, financial counseling, patient navigation program within our specific key time points, our patient rehabilitation, pastoral care, and two existing structure. This smaller program navigators could achieve the most basic ospita certified RN breast health navigators. would be just the first step toward functions which are: Our plan to increase patient support ser- establishing a fully developed, com- ■■ To eliminate barriers to care vices included growth on several fronts: prehensive Patient Navigator Program ■■ To ensure timely delivery of ■■ Hiring a patient support specialist to in our facility. Below is a description of services amaritan H assist with insurance authorizations. the eight-step process we devised as a ■■ To save lives from cancer This staff member will also help road map to navigate toward success. ■■ To improve patient satisfaction.

f Good S patients apply to drug replacement y o programs as well as organizations Step 1: Analyze the Role of the Step 2: Identify Our Existing that assist with co-pays. Patient Navigator Strengths rtes u ■■ Adding a dedicated social worker in Analyzing the patient navigator role Our program already had in place a the outpatient setting to help grow allowed us to identify key functions number of components that would

raph co our offering of support groups and we could realistically take on with our support a navigation program including g build a survivorship program. existing staff. Our goal: to successfully an established breast health navigator, ■■

hoto Expanding the use of patient naviga- incorporate as much of the navigator a physician champion, certified staff, P tors across the service line. role into our program as possible, while existing support services, and documenting its effectiveness. We accreditations. If you are a community hospital similar believed these actions would best pre- Established breast health in size to our facility, you may face the pare us for submitting grant applications navigators. Our Breast Care Center same challenges that we do. You have in the future. And procuring grant funds has a well-established patient naviga- a dedicated, well-educated staff, as for a full-time patient navigator would tion program, a huge advantage to well as varied support services, but you serve to fully expand the role and be a our facility. Approximately 80 analytic lack a formal program to ensure that all bridge to eventually having a hospital- breast cancer cases are accessioned patients are getting the information and funded FTE navigator position. by our registry each year. In 2006 support that they deserve. Patient navigator key time points Good Samaritan Hospital established Patient navigation has been a are:1 the Breast Care Center to provide growing force in cancer care since the ■■ Connecting individuals to screening comprehensive care to those patients ground-breaking work by Harold P. ■■ Following patients post-screening who present with a positive diagnosis Freeman, MD. Patient navigators ■■ Assisting patients through treatment as a result of screening. As part of this can serve as compassionate, effec- ■■ Providing support to survivors. program, Traci Hill, RN, received training

ACCC’s Cancer Care Patient Navigation: A Call to Action S25 to become a Certified Breast Health (BICOE) through the American College specifically assigned to education or to Navigator (CBHN). She completed a of Radiology (ACR). patients experiencing chemotherapy or 40-hour comprehensive training pro- radiation therapy for the first time. gram on all aspects of patient naviga- Step 3: Identify Our Challenges Prior to initiating the navigator role tion for breast cancer patients through as a Community Hospital (beyond the breast care center) we EduCare, Inc., and received certifica- Our cancer center faced several met several times with our nurses to tion. A second nurse, Cindy Mouzin, challenges to implementing patient discuss what the change would mean RN, was also sent for breast health navigation. For example, our screening to our patients, how best to manage navigator training and certification. She programs take place across the com- the process, and what documents they now assists on all biopsies in the mam- munity and are not centralized through thought would be worthwhile. We mography portion of the Breast Care our hospital. wanted to give patients an easy way to Center. Together these two nurses pro- Another challenge: all of the patient organize their papers and keep track of vide complete navigation services for all services listed under our strengths are smaller forms as they moved through of our breast cancer patients. shared services within the hospital. In the healthcare system. Everyone Physician champion. We have a other words, they are not immediately agreed to use an expandable file folder strong physician champion for patient available to outpatients without sched- with a fold-over top to hold the forms. navigation at our facility. Even better, uling an appointment. The folder had a place for the patient we did not have to look for a cham- We also faced staffing issues. navigator’s card, as well as a card pion—he came to us. Kurt Maddock, Specifically, our current RNF TEs have for the managing physician. We also MD, is a breast surgeon and medical limited hours to fill the role of Patient included an insert for other business director of our Cancer Program. He Navigator. cards that patients invariably receive championed the CBHN training for the We saw a lack of an official sur- during office visits. After selecting a file nurses in the Breast Care Center. As a vivorship program as another barrier. folder with 12 expandable pockets, we strong advocate for patient navigation, (Developing a survivorship program is a organized the educational information we have his full support as we expand cancer program goal for 2009.) under five headings: patient navigation across the cancer 1. Intake Forms. This section includes service line. Step 4: Develop the Bones of Our forms for the initial entry into the pro- Certified staff. The majority of Navigation Program gram: Intake Form, Identification of our nurses are ONS certified. As stated Now it was time to develop policies and Barriers to Care, and a Weekly Con- above, our Breast Health Navigators are procedures to formalize our navigation tact Record. Our tools were based also certified. Our nurses have com- process. We started by looking at the on templates provided through pleted the Certified Breast Care Nurse number of patients who were going to EduCare, Inc., and the Pfizer patient (CBCN) courses offered by the Oncol- use our navigation services each year. navigation toolkit, which is available ogy Nursing Society (ONS) and will be Our literature search revealed an online at www.patientnavigation. sitting for the exam in the spring. To effective navigation ratio of 1 FTE for 25 com. Using the information from the date, we have not pursued any general to 30 patients under treatment and 75 intake form, navigators can make patient navigation certifications. to 80 post-treatment. Our cancer center appointments for patients based on Existing support services. Our treats approximately 50 patients a day their self-identified needs. These cancer center already provides the fol- and has 450 analytic cases per year. can include dietary, rehabilitation, lowing supportive care services to our We have 7 oncology nurses and 2 certi- nutrition, financial, and assistance cancer patients: social services, dietary fied breast health navigators. Of our from our Patient Support Specialist. counseling, patient support groups, analytic cases per year, 80 are breast 2. Medication Record. This record financial counseling, rehabilitation, and cancer patients. The remaining cases is fully reconciled with the patient’s pastoral care. divide into approximately 50 cases per hospital medication record. Facility accreditations. Our nurse. These cases are a combination 3. Patient Support Services. We cancer program has received several of patients undergoing treatment and include flyers for our American accreditations including: JCAHO; those in follow-up. The simple rule of Cancer Society (ACS) support ACoS, American College of Surgeons thumb at our facility is the first nurse to groups, as well as information on CHCP; Magnet status (this speaks to communicate with the patient becomes our Resource Library and Boutique, the dedication of our nurses and our that patient’s navigator. This approach which offers free wigs, hats, and hospital’s support of the continuum of works for us because all of our nurses mastectomy bras. care for the patient); and designation as are scheduled in the same work areas 4. Insurance. This information is gen- a Breast Imaging Center of Excellence with the same rotating duties. No one is erated at patient registration, but we

