How Patient Navigation Drives Quality and Produces Profit ...
Transcript of How Patient Navigation Drives Quality and Produces Profit ...
How Patient Navigation Drives Quality and Produces Profit
in Health Care
Judy C. Kneece, RN OCNEduCare Inc., Charleston, SC
Learning Objectives
• Define patient navigation
• Describe the benefits of patient navigation on quality-of-care
Financial Disclosure
• Educare Inc., President
– Salary
• Nursenav Oncology, Shareholder
Quality:Organization's efficiency,
outcomes of care and level of patient satisfaction.
- Health Resources Administration
Quality is NEVERan Accident
Quality is ALWAYSthe Result of
Intelligent Planning
American College of Surgeons
• ACS recognized that Patient Navigation was an essential component of quality health care delivery
– 2008: NAPBC included Patient Navigation as an accreditation standard
– 2012: CoC added Patient Navigation as an accreditation standard
Patient Navigation DefinitionCommission on Cancer; C-Change
“Individualized assistance offered to patients, families and caregivers to help overcome healthcare systems barriers
And facilitate timely access to qualitymedical and psychosocial care
From pre-diagnosis through all phases of the cancer experience.”
How Patient Navigation Creates a Culture of
Qualityfor the Patient
is wrapped a patient.
CAUTION:
Handle with care.”
“Around each cancer
Dr. Henry P. Leis
The Patient
A Dedicated Team of Physicians Focus on Quality Care for a Patient’s Cancer
Patient NavigatorFocuses on a Patient’s
Quality of Care
Cancer Care Delivery
• 15% of cancer care is delivered in Comprehensive Cancer Centers with all physicians and support staff located on-site
– Ideal model for patients and physicians
• 85% of cancer care is delivered in Community Cancer Centers with physicians practicing independently at multiple sites that are separated by distance and time
– Creates barriers for patients in navigating their own care
– Creates problems for physicians in delivering collaborative care
Cancer Care Delivery
• Community Cancer Centers face a challenge in delivering the same patient-centered cancer care as Comprehensive Centers
– Challenge: Finding a cost-effective solution to close gaps in care delivery
Making the Case for
Patient Navigation
The
Patient
Experience
Diagnosis:
CANCER
ShockedEmotionally Overwhelmed
Forced to Proceed: No Time for Delay
Patient Faces an
UnknownHealth Care System
Totally Unprepared
Silo Care Delivery
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DiagnosticRadiology
PathologyPlastic Surgery
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Physicians Practice Independently, Separated by Time and Space
Dr. Fitzhugh MullanCancer Diagnosis 1982: Age 32
“I was experiencing medicine from the other end of the stethoscope, coming from a very personal perspective.Various specialists were doing diligent work, but kind of “smokestack” work, each in their own chimney.This was a graphic demonstration of what I think is a major ailment in our system, which causes gross inefficiency.”
Vital Signs: A Young Doctor’s Struggle With Cancer
Dr. Mullan’s writings created widespread
awareness and advocacy for reform
1986: Co-Founded the National Coalition for Cancer Survivorship (NCCS)
Identifying Gross Inefficiencies in Silo Care
Patient Challenges
Health Care Provider Challenges
Patient: Inefficiencies Experienced
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DiagnosticRadiology
PathologyPlastic Surgery
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Care Fragmented ─ Hard to Navigate on Own
Medical Language Difficult to Understand
Patient’s Emotions are at Highest Level
Barriers to Patient Care Not Addressed
Conflicting Advice Received from Physicians
Lengthy Wait -Time Between Appointments
Healthcare Team: Inefficiencies Experienced
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Time from Diagnosis to Treatment Increases
Communication Between Physicians is Difficult
Uncoordinated Care Decreases Patient SatisfactionTransitions of Care May Increase Error Potential
Potential for Duplication of Services Increases
Malpractice Potential Increases
Major Cause of Inefficiencies in Silo Care Delivery
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DiagnosticRadiology
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Gaps of Time Created During Delivery of Care
Examining the Gaps in Silo Care Delivery
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DiagnosticRadiology
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White Space:Transition Period Between Service Lines
Where There is NoPatient Ownership or Accountability
White Space in an OrganizationHarvard Business Review
“The large, but mostly unoccupied territory, in every organization where rules are vague, authority is fuzzy,budgets are nonexistent and strategy is unclear — and where, as a consequence, errors occur.”
