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Proving Value and Measuring Outcomes for

Patient Navigation

Elaine Sein, RN, BSN, OCN, CBCN

Senior Project Manager

September 18, 2010

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Objectives

• Define building blocks to successfully develop, implement and sustain the role of the nurse navigator in a community cancer program

• Identify how the nurse navigator contributes to oncology clinical service line, quality outcome measurements, retention and downstream financial revenue

Health Care Policy/Care Coordination

• 2001 Presidents Cancer Panel

• 2005 C-Change

• 2005 Cancer Patient Navigation Act

• 2005 NCI funded Patient Navigation Research Project

• 2006 CMS funded (6) navigator demonstration projects

• 2007 American Cancer Society (60 navigator programs)

Health Care Policy/Care Coordination

National Quality Forum/

National Priority Partnership

• 2008 Care Coordination

– Portfolio of care coordination preferred

practices and performance measures

• Structure

• Process

• Outcome Measures

http://www.qualityforum.org/projects/ongoing/care-coordination

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Patient Navigation

• Institute of Medicine Cancer Care for the Whole

Patient

– All cancer care should ensure the provision of

appropriate psychosocial health services:

• Facilitating Effective Communication

• Identifying each patient’s psychosocial needs

• Designing & implementing a plan that :

– Links the patient with needed psychosocial care

– Coordinates biomedical and psychosocial care

– Engages & supports patients in managing illness

• Systematically follow up on evaluating and adjusting plan

Institute of Medicine (IOM), Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs

Washington, D.C. : The National Academies Press, 2007

Critical Attributes of Patient Navigator

• Facilitates access to care

• Skilled communicator and listener

• Knowledgeable of the cancer system and

resources in which they work

• Acts as an empathetic patient advocate

• Provides information and education

Pedersen, A., Hack, T. (2010) Pilots of Oncology Health Care: A Concept Analysis

of the Patient Navigator Role. Oncology Nursing Forum, (37) 1.January

Patient Navigation: Art or Science

• Qualitative Analysis of Research

– 2007 Pub Med database > 45 articles

– 16 studies provided data on efficacy of

navigation

• Improvement in timeliness to screening-10.8% to

17.1%

• Improvement in adherence to diagnostic follow-

up care 21% to 29.2%

K. Wells et al. Cancer 2008;113:1999-2010© 2008 American Cancer Society

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Rationale for Patient Navigator Role

Development

• National Quality Forum focus: Care Coordination

• Steady growth of multidisciplinary disease management programs

• Compliance with ACoS new standard

• National Accreditation Program Breast Centers (ACoS)

• ONCC Breast Care Nurse Certification

• ONS/AOSW/NASW joint position statement on patient navigation

Clinical Navigator Accountabilities

Clinical

– Educating patient

and nursing staff

– Supportive-care

triaging

– Coordinating

continuum of care

– Navigating

complex cases

Clinical Navigator Accountabilities

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Value of Nurse Coordinator/Navigator

Role in Multidisciplinary

Disease-Management Program

Builds disease team

Interdisciplinary team utilizes guidelines

(NCCN)

Improves processes and outcomes

Streamlines program

Increases patient referrals and research

Increases patient satisfaction

Building Disease-Management Teams

Disease-Management Team

Virtual

Navigation

Prospective

Treatment

Planning

Conference

Multidisciplinary

Clinic

Navigator Role in Prospective Treatment

Planning Conference

• Consensus planning among interdisciplinary

team

• Treating physician presents case for

discussion

• Navigator records recommendations and

research opportunities

• Navigator forwards conference minutes to

referring physicians

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Virtual Model (Without Walls)

• Goal: To combine multidisciplinary care

through a “virtual clinic” setting, where

coordinators work to facilitate timely

multidisciplinary evaluation through

coordinated appointments.