S26 ACCC’s Cancer Care Patient Navigation: A Call to Action Good Samaritan Hospital’s new Cancer Pavilion opened in April 2008.

legislation has increased both awareness of patient navigation and the number of available grants. Your local found that having a copy in the folder the American College of Surgeons libraries may be an additional resource has been helpful to patients as they CP3R NCDB studies. Beginning in if they have user passwords to specific make their various office visits. 2009, ACoS requires accredited facili- grant writing websites such as www. 5. Demographics. This information is ties to not only report compliance rates foundationcenter.org. . also generated at patient registra- to their own Cancer Committee but nd , I tion. And again, patients have found also to set benchmarks and establish Step 8: Transition to it helpful to have a copy in their plans to address low performance Hospital-funded FTE Employee folder as they make their office rates. Our facility went one step further Our goal is to have a hospital-funded incennes visits. Our demographic form and is now reporting current data four FTE patient navigator by 2012. Once l, V contains basic information such to six months out. We felt this was our current, abbreviated navigated as address, next of kin, insurance important because the online NCDB program has been in place for one ospita information, etc. data reflect 2006 data with 2007 soon year, we will submit grant applica- 6. Education. We do not pre-load this to follow. tions. A grant-funded FTE will allow portion of the file folder. Instead, the The navigators are all well-versed us to expand the navigation services 3 amaritan H information is specific to the patient on the CP R studies and the qualifi- to capture all patients receiving initial and his or her disease process. The cations for the patient subsets. We suspicious findings of what may be navigators believe it is important to felt this was an ideal way to use and cancer. Establishing these expanded f Good S first review the information with the measure the patient navigator skill set. services will take some time as it will y o patient prior to putting it into the file If navigators know up front that the require structuring a system to gather

rtes folder. patients’ disease and stage qualifies community-wide screenings. If we u them to be included in a study, they are lucky enough to receive a grant to Our hope is that patients view the file can be proactive in watching for the establish a comprehensive navigation hoto co folder and all of its documents as their appropriate appointments for specialty program over a two-year period, we P own “tool box.” consultations. More importantly, the anticipate having well-established cost navigators can make sure that the and effectiveness outcomes on the Step 5: Initiate the Navigator patient follows through on these patient navigation program ready to Role appointments. submit for FTE approval in our hospital Once the formal processes and tools The resulting data on performance budget. were in place, it was time to educate rates are tracked by our quality depart- For our community cancer center, the community about our new naviga- ment and reported to the Cancer Com- incorporating the patient navigator role, tion program. Our patient navigation mittee six times a year. even in a limited fashion, has been well service is featured on hospital and received and extremely valuable to our cancer center brochures, on the hos- Step 7: Apply for Grant Funding patients. Like many projects that seem pital’s website, and on flyers available The Patient Navigator Outreach and overwhelming at first glance, growing in the cancer center’s resource area. Chronic Disease Prevention Act of a patient navigation program is achiev- The most effective communication, 2005 (The Patient Navigator Act) was able if you break it down into manage- however, is from our navigators them- signed into law on June 29, 2005. able sections. As Theodore Roosevelt selves when they first see the patient. This Act authorized $2 million in FY said, “Do what you can, with what you When we have fully expanded our 2006, $5 million for FY 2007, $7 mil- have, where you are.” 4 program and incorporated navigation lion for FY 2008, $6.5 million for FY services at the most basic screening 2009, and $3.5 million for FY 2010 to Joann Zeller, MBA, RTT, CTR, is level, we anticipate a full marketing the Health Resources and Services director of Oncology Services at Good campaign to include our regional Administration (HRSA) to provide Samaritan Hospital in Vincennes, Ind. physicians. grants to eligible entities. The grants are to recruit, assign, train, and employ Step 6: Measure Program patient navigators who have direct References Effectiveness knowledge of the communities they 1 Katz Mira L. Patient Navigation Measure- Our Cancer Program has an ongoing serve to facilitate the care and improve ment Tools. Overcoming Disparities through process improvement initiative that healthcare outcomes for individuals Patient Navigation. Detroit, Michigan. tracks our current compliance rate with with cancer or chronic disease. This September 20, 2007.