During Transitions of Care, the Patient is Left to Find Her Own Way
Potential Hazards:Patient Out-Migration or Malpractice
How Can Community Cancer Centers Close Gaps in Care Delivery?
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DiagnosticRadiology
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The Answer
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DiagnosticRadiology
Pathology Plastic Surgery
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Patient NavigationFull Continuum of Care
Multidisciplinary Care ConferencesPhysicians Review All Patient Cases Weekly
Weekly Multidisciplinary ConferenceCloses White Space Gaps in Physician Communication
Facilitates Collaborative Decision Making
Navigator Serves as a Patient’s Personal GPS
Navigator Provides Emotional Support,
Education, Assessment, Triage,
and Advocacy Throughout the
Continuum of Care
Navigation Closes White Space Gaps During Transitions of Care With Patient Surveillance and Communication
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Multidisciplinary Care ConferencesPhysicians Review All Patient Cases Weekly
Create a VIRTUAL Cancer Center
Combined With
Patient NavigationFull Continuum of Care
How Patient Navigation
ImpactsPatient and Facility
QualityOutcomes
Patient Benefits
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DiagnosticRadiology
PathologyPlastic Surgery
SurgeryMedical
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Navigates Patient Through All Service Lines
Educates Patient and FamilySupports Patient and Family EmotionallyAddresses and Removes Barriers to Care
Teaches Self-Care Skills
Monitors Phycological and Physical Status
Serves as Patient Advocate to Care Team
PathologySurgery
Facility Benefits
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Decreases Time from Diagnosis to Treatment
Facilitates Communication Between Physicians
Decreases Hospital Readmissions
Decreases Duplication of Services
Decreases Inappropriate Access to Care
Manages Patient Transitions of Care
Patient NavigationHas Succeeded InClosing The Gaps
in Community Cancer Care Delivery
How Patient Navigation
Translates into Creating Facility Profit
Presenting the Evidence of How Patient Navigation
Increases Financial Profitability
How Navigation Increases Facility Financial Profitability
Reduces Patient Out-MigrationHenrico Doctors’ Hospital, Richmond, Virginia
Increases Patient SatisfactionFroedtert & The Medical College of Wisconsin Cancer Center
Reduces No-Show AppointmentsAccenture-MetroHealth, Cleveland, Ohio
# 1
Case Study
# 2
Case Study
# 3
Case Study
Patient Navigation Impact on Patient Satisfaction
Froedtert & The Medical College of Wisconsin Cancer Center
# 1
Case Study
Patient Satisfaction Study
3 Year Study
Patient Navigation
Impact on Satisfaction
Froedtert & The Medical College of Wisconsin Cancer Center
Patient Evaluations: Quality of Care
100908070605040 302010
0
2002 2003 2005
91%
57%
97%
70% IncreaseFroedtert & The Medical College of Wisconsin Cancer Center
Overall Score: Patient Satisfaction
Froedtert & The Medical College of Wisconsin Cancer Center
100908070605040 302010
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2002 2003 2005
High50s
Low30s
93%
210% Increase
“Research confirms a definite link between a patient’s perceptions
of quality to the profit margins for healthcare facilities.”