Role of the Nurse Navigator-One Call to the Navigator Can Initiate:

Schedules timely

Appointments & prepares

Patient

Arranges 2nd opinion

Maintains Continuity of

care

Performance

Improvement

Identifies Barriers

To Care

Coordinates

Multidisciplinary

Conference and

Quality

Measures

Education Across the

Spectrum for Team

Family &Patient

Radiologist Refers patient

At imaging Calls Physician

& Navigator

Emotional Support &

Immediate navigation

One call away

Patient Remains the

Center of Care

Navigators posted On Internet

Patients Can Call Or Email

No time constraints

Navigator May Open Door to Future

Clinical Trial Conversation

Any Physician or Specialty

Can Request Navigation For Breast Disease or Cancer

Navigation

Opportunities for identification Of New Services

Greatest Role of Navigator Patient Focused Advocate

Navigator is the Bridge and Communication Link

Between Services and Specialists

Navigator Can

facilitate Access to Available

Financial Resources & Grants

Navigator Refers to Surgical Services

Medical Imaging Laboratory

Supportive services Increasing Patient Volume, Retention and Satisfaction

Opportunity to Identify

Individuals at High Risk (FRAP ) Assessment

at Every Intake

Hunterdon Medical Center model

Role of the Nurse Navigator-One Call to the Navigator Can Initiate:

Schedules timely

Appointments & prepares

Patient

Arranges 2nd opinion

Maintains Continuity of

care

Performance

Improvement

Identifies Barriers

To Care

Coordinates

Multidisciplinary

Conference and

Quality

Measures

Education Across the

Spectrum for Team

Family &Patient

Radiologist Refers patient

At imaging Calls Physician

& Navigator

Emotional Support &

Immediate navigation

One call away

Patient Remains the

Center of Care

Navigators posted On Internet

Patients Can Call Or Email

No time constraints

Navigator May Open Door to Future

Clinical Trial Conversation

Any Physician or Specialty

Can Request Navigation For Breast Disease or Cancer

Navigation

Opportunities for identification Of New Services

Greatest Role of Navigator Patient Focused Advocate

Navigator is the Bridge and Communication Link

Between Services and Specialists

Navigator Can

facilitate Access to Available

Financial Resources & Grants

Navigator Refers to Surgical Services

Medical Imaging Laboratory

Supportive services Increasing Patient Volume, Retention and Satisfaction

Opportunity to Identify

Individuals at High Risk (FRAP ) Assessment

at Every Intake

Hunterdon Medical Center Model

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Multidisciplinary Clinic

Clinic Flow Model

• Coordinated consultation by entire team in

one visit

• Orientation Class

• Prospective Treatment Planning

Conference

• Patient Leaves with Summary of

Treatment Recommendations

Fox Chase Cancer Center model

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Navigator Implementation

• Recruiting ideal candidate

• Identify key functions by program model

• Volume based benchmarks

• Carving out tasks for delegation

• Tracking benefits of program

Navigator Training

• Assessment knowledge in care

coordination and navigation skills

• Preceptorships with established navigation

programs

• Walk through current patient flow through

the eyes of the patient

• Resources available to assist with role

development.

Navigation Resources

• Academy of Oncology Nurse Navigators

• American Cancer Society

• Association of Community Cancer Centers: Call to Action on Patient Navigation

• EduCare, Inc.

• FCCC/FCCCP Breast Care Navigator Orientation Manual- grant funded (ACS)

• Harold Freeman Patient Navigation Institute

• National Consortium of Breast Centers

• National Coalition of Oncology nurse Navigators

• Oncology Nursing Society Nurse Navigation SIG

• Patient Navigation Resource Guide - FCCC- grant funded PA (DOH)

• Pfizer Patient Navigation in Cancer Care

• State Navigation Networks

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Navigation Resources

• Academy of Oncology Nurse Navigators

• American Cancer Society

• Association of Community Cancer Centers: Call to Action on Patient Navigation

• EduCare, Inc.

• FCCC/FCCCP Breast Care Navigator Orientation Manual- grant funded (ACS)

• Harold Freeman Patient Navigation Institute

• National Consortium of Breast Centers

• National Coalition of Oncology nurse Navigators

• Oncology Nursing Society Nurse Navigation SIG

• Patient Navigation Resource Guide - FCCC- grant funded PA (DOH)

• Pfizer Patient Navigation in Cancer Care

• State Navigation Networks

Promoting Navigator Role

Accomplished through a phase in approach

• Phase 1 : Hospital Subcommittees

• Phase 2 : Medical staff meetings for surgery,

medical oncology

• Phase 3: Referring Physicians

• Phase 4: Roll out to Community

Marketing Program

Building physician relationships in the community

Nurturing trust and a shared vision to improve patient care

Creating top-of-mind awareness influencing physician referrals

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Taking Your Navigation Program to the