ACCC’s Cancer Care Patient Navigation: A Call to Action S27 A Regional Navigators’ Network A First-person perspective

by Debbie Williams, RN

I am a breast health on the new trails we are blazing! our region is great, especially with our specialist and breast cancer Many patient navigators at facili- underserved populations. ties in our region are still working to Our community has excellent patient navigator at Alexian break down barriers and establish their resources available for patients, and Brothers Health System. programs. They face many challenges our regional navigators’ network is an I am also a breast cancer including gaining approval and accep- opportunity for us to share information tance from their colleagues and care- about these local resources. We also survivor. One important givers. At the outset of navigation ser- help support each other and network aspect of my role as a breast vices, physicians may be uncertain of about ways in which we’ve succeeded health specialist and breast the navigator’s role in patient care and in overcoming barriers to patient naviga- may feel threatened. When working tion. Our regional navigators’ network cancer patient navigator is with new physicians who are unfamiliar is also a support group, providing an to be available for all and with my patient navigator role, I explain opportunity to share how difficult it can that I serve as an extension of their be to cope with the loss of a patient. not limit the possibilities. office and can work alongside them to We meet quarterly, with each I am fortunate and proud to provide patients with the resources and meeting held at a different facility in the work at a community cancer information they need in order to feel in region. We tour each others centers control and supported throughout their and work places and see firsthand what center that has valued the cancer journey. It can take years to earn others have been able to accomplish. navigator role for more the trust and support needed to be able Our meetings start with an educational than nine years and has a to reach and help those who would presentation, followed by networking benefit the most. Sometimes even the and information sharing. We discuss well-established navigator patients themselves are cautious about the community we serve and the chal- program. letting us slip into their lives at a time lenges we face. I encourage all commu- when they feel the most vulnerable and nities to try and establish such a group. lost. However, patients soon recognize The networking possibilities and part- the navigator’s value and that our office nership opportunities are invaluable. 4 is a safe and secure place. In the same way that a new patient Debbie Williams, RN, is breast health ne of my favorite learns to navigate the healthcare sys- specialist and breast cancer patient quotes and one that tem when diagnosed, we navigators navigator at Alexian Brothers Health I use today when I are learning where and how to help System in Elk Grove Village, Ill. Otalk with my own breast cancer patients patients in need so that our services will is—To know the road ahead, ask those have the greatest impact. Our Network coming back. These words sum up per- of Navigators is unique because our fectly the value of our regional Network group is open to all navigators—those of Navigators in the Chicago area. Our who are hoping to start a program as Network has been meeting for a year well as experienced navigators in an now, and we often find it difficult to end established program. Among our group our meetings on time because of the are nurse navigators—the largest seg- networking opportunities available. We ment—and community-based naviga- have forged a bond between us based tors who provide education on detection and prevention and how to access the healthcare system for screenings and care. The need for navigation in

S28 ACCC’s Cancer Care Patient Navigation: A Call to Action Thoracic Oncology Patient Navigation Creating a site-specific navigation program