Press Ganey:
Return on Investment: Increasing Profitability by Improving Patient Satisfaction 2013
Patient Satisfaction
Translates into Financial Profit
Patient Navigator:
A Guardian of Patient Satisfaction
Throughout Full Continuum of Patient Care
How Patient Navigation Reduced Out-Migration
Henrico Doctors’ HospitalRichmond, Virginia
# 2
Case Study
Understanding the High Cost of
Patient Out-Migration
For Cancer Programs
Patient Out-Migration
Out-Migration is a Loss of
Downstream Revenue for a Cancer Program
and All Practicing Physicians
It is Not Just ONE Patient Leaving
Understanding Downstream Revenue
Breast Cancer
Screening Mammogram
Diagnostic Mammogram
Minimally Invasive Biopsy
Surgical Biopsy
Cancer SurgeryCancer Treatment
$ Radiology Charges$ Radiologist Fee
$ Radiology Charges$ Radiologist Fee
$ Radiology Charges$ Radiologist Fee$ Pathology Lab$ Pathologist Fee
$ Lab/EKG$ Operating Room$ Central Supply$ Pharmacy
$ Pathology Lab$ Pathologist Fee$ Surgeon Fee$ Radiology
(specimen)$ Lab/EKG$ Operating Room$ Central Supply$ Pharmacy
$ Pathology Lab$ Pathologist Fee$ Surgeon Fee$ Hospital Stay$ Radiology (specimen )
$ Nuclear Medicine$ Plastic Surgeon
(numerous surgical charges)
$ Medical Oncologist Fee$ Lab Fees$ Infusion Center$ Pharmacy Fees
$ Radiation Oncologist$ Radiation Therapy$ Physical Therapy$ Occupational Therapy$ Psychological Services
$ Genetic Evaluation Fees$ Complementary Therapies
Spin-Off Revenue
Cancer Surveillance
Downstream Revenue:
Breast Cancer
Breast Cancer Survivor Years of Surveillance
89%Survive
63%Survive
78%Survive
83%Survive
5 Years 20 Years15 Years10 Years
American Cancer Society 2016
63% Remain in Long-Term SurveillanceContinued Source of Downstream Revenue
20 Years
Spin-Off Revenue
Cancer Surveillance
$ Medical Oncologist Fee$ Lab Fees$ Radiology Imaging$ Radiologist Fees$ Nuclear Medicine$ Numerous Miscellaneous
Recurrence
$ Medical Oncologist Fee$ Lab Fees$ Radiology/Radiologist Fees$ Interventional Biopsy ?$ Nuclear Medicine ?$ Surgeon ?$ Operating Room ?$ Lab Fees ?$ Hospital Charges ?$ Pathology ?$ Pathologist Fees ?$ Infusion Center ?$ Pharmacy Fees ?$ Radiation Oncologist?$ Radiation Therapy? $ Physical Therapy ?$ Home Health ?$ Hospice ?
Screening Mammogram
Diagnostic Mammogram
Minimally Invasive Biopsy
Surgical Biopsy
Cancer SurgeryCancer Treatment
$ Radiology Charges$ Radiologist Fee
$ Radiology Charges$ Radiologist Fee
$ Radiology Charges$ Radiologist Fee$ Pathology Lab$ Pathologist Fee
$ Lab/EKG$ Operating Room$ Central Supply$ Pharmacy
$ Pathology Lab$ Pathologist Fee$ Surgeon Fee$ Radiology
(specimen)$ Lab/EKG$ Operating Room$ Central Supply$ Pharmacy
$ Pathology Lab$ Pathologist Fee$ Surgeon Fee$ Hospital Stay$ Radiology (specimen )
$ Nuclear Medicine$ Plastic Surgeon
(numerous surgical charges)
$ Medical Oncologist Fee$ Lab Fees$ Infusion Center$ Pharmacy Fees
$ Radiation Oncologist$ Radiation Therapy$ Physical Therapy$ Occupational Therapy$ Psychological Services
$ Genetic Evaluation Fees$ Complementary Therapies
Spin-Off Revenue
Cancer Surveillance
$ Medical Oncologist Fee$ Lab Fees$ Radiology Imaging$ Radiologist Fees$ Nuclear Medicine$ Numerous Miscellaneous
Recurrence
$ Medical Oncologist Fee$ Lab Fees$ Radiology/Radiologist Fees$ Interventional Biopsy ?$ Nuclear Medicine ?$ Surgeon ?$ Operating Room ?$ Lab Fees ?$ Hospital Charges ?$ Pathology ?$ Pathologist Fees ?$ Infusion Center ?$ Pharmacy Fees ?$ Radiation Oncologist?$ Radiation Therapy? $ Physical Therapy ?$ Home Health ?$ Hospice ?
