Improving Quality Care and Navigation Through Metrics and g gRisk Stratification

Jennifer R. Klemp, PhD, MPH, MAAssociate Professor of Medicine,

Division of Clinical Oncologyv s o o C c co ogyDirector, Cancer Survivorship

Co-Program Leader, Cancer Prevention and Survivorshipand Survivorship

Founder/CEO, Cancer Survivorship Training, INC

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Objectives

Discuss a national demonstration project toDiscuss a national demonstration project tostandardize navigation metrics and return on theinvestment, patient experience, and clinicaloutcomes. In addition, explore the role ofnavigation in the rapidly expanding field of cancergenetic and genomics.g g

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AONN N i l E id B dAONN+ National Evidence-Based Oncology Navigation MetricsDriven by the “Triple Aim” :1. Improve the patient experience of careof care2. Improve the health of populations 3. Reduce the per capita costs of

di lmedical care

National standards to adhere with value-based care are now propelling cancer programs to be accountable to measure:

1. Quality of care delivery 2. Cost

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Problem: Lack of Standard Metrics

There is a void in the literature regarding the keyThere is a void in the literature regarding the key areas that measure the success of navigation programs:

• Patient experience (PE)• Clinical outcomes (CO) • Business performance or return on investment (ROI)Business performance or return on investment (ROI)

The creation of standardized national metrics to ti i it l tmeasure programmatic success is vital to:

– Coordinating high-quality, team-based care– Demonstrating the sustainability of navigation programs g y g p g

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Recent review --

8/7/2019 5Funded by the Susan G. Komen Fdt.

Standardized Navigation MetricsStandardized Navigation Metrics Demonstration Project Results

After completion of an extensive literature review