by Susan Abbinanti, MS, PA-C

When you are diagnosed with lung cancer, there are many ally non-billable. Therefore, adminis- procedures you need to have to establish a comprehensive trative support and understanding of the patient navigator’s role is crucial. diagnosis. The patient navigator takes the burden off the patient At Alexian Brothers, we believe that to get those tests and procedures scheduled. They are an patient navigation helps improve important link between the doctor, the patient, and all other patient outcomes and satisfaction, which translates to more patients adjunct services. Perhaps most importantly, patient navigators choosing to remain within our hospital are the ‘constant’ in the continuum of care to return the patient to system for care. This, in turn, increases downstream revenue for our hospital. wellness. They offer patients a personal contact to help alleviate Navigation services can also their fears and concerns. be attractive to referring physicians. —Patti Jamieson-Baker, MBA Today, physicians are often on staff at Vice President multiple hospitals. Ensuring that pri- The Cancer Institute at mary care physicians are aware of the Alexian Brothers Hospital Network quality care that their thoracic oncology patients receive from our thoracic oncology coordinator can potentially he evaluation and manage- objective staff member who would be help grow patient volumes. ment of lung cancer can an advocate for the patients and the be complex. The majority thoracic oncology program—rather Culture Counts Tof lung cancer cases are diagnosed than any specific agenda or physician The culture of the institution is a key at an advanced stage, with treatment group(s). An initial period during which factor in developing a workable thorac- often involving intensive multi-modality physicians would need to develop a ic oncology navigation program. Plan- therapies. So in 2006, Alexian Broth- level of trust in the new coordinator’s ning for our program included investi- ers Hospital Network, which includes abilities was anticipated. gating multiple navigation models and a 400-bed community hospital com- The thoracic oncology coordinator a site visit to a well-established lung prehensive cancer program and a is a hospital network employee based cancer patient navigation program at nearby 331-bed community hospital at The Cancer Institute at Alexian St. Joseph Hospital in Orange County, cancer program in northwest suburban Brothers Hospital Network. Naviga- California, to observe a best practice Chicago, began offering lung cancer tion services provided by the thoracic model in operation. During our litera- patient navigation services. Here’s oncology coordinator are loosely mod- ture search we identified one naviga- how the site-specific program was eled after Alexian Brothers’ breast tion model that referred suspected or developed and implemented. navigation program, which has been newly diagnosed lung cancer patients in operation since 2000. In a similar to a call center where a patient coordi- Thoracic Oncology Coordinator fashion, the thoracic oncology coordinator or navigator scheduled tests and Under the direction of a newly hired nator provides support and education specialty physician appointments. Giv- dedicated thoracic surgeon, Alexian for thoracic oncology patients and their en that both Alexian Brothers Medical Brothers initiated a formal thoracic families at the time of diagnosis, during Center and St. Alexius Medical Center oncology program in 2006. The thoracic treatment, and beyond. Specific duties are community hospitals with patients oncology program included a newly include: coming into the system from multiple created FTE patient navigator position. ■■ Planning multidisciplinary on- and off-site private physician of- Because the navigator would provide conferences fices with well-established referral care to all thoracic oncology patients— ■■ Acting as a liaison between patterns, the call center model was not just lung cancer patients—the job members of the care team not viewed as a good fit. title for the new position was thoracic ■■ Tracking programmatic quality Many primary care physicians oncology coordinator. The decision indicators refer patients with suspected lung was made to hire a mid-level provider ■■ Networking with community cancers to a pulmonologist for further from outside the hospital system for organizations evaluation, but a significant number this newly created position. Because ■■ Providing community education. will either send the patient to a sur- the new coordinator had no prior rela- geon or direct the diagnostic workup tionships within the hospital network, In the present healthcare system, themselves. Under our model, the the individual could be perceived as an patient navigation services are gener- thoracic oncology coordinator is

ACCC’s Cancer Care Patient Navigation: A Call to Action S29 available to all physicians’ offices and patients to assist with scheduling diagnostic tests; however, the pattern that naturally developed in our hospital network was for the thoracic oncology coordinator to meet most Multidisciplinary lung cancer conferences are an integral component of the thoracic patients after diagnosis. oncology program at Alexian Brothers Hospital Network. That said, given the multiple points of entry into our healthcare system, meeting all Internet, and often limit their exposure of interest. Two of the most popular lung cancer patients can be challeng- to information afterward. In response topics are complementary medicine ing for our thoracic oncology coordina- to patient feedback, our lung- and physician question-and-answer tor. Some third-party payers require cancer-specific booklets are concise, sessions. For patients who are not that the diagnostic workup be done as with more comprehensive printed comfortable in a group setting, the an outpatient, and sometimes even at material provided upon request. thoracic oncology coordinator can multiple locations. If the patient has Families and significant others connect them with another patient in a etwork metastatic disease, he or she may be can benefit from receiving written similar situation who has already gone l N referred from the primary care physi- information on strategies for being through treatment and volunteered to cian’s office directly to an off-campus supportive to someone with a cancer be available for one-on-one support. ospita oncologist. When the oncologist’s diagnosis. At the same time, well- During Lung Cancer Awareness month office is off-site, the thoracic oncology meaning family and friends often in November, all lung cancer patients coordinator may initially contact the research multiple treatment options, are invited to a lung cancer survivors’ rothers H patient by phone. The patient is then many which make claims that are luncheon. Some of the same patients ian B x met in person at a later time when he not evidence-based. The thoracic have returned for several years, e or she is at the hospital for a scheduled oncology coordinator is available providing hope and encouragement f Al

test. to provide individualized emotional to others. y o and educational support for patients When appropriate, the thoracic rtes

Patient Benefits and their families in an objective and oncology coordinator refers patients u Our thoracic oncology navigation understandable fashion. and family members to other support program has benefited patients in Psychosocial support and services, such as nutrition or social hoto co several ways. Patient education, advocacy. Receiving a diagnosis of work. P psychosocial support, and advocacy lung cancer can be a frightening and Scheduling assistance. For services are some of the key functions confusing time for patients and their lung cancer patients, traveling long of our thoracic oncology coordinator. families. The availability of information distances to a tertiary care center Education. We collect on the Internet can be overwhelming. for chemotherapy or daily radiation educational and supportive materials If the patient is a current or former therapy treatments can be a hardship. at no cost from multiple sources, smoker, an added component of The median age at diagnosis for lung including national lung cancer guilt can affect not only the patient’s cancer patients is 71 years.2 Many organizations and pharmaceutical willingness to be treated, but family patients have significant co-morbidities companies. The thoracic oncology support as well.1 and transportation issues. Most coordinator individualizes these Frequently, patients ask our patients express a desire to receive materials on a case-by-case basis. thoracic oncology coordinator to treatment for lung cancer close to Educational and supportive materials simply provide hope. Both hospitals home, where their primary care are then either mailed to the patient’s within the Alexian Network offer physician can remain involved. home or delivered to the office of a lung cancer support groups, and the At the urging of family, newly physician on the patient’s treatment thoracic oncology coordinator plans diagnosed lung cancer patients often team. Lung cancer patients typically and attends all of these meetings. seek a second opinion at an academic express dismay at the prognostic The groups meet monthly and often institution. A thoracic oncology statistics they read in books or on the feature speakers on various topics coordinator can support the patient