Henrico Doctors’ Hospital
Out-Migration Study Results
Oncology Issues: Making The Case For the Nurse Navigator, 2011
Conducted 4-Year Study
Downstream Revenue
Analyzed Patient Out-Migration
After Mammography Screening Callbacks
240 Patients Exited Care Previous Year
Breast Center Navigator Hired
Interventions:• Contacted call-back patients within 24
hours • Explained why additional studies were
needed• Answered patient questions• Offered expedited appointment for
additional views/tests
Out-Migration 1 Year Later
1 Year Before Navigator240 Call-Back Patients Exited Care
1 Year After Navigator Hired28 Call-Back Patients Exited Care
88% Reduction in Out-Migration
28 Patients
240Patients 212 Patients
Retained
Henrico Doctors’ Hospital
Revenue* Gained: 212 Saved Patients
1 Year 212 Patients
315Imaging Procedures
$125,000.00
Diagnostic Imaging Procedures
*Quantified by data analysis of billable services of cancer and non-cancer patient
212Saved Out-Migration Patients
Oncology Issues: Making The Case For the Nurse Navigator, 2011
29*Positive Breast Cancers
Diagnosed
* 13.7 Percent
Revenue Gained: 212 Patients
29Positive
Breast Cancers
1 Year29 Diagnosed Positive Breast Cancers
Cancer and Non-Cancer Downstream Revenue
$225,000.00
Total Revenue Gained
1 Year
$225,000.00
$125,000.00 Imaging Revenue
$350,000.00Total Revenue
Cancer Revenue
4 Years Later: Our Migration
10 Patients or Less Exited
Screening Mammography Call-Backs
4 Years Later
240 Mammography Call-Back Patients Left
1 Year Before Navigator
10 Patients or Less Exited Yearly AfterNavigator Added
95.8% Reduction240 Yearly
< 10
Out-Migration Reduction After Nurse Navigator
Value of One Nurse Navigator
$225,000.00 X 4 Years = $ 900,000.00
$125,000.00 X 4 Years = $ 600,000.00
$1,500,000.004 Years
Imaging Revenue
4 Year Estimated Revenue*
Cancer Treatment
No-Show Appointments: Navigator Impact
Accenture-MetroHealthCleveland, Ohio
# 3
Case Study
Cost of No-Show Appointments Cancer Treatment
Accenture-MetroHealth; Cleveland, Ohio
$1,500 Per Appointment
Navigators Implementation: 6 Month Study
• Navigators reduced no-show and cancellation rates by 3%
• Reduction generated enough revenue in 3.5 months to pay annual salaries of 2 full-time Navigators
Accenture-MetroHealth; Cleveland, Ohio
No-Show Appointment Reductions: Financial Impact
End of 1st YearEach full-time
Navigator position generated
$150,000 revenue
Accenture-MetroHealth; Cleveland, Ohio
“Extrapolating these results, two FT navigators across 7 high-cost priority areas in
cancer care delivery could yield $2.1 million dollars a year.”
Accenture-MetroHealth; Cleveland, Ohio
Harvard Business Review: David Balderson, Kaveh Safavi, MD
Three EssentialKeys
For A Successful Patient Navigation
Program
#1Written
Clinical Navigation Guidelines
Navigation Program
Navigation Process
• Written navigation guidelines are essential• Center needs to develop own guidelines which
incorporate the needs of their stakeholders for every navigation process throughout the continuum of care– What needs to be done– When it needs to be done– Who needs to the perform task
Clinical Oncology Advisor: June 2017
“Clinical pathways are a critical structural element in the effort to reduce variability in healthcare and to make costsand outcomes more measurable, predictable and accountable. As value-based reimbursement models become more common, reliable care coordination and clinical pathways are essential to reducing cost and variability of oncology care and improving outcomes.”
Patient Navigation Guidelines
Screening Diagnostic Period Diagnosis Treatment
Sample of Navigation Process Needed for Breast Navigator
Patient Navigation Guidelines
Sample of Navigation Process Needed
Survivorship Surveillance
• Clinical navigation guideline development can start with examples provided by:
– NICE (NIH Health and Care Excellence)
– NCCN (National Comprehensive Caner Network)
– Blue Cross/Blue Shield Michigan (shown to improve clinical outcomes while increasing profit)
Navigation Clinical Pathway Development
• Necessary to customize your clinical pathways with your stakeholder’s input and expressed needs– Builds consensus and compliance
• Written clinical pathways should be shared with all stakeholders after development– Clearly outlines and defines expectations for providers– Ensures quality standards are understood
Navigation Clinical Pathway Development
#2Evaluation of Every Navigation Process
for Effectiveness and Efficiency
Navigation Program
Navigation Process Evaluation
• Essential to evaluate every process for:– Right Job
• Done at the Right Time• Performed using the most cost-
effective and outcome-efficientmethod
Evaluate Every Process For Efficiency
• Is this task necessary?– Is it a required standard-of-care or
law?
• Look at every piece of paper– Can it be eliminated or can the process
computerized?