Next Level

• Role of Navigator in

Quality Improvement

Initiatives

• Selecting the Right

Metrics

• Creating an

Outcomes Data Base

Core Principles of Quality Care

• Evidenced –Based

• Patient Centered

• Systems Minded

Definition of Quality Improvement

• Quality or performance improvements are the

actions taken, processes implemented, or

services created to improve patient care

Cancer Program Standards. 2004 Revised Edition. Retrieved February 1,

2007 from www.facs.org/cancer/coc/cocprogramstandards.pdf .

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How Disease Management Yields Better

Quality

Patients get the right service at the right time by the right expert

Patient/family satisfaction

Evaluates timing of processes

Communication channels evaluated continuously

Outcomes measured

Preferred contracts with payors

The Role of the Nurse Coordinator/Navigator in

Quality Outcomes and Measurements

• Development in collaboration with multidisciplinary

team

• Quality Indicators

– Encompass the continuum of care

• Screening, diagnosis, treatment, research,

supportive care, follow-up/survivorship

– Timing of care

– Patient satisfaction

Selecting the Right Metrics

• Patient Focused

– Retention rate

– New patient volumes

– Patient Satisfaction

• Physician Focused

– Number of physician

referrals

– Physician satisfaction

• Clinical Quality

– Timeliness of care

– Number of clinical trial

participants

– Care in concordance

with guidelines

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Quality Improvement Standards

• Association of Community Cancer Centers

• American College of Surgeons

• American Society of Surgical Oncology

• American Society of Clinical Oncology

• American Society of Therapeutic Radiology Oncology

• National Quality Forum

• National Accreditation for Breast Center (NAPBC)

• National Comprehensive Cancer Network

• Oncology Nursing Society

• National Consortium of Breast Centers

• Oncology Roundtable

• C4QI-Comprehensive Cancer Center Consortium for Quality Improvement

C4QI Scoring Methodology

Criterion Definition Score =1 Score =5

Meaningfulness Measures potential

impact

Least impact on

quality

Highest impact on

quality

Ease of Collection Assess level data

collection difficulty

Most difficult to

collect

Easiest to collect

Resource Intensity Assess expense/

staff time

Greatest resource

intensity

Lowest resource

intensity

Literature Support Gauges degree

EBP

Least scientific

evidence

Most scientific

evidence

Breath Measures

applicability

Applicable to

lowest % of

patients

Applicable to

greatest % patients

2007 Advisory Board Company

Evaluation/Metrics Resources

• Advisory Board/Oncology Round Table: (www.advisory.com)

• American College of Surgeons (ACoS) (www.facs.org)

• American Society of Clinical Oncology (ASCO) (www.asco.org)

• Association of Community Cancer Centers (ACCC) (http://accc-cancer.org)

• National Comprehensive Cancer Network (NCCN) (www.nccn.org)

• National Quality Forum (NQF) (www.qualityforum.org)

• National Consortium of Breast Centers, Inc. (NCBC) (www.breastcare.org)

• Oncology Nursing Society (ONS) (www.ons.org)

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Creating an Outcomes

Data Base

• Program Dependent

• Technology

Dependent

• Resource Dependent

Navigation Software

• Builds the platform for tracking navigation

activities and evaluating quality

improvement needs

• Options:

– Home grown

– Commercial

PRESAGE

(Population Research Application Generation

Environment).

• A package of software tools used to quickly

develop customized web-based information

systems.

• Accessed via a web browser

• Uses HTTPS/SSL for all communications

between the browser and FCCC servers.

• All users must have an FCCC FoxNetID and are

assigned roles, on successful login, that limits

their access to application features and data.