S30 ACCC’s Cancer Care Patient Navigation: A Call to Action and family in their desire to be seen at When areas for improvement have awareness about lung cancer in general another medical facility and can help been identified, physician support has and the hospital network’s thoracic gather the necessary medical records. been excellent because our quality oncology program specifically by: If the recommended treatments are improvement activities are evidence- ■■ Participating in local walks or hikes the same at both institutions, the based and supported by the hospital’s ■■ Planning performances and ben- majority of lung cancer patients opt Cancer Committee. efits by artists who desire to help to receive their treatment locally. The State-of-the-art technology raise awareness and funds thoracic oncology coordinator is often and treatment. Another priority of the ■■ Accepting speaking engagements involved in supporting the patient thoracic oncology program is being at local civic organizations through this decision. able to offer lung cancer patients the ■■ Networking with other thoracic latest technology. Our thoracic oncol- oncology coordinators to foster the Programmatic Benefits ogy coordinator is knowledgeable exchange of information and strate- Thoracic oncology navigation ser- about cutting-edge treatments and gies used by other programs. vices also offer a number of program- able to provide the most accurate and matic benefits: 1) expediting the up-to-date information to patients and In 2007 about 20 navigators and nurse diagnostic workup and start of treat- families. For example, the thoracic coordinators attended the first regional ment; 2) improving patient participa- oncology coordinator often attends thoracic oncology conference for tion in clinical trials; and 3) increasing product demonstrations and/or navigators and coordinators. Spear- patient volumes. Other programmatic observes the delivery of new technolo- headed by Michele O’Brien, a thoracic benefits include: gies to stay abreast of new technologic oncology CNS, the meeting focused Multidisciplinary lung cancer and treatment advances. Our thoracic on developing the nurse coordinator conferences. These conferences are oncology coordinator also communi- role in thoracic oncology. It has now an integral component of our thoracic cates with staff physicians regarding become an annual event. oncology program. The thoracic oncol- new technology-based treatments While navigation services are con- ogy coordinator participates in case gleaned from peer-reviewed literature sidered an important aspect of com- selection, helping prioritize cases if the or at professional conferences. prehensive cancer care, programmatic agenda is full. The thoracic oncology benefits need to be measurable. To coordinator prepares a concise, com- Spreading the Word that end, Alexian Brothers purchased prehensive case summary to assure There was an early focus on internal and implemented a thoracic oncology that the physicians attending the and external marketing of our lung database. It is anticipated that the multidisciplinary conferences have all cancer navigation services. Internal information gleaned from this database the necessary information to discuss marketing included articles in physician will help us identify strengths and the case. As physicians become more newsletters, lunch-and-learn presenta- weaknesses that will help in develop- aware of lung cancer patient treatment tion in physicians’ offices, and partici- ing program goals, without duplication options, nihilism does not appear as pation in hospital CME activities, such of statistics generated by the cancer prevalent. One of the goals of the tho- as grand rounds. External marketing registry. 4 racic oncology program is to increase included exposure in local publications, the number of cases discussed pro- speaking to community groups, and Susan Abbinanti, MS, PA-C, is thoracic spectively. involvement with community respira- oncology coordinator at The Cancer Accurate staging is key to optimal tory organizations. Patient and family Institute at Alexian Brothers Hospital lung cancer management. To date, word of mouth and comments on the Network in Elk Grove Village and our outcomes measurements have Internet are under-recognized but pow- Hoffman Estates, Ill. focused on increasing physician aware- erful motivators. ness and compliance with national Lung cancer is not a “sexy” topic References guidelines so as to standardize the by any means. A lot of stigma is still 1Dvorak P. Lung cancer’s double evaluation and management of tho- associated with lung cancer. Raising burden. Washington Post. January 20, 2009. Available online at: http://www. racic malignancies. We evaluate each community awareness is important washingtonpost.com/wp-dyn/content/ patient case for adherence to national both from the standpoint of educating article/2008/12/12/AR2008121203425_ guidelines in diagnostic evaluation and the public about signs and symptoms pf.html. Last accessed March 10, 2009. 2 treatment planning. Referring physi- of lung cancer as well as programs National Cancer Institute. SEER Stat Fact Sheets, Cancer: Lung and Bronchus. cians can now expect that their lung that support lung cancer patients and Available online at: http://seer.cancer.gov/ cancer patients are managed accord- research funding. The thoracic oncology statfacts/html/lungb.html. Last accessed ing to a uniform set of guidelines. coordinator helps increase community March 10, 2009.