• Is an education process repeated?– Yes: Requires written instructions or
patient teaching materials
Evaluate Every Process
• Is the right skill-level employee performing the task?
Navigator: Common Financial Drain
• Nurse Navigator becomes high-paid clerical employee – Spends large amount of time entering
data and performing non-nursing tasks
• For program to be profitable, Nurse Navigators must spend time facilitating nursing tasks
Can a Navigator Task Be Delegated?
Med Tech NurseSocial Worker
$ $$$$ $$
Clerical
• To be financially profitable, care needs to be delivered by a team of professionals, not just a Nurse Navigator
Effective Navigation Program
Clerical Med Tech NurseSocial Work
#3Provide Navigator Tools Needed for
Efficiency
Navigation Program
Most Common Navigator Challenge
“How Can I Get It All Done?”• Barriers to Care• Patient Navigation• Distress Assessment• Survivorship Care Plan
Finding Leverage
Navigators Need Tools to Leverage Efficiency
Key: Electronic Medical Records
Cancer Navigation Software
2006
Cancer Navigation Software
• Decreases time constraints required for data entry and data retrieval
• Provides work-flow and navigation processes– Serves as a “tutor” for successful
implementation of facility clinical paths
Cancer Navigation Software
• Calendar linked to patient’s record creates reminders and task lists – Decreases potential for patient task to
be overlooked
Cancer Navigation Software
• Patient portal allows secure communication between patient and navigator
Cancer Navigation Software
• Records data from all interventions: – Barriers Assessment – Distress Assessment – Referrals and outcomes for identified
barriers/distress– Educational materials provided to patient– Ancillary/community support referrals
Cancer Navigation Software
• Automatically builds Treatment Summary for Survivorship Care Plan required at end of treatment– Reduces hours of time manually compiling
treatment summary and history into a task of only minutes
– Decreases errors from manual extraction of data from patient record to compile Survivorship Treatment Summary
Administration Benefits
• Provides complete administrative overview of all navigation processes
• Captures key data elements for benchmarking
• Captures downstream revenue
• Captures patient demographics
Administration Benefits
• Tracks referrals in and out of a program
• Tracks designated quality measures
• Generates patient progress reports for physicians
Navigation Software Selection
• Select software that navigates all cancers and is not cancer-specific
• Web-based software preferred – Access from anywhere, allows
Navigators to be more productive– Automatic software updates
• Ability to compile Survivorship Treatment Summary
Patient Navigation: The New Pathway to
Deliver Quality Care and Ensure
Financial Profitability
American Cancer Society
“Economic evaluation of the patient navigator program suggests that such programs can be a cost-effective use of limited resources and yield a net financial benefit for providers.”
Cancer: 2012
Navigation Financial BenefitsJAMA Oncology: June 2017
“Costs among the navigated patients declined a mean of $781.29 more per patient per quarter than among the non-navigated patients, which could be estimated as a $475,024 reduction in cost annually for a navigator managing 152 patients throughout the year. For a navigator with an annual salary investment of $48,448 (salary and fringe benefits), we estimated a return on investment of 1:10.”
Resource Use and Medicare Costs During Lay Navigation for Geriatric Patients With Cancer: JAMA Oncology
Medicare Recognizes Value of Navigation
• April 2017: Centers for Medicare and Medicaid Services (CMS.gov) announced oncology providers’ financial incentives– Oncology Care Model (OCM) offers oncology providers
reimbursement according to performance and outcomes
– Oncology providers must commit to:• Offer patients enhanced services including care
coordination and patient navigation • Follow national treatment guidelines CMS April 2017: Press Release
Medicare Recognizes: Financial Value of Patient Navigation that Follows
Clinical Pathways on Increasing
Patient Outcomes While Decreasing Cost
Creating a Culture of Patient Quality
Patient Navigation has proven value directly linked to closing inefficiency gaps in healthcare delivery while:
Increasing Patient Satisfaction
Creating and Maintaining Quality Outcomes
Producing Financial Profits
Truth Stages
All truth passes through three stages: • First, it is ridiculed• Second, it is violently opposed• Third, it is accepted as being
self-evident
Patient Navigation Now Has a History of
Self-Evidence Arthur Schopenhauer
Patient Navigation Has Proven to Benefit Both:
Patients and Health care Facilities
Creating a Culture of Quality
While Ensuring Financial Benefits
REQUIRESPatient Navigation
Thank You!
Judy Kneece