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Enter your username

and password

(and click “Login)

This screen will not be used

Click on FCCC Breast Metrics on the

menu to the left

Creating an Outcomes

Data Base Breast Cancer

Time to diagnostic mammogram

Time to needle biopsy

Time to surgical biopsy

Time to surgery

Pathology turnaround time: surgery

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Tracking Success:

• IT staff created “homegrown” database

• Intake

• Assign Navigator

• Patient Summary

• Reminders/Task list (“ticklers”)

• Surgery tracking

• Surveillance letter

• Satisfaction surveys, results

Major

accomplishment

Virtua Health

Patient Summary

Commercial Software

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Commercial Software

Evaluation and Sustainability of

Navigator Role

• Outcome measures are carved out of nurse navigator responsibilities

– Clinical • Timing , Access and Throughput measures

• Patient Education

• Supportive Care Triaging

– Administrative • Program performance monitoring

• Patient satisfaction • Accruals to clinical trials

• Outreach activities to both physician referral base and the community

• Disease specific volume increases and patients that stay in system

• Navigator report to cancer program

• Dashboard on tracking volume and key functions

Navigator Report

Example Breast Program Goals for 2010 • Quality Improvement Initiatives

• Clinical outcomes – Breast Metrics being captured by institution (use of

dashboard for reporting)

– Equipment /Technology upgrades

• Process and access measures

– Increase number of physician referrals to program

• Community Outreach Activities

– Community Education and screening programs with potential for referrals to institution for diagnostics and treatment

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Navigator Report

• Breast Cancer Support Group Activities

• Professional Education

– Education programs for physician groups and nursing

regarding Breast Cancer and institution specific

program

• Grant Funding

– Seek grant funding to support development of patient

education materials and survivorship program

• Dashboard Metrics Report enclosed in report (institution

specific)

Return On Investment

Downstream Revenue

Screening Mammogram

Diagnostic Mammogram

Minimally Invasive

Biopsy

Surgical Biopsy

Breast Cancer Surgery

Reconstructive Surgery

Breast Cancer Treatment

Breast Cancer

Surveillance

Recurrence

Advisory Board Oncology

Roundtable 2007

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Navigation Program Success

PATIENT FOCUSED CARE

Measured by increased tumor-registry

volume and market share

Downstream revenue generated

Grant support generated

Addition of state-of-the-art technology

Increase in research that best fits patient

population

Patient, family and physician satisfaction

Fox Chase Cancer Center Partners Breast Care

Coordinators/Navigators

Goals and Objectives

• Educational and networking opportunities for navigators

• Develop standards of practice

• Provide mentoring opportunities

• Improve the care of patients by monitoring and measuring outcomes

• Disseminate information on program development with members, community agencies and administrators

• Develop grants to offset costs of program development

Fox Chase Cancer Center Partners

Breast Care Coordinators/Navigators

• Accomplishments: – 2003:6 members and 2010: 20 members

– Quarterly meetings for role development, education and mentoring opportunities

– 2006 Breast Conference with focus on breast program development and nurse navigator role

– 2009 Development of an orientation manual for nurse navigators – 2009-2010 Quality Improvement Metrics Protocol- now open at 10

sites

– Founding members of ONS Breast Care Special interest group

– Founding members of the ONS Nurse Navigation Special Interest Group

– Members participated in ONS project team for breast certification – Member participation ONS project team Nurse Sensitive Quality

Indicators for Breast Cancer.

– Members now speaking at national conferences and authoring articles on navigation.

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Fox Chase Cancer Center Partners

Breast Care Coordinators/Navigators

Fox Chase Cancer Center Partners

Breast Care Coordinators/Navigators

Lessons Learned

• Define goals of nurse navigator role and program

• Start S-L-O-W

• Keep it simple

• Establish Inclusive teams

• Determine baseline measures and target outcomes

• Utilize National Quality Measurements

Recognize the domino effect of your actions

Think ROI.

Capture downstream/ soft revenue.

• Network with other Oncology Nurses and Nurse Navigators

• Communicate – Communicate- Communicate

Remember the VOICE of your customer (PATIENT SATISFACTION)

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Alone we can do so little;

together we can do so much.

Author: Helen Keller

Elaine Sein RN, BSN, OCN, CBCN

Senior Project Manager

Coordinator Fox Chase Cancer

Center Partners Breast Care

Coordinators/Navigators

Fox Chase Cancer Center

Fox Chase Cancer Center Partners

Philadelphia, PA

Elaine.Sein@fccc.edu http://www.fccc.edu/healthProfessionals/consulting/more.html

215-728-3833