ACCC’s Cancer Care Patient Navigation: A Call to Action S31 Broward Health’s Breast Cancer Navigation Program Meeting the needs of underserved patients

by Pia Delvaille, ARNP, MSN

Broward Health, a nonprofit community health system, is Our Team At-a-Glance one of the ten largest public health systems in the United Our first step was to establish a navigation planning team composed of States. Broward Health has more than 30 healthcare Nicholas Tranakas, MD; Pia Delvaille, facilities including Broward General Medical Center, North ARNP, MSN; and Paulet Reyes, RN, BSN. The team was responsible for Broward Medical Center, Imperial Point Medical Center, establishing criteria and guidelines Coral Springs Medical Center, Broward Health Weston, and for referral to the Breast Navigation Chris Evert Children’s Hospital at Broward General. Broward Program. The next step was to intro- duce the navigation program to all Health is a medical safety net for Broward County residents. Broward Health departments, clinics, For more information, go to www.browardhealth.org. and community affiliates who would be involved in referral and care of the patient. To accomplish this, the planning team scheduled appointments to meet with these groups during their roward Health is a In 2008 Broward Health provided staff meetings. community healthcare 29,380 mammograms, nearly 3,000 to Next, the navigation planning system serving 1.7 women who were uninsured and could team developed forms for patient Bmillion residents in the northern part of not afford to pay.1 referrals, patient intake, program evalu- Broward County in southeastern Flor- In 2006 Broward Health applied ation, patient progress notes, and ida. Our healthcare system is respon- for a patient navigation grant through a referral log (see pages S34–S38). sible for the care and treatment of the American Cancer Society With tremendous growth in the uninsured patients in this geographic (ACS). We received a grant of nearly first year, our navigation program soon area. According to 2007 data from the $150,000 from the Florida Division outgrew the capabilities of our single U.S. Census Bureau, approximately of the American Cancer Society, nurse navigator. In 2007 we received 340,000 residents within Broward allowing us to establish our Breast a $150,000 AVON Foundation grant, County fall into this patient population. Navigation Program and to hire one which allowed us to expand our navi- The Breast Cancer Navigation Program full-time RN patient navigator.1 This gation services by adding a bilingual at Broward Health began in Septem- effort was spearheaded by Nicholas social worker who is also a trained ber 2006 when we realized that our Tranakas, MD; Lori Kessler, manager, mental health professional.2 healthcare system was becoming disease state, and the author. The Today our breast cancer naviga- more and more difficult for patients to grant was specifically used to fund the tors are a part of the Comprehensive navigate. Multiple obstacles hampered RN patient navigator position. The RN Cancer Center and Breast Center our patients from diagnosis through navigator is located in the Case Man- Team. The navigators’ offices are treatment—ranging from uninsured agement Department, and she travels located in the Disease State Manage- patients without funds to pay for care to the different Breast/Cancer Centers ment Department, and they report to patients without transportation to throughout the Broward Health Sys- to the Manager of Disease State come in to receive care. Accordingly, tem. Initially, the navigator was self- Management and the Breast/Cancer our Breast Cancer Navigation program taught, using the Navigator Pathways Center ARNP. was designed to serve this under- and the Patient Navigator Training An abnormal finding on a mam- served population. Manual from the HANYS Breast mogram triggers a patient referral to Cancer Demonstration Project and the breast cancer navigator who does Reaching Out to the Underserved Pfizer Oncology. She later attended a detailed intake to assess the patient’s We educate our community on the the Harold P. Freeman Patient Naviga- needs. The patient is then in the screening guidelines for good breast tion Institute certification course in navigation program through comple- health through outreach programs Harlem, N.Y. tion of care. If the patient’s work up is conducted by our physicians, nurses, Our Breast Cancer Patient Naviga- negative for cancer, the patient is put and outreach staff. Broward Health tion program was designed to navigate back on the schedule for follow-up as also offers several options for free medically underserved women of all recommended by the physician, and mammograms and clinical breast ages, living below 200 percent of the the patient is educated and told to call exams through our healthcare system Federal Poverty Level, who received for any changes or concerns. Once and affiliated community resources. an abnormal mammogram.2 patients are diagnosed with cancer,

S32 ACCC’s Cancer Care Patient Navigation: A Call to Action Services Offered by the Breast Navigation Program

■■ Assessment of patients and identification of barriers or possible barriers to care. ■■ Assistance with paperwork needed to access healthcare system for care. ■■ Help scheduling appointments in a timely manner. ■■ Identification and help accessing national and community resources. ■■ Weekly communication with patients while they are undergoing treatment. contacted by the navigator ■■ Ongoing communication with the multidisciplinary team to ensure seamless ■■ Patient will receive follow-up proce- care of the patient. dure (biopsy, ultrasound, etc.) within ■■ Assistance to establish a medical home (i.e., a facility where patients can 5–10 days (after initial call from receive healthcare). navigator) ■■ Patient will be notified of procedure ■■ Continued support of patient on a quarterly basis once treatment is results within 72 hours (after the completed. procedure has been carried out) ■■ All biopsies will be scheduled within 48 hours (after abnormal finding) ■■ All biopsy procedures will be Table 1: ACS Benchmarks/Broward Health Outcomes completed within 7 days (after the patient is notified of an abnormal ACS Broward Health result of the diagnostic mammogram or ultrasound) American Cancer Society estimated 53 days 51 days ■■ Pathology results will be commu- benchmark for navigation from nicated to patient within 72 hours abnormal mammogram to care (after biopsy has been performed) Time from abnormal findings to 13 days 13 days ■■ Patients with a positive cancer find- diagnosis ing will be referred to Broward’s Comprehensive Cancer Center Time from positive diagnosis to 37 days 25 days within 7 days initiation of treatment ■■ Patients will receive first cancer treatment within 14 days after refer- Contacted by navigator case manager within 3 days 1 day ral to the patient navigator. Follow-up procedure scheduled within 4 days 1 or less Outcomes from the breast navigation Receive follow-up procedure within 5-10 days 8 days program are excellent (see Table 1), and the program helped keep the cost of Woman notified of procedure results within 3 days 3 days care down for patients who qualify for navigation services. Broward Health’s Biopsy scheduled within 4 days less than 4 days Administration is currently reviewing Biopsy procedure within 7 days 7 days the Breast Navigation Program with the goal of continuing the program and Pathology results within 3 days 3 days expanding navigation services to all cancer patients. 4 Referred to Cancer Center within 7 days 13 days*

Receive first cancer treatment within 14 days 12 days Pia Delvaille is an Advanced Practice Registered Nurse in the Comprehen- sive Breast/Cancer Center at Broward * Challenges and barriers affecting outcomes: Co-morbid conditions that needed to be Health-Broward General Medical resolved prior to referral to cancer center and start of cancer treatment. Center. Pia has worked in oncology for 25 years. they are followed by the breast naviga- Cancer Society (see Table 1 on this References tors from diagnosis through treatment page). At Broward Health, we devel- 1Broward Health. Breast Cancer Navigator and for five years after the completion oped the following outcome measures Program. Available online at: http://www. browardhealth.org/?id=196&sid=2. Last of treatment. for our navigation program: accessed 03.04.09. ■■ Patient will be contacted by a naviga- 2Broward Health. Avon Foundation Outcome Measures tor within 72 hours of referral (after Awards Grant to Broward Health Breast Starting in 2007, we began evaluating an abnormal finding) Cancer Patient Navigator Program. Available online at: http://www.broward- ■■ our navigation program using outcome Follow-up procedure will be sched- health.org/news/?sid=1&nid=119. Last measures developed by the American uled within 48 hours of patient being accessed 03.04.09.

ACCC’s Cancer Care Patient Navigation: A Call to Action S33 BREAST CANCER PATIENT NAVIGATION PROGRAM INDICATORS1,2

PATIENT NAME______MEDICAID/SOCIAL SECURITY NUMBER______

DATE OF BIRTH______/______/______AGE______RACE/ETHNICITY______PRIMARY LANGUAGE______EMERGENCY CONTACT______BREAST CANCER PROVIDER: BCC CCC NBMC CC PCP ______CM______DATE CASE OPENED______/______/______DATE CASE CLOSED______/______/______

PREVENTATIVE CARE MONITORS: Continuity, Patient Participation, Efficacy and Appropriateness of Care 01. fIRST VISIT Date of last mammogram: Date of biopsy: Date of last ultrasound: 1st visit date:

09. CHECKLIST: (Case manager to initial or mark N/A) gilda’s Club Educational materials American Cancer Society Medicaid transportation Childcare Smoke cessation classes Social Worker Counseling: Smoking genetic Nutrition Educate on breast self exam Substance abuse/Mental health Physical therapy Case closed letter

1Breast Cancer Patient Navigator Program Indicators worksheet/tool to be placed in internal DSM case file upon opening of each case. Tool to be retained in the patient’s internal DSM case file. This tool should not be placed in enrollee’s medical record.2Completion of Breast Cancer Patient Navigation Program Indicator’s worksheet done from the following data sources: documents faxed from provider’s office, information obtained telephonically from provider’s office, PCP provider office or primary care center, and Breast Cancer Center medical record.

S34 ACCC’s Cancer Care Patient Navigation: A Call to Action Breast Cancer Patient Navigator Program Referral Form/Intake Summary

FAX TO: ______

DATE: ______

TO: Breast Cancer RN Nurse Manager: ______

Breast Cancer Social Worker:______

REFERRED BY: ______PHONE: ______

F fAX: ______

CRITERIA FOR REFERRAL:

n Uncompensated care patient with a minimum of a positive mammogram or newly diagnosed with breast cancer

n Patient must be aware of her most current diagnostic results and/or mammogram status

CHECK BOX IF PATIENT IS AWARE OR HER POSITIVE (+) MAMMOGRAM, BIOPSY, DIAGNOSIS, ETC.

Patient Name: ______

Primary Care Provider: ______

Social Security Number: ______

Phone Number: ______

Address: ______

Site of appointment: ______

Next appointment: ______

Date of Breast Cancer Diagnosis: ______Intake Form Attached: yes ______No ______

Other Pertinent Information:

The information contained in this facsimile message is intended only for the personal and confidential use of the designated recipients named above. This message may be an attorney-client communication, and, as such, is privileged and confidential. If the reader of this message is not the intended recipient or an agent responsible for delivering it to the intended recipient, you are hereby notified that you have received this document in error and that any review, disclosure, dissemination, distribution, or copying of this message or the taking of any action in reliance of its contents, is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and return the original message to us by mail. Thank you.

ACCC’s Cancer Care Patient Navigation: A Call to Action S35 TRACKING TOOL—BREAST CANCER NAVIGATION

PATIENT NAME: ______ID NUMBER: ______

DATE ENROLLED: ______/______/______DATE DISENROLLED: ______/______/______

MR# ______

Positive Mammogram Date Date Date Date Date Date Date Date Date

Enrollee contacted

Positive mammogram/provide educational materials

Schedule follow-up appointment

Attend appointment with patient (per patient request)

Medical records reviewed (results within 72 hours)

Resolution

Positive Breast Cancer

Positive breast cancer diagnosis/ provide educational materials

Schedule breast cancer treatment

Nutritional education/referral

Monitor lab results

Family education and support

Refer to support groups

Cultural/language preferences in educational materials

Interventions: Forms (F), Childcare (C), Transportation (T)

Interventions: Eligibility (E), Financial (F), Caregiver (CG)

Communicate with other disciplines

Case manage chronic health conditions

Resolution

S36 ACCC’s Cancer Care Patient Navigation: A Call to Action BREAST CANCER NAVIGATOR PROGRAM PATIENT SATISFACTION SURVEY

You are enrolled in the Breast Cancer Navigation Program at Broward Health. With your participation, we can help you to manage your breast cancer diagnosis and treatment and help you to live a healthy lifestyle.

Please answer these questions for us. The results of the survey will be used to improve our services to you.

Does Very Not Excellent Good Good Fair Poor Apply

1. How well did the Breast Cancer RN Navigator and/or Social Worker explain the purpose of the Breast Cancer Program to you?

2. Did the program help you understand your breast cancer diagnosis and treatment better?

3. Were the educational materials and/or community resources provided to you helpful?

4. How well did the Breast Cancer RN Navigator and/or Social Worker Program help you to better understand Broward Health’s healthcare system?

5. How would you rate the care and concern provided you by the Breast Cancer RN Navigator?

6. How would you rate the care and concern provided you by the Breast Cancer Social Worker?

7. How would you rate the Breast Cancer Navigation Program overall?

Comments

What did you like best about the program?

Other comments:

ACCC’s Cancer Care Patient Navigation: A Call to Action S37 BREAST CANCER NAVIGATION PROGRESS NOTES

Date of Initial Mammogram:

Results:

Identified Barriers/Concerns:

Plan of Care:

Resolution and Date:

Notes:

Breast Cancer Navigator Case Manager: Date:

ADDRESSOGRAPH

Patient Name: ______

MR# ______

Date of Birth ______

BREAST CANCER NAVIGATOR CONTACT LOG

Type of Date Patient Name Contact Action Follow-up

S38 ACCC’s Cancer Care Patient Navigation: A Call to Action Outcome Measures Tool

This tool can help your organization identify outcome measures for your patient navigation program. Keep in mind, measures will be specific to individual programs. patient satisfaction 1. Patient satisfaction score prior to implementation of navigation services (baseline score). 2. Patient satisfaction score 6-12 months after navigation program has unrolled. Continue to monitor scores on an ongoing basis. 3. Number of patients leaving the cancer center for treatment elsewhere prior to implementation of navigation services. 4. Number of patients leaving the cancer center for treatment elsewhere 6-12 months after navigation program has unrolled. Continue to monitor scores on an ongoing basis. 5. Number of patient referrals prior to implementation of navigation services. 6. Number of patient referrals 6-12 months after navigation program has unrolled. Continue to monitor scores on an ongoing basis. 7. Patient satisfaction with navigation program. Continue to monitor scores on an ongoing basis.

PATIENT ENCOUNTERS 1. Time to diagnostic mammogram BEFORE and AFTER implementation of navigation services. 2. Time to needle biopsy BEFORE and AFTER implementation of navigation services. 3. Time to diagnosis BEFORE and AFTER implementation of navigation services. 4. BEFORE and AFTER implementation of navigation services, the time to initial treatment from: a) Initial visit, b) diagnostic mammogram, 3) diagnosis. 5. 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. 6. Time from OR to chemo/radiation BEFORE and AFTER implementation of navigation services. 7. Number of referrals to: a) navigator, b) genetic counseling, c) nutrition, d) social work. 8. Number of underserved BEFORE and AFTER implementation of navigation services. 9. Number of unavoidable admissions/ER visits BEFORE and AFTER implementation of navigation services. 10. Length of hospital stay BEFORE and AFTER implementation of navigation services.

PROGRAMMATIC COMPONENTS AND PERFORMANCE IMPROVEMENT 1. Track tumor conference recommendations based on guidelines (e.g., NCCN, ASCO). 2. Create standing order sets by disease site and measure use of tools. 3. Track percentage of patients provided with educational materials/information, BEFORE and AFTER implementation of patient navigation services. 4. Track percentage of patients given information on clinical trials and monitor percentage of patients put on clinical trials. 5. Create site-specific navigation programs. 6. Establish a Patient and Caregiver Advisory Committee. 7. Develop marketing materials and measure physician referrals BEFORE and AFTER implementation of navigation services. 8. Establish survivorship program and measure patient satisfaction. 9. Develop end-of-treatment celebration and measure satisfaction. 10. Create support groups and other educational programs and evaluate.

ACCC’s Cancer Care Patient Navigation: A Call to Action S39 N

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W Association of Community Cancer Centers E 11600 Nebel Street, Suite 201 Rockville, MD 20852 301.984.9496 www.accc-cancer.org

SW Publication and distribution of this bookletSE were made possible through a sponsorship funded by sanofi-aventis U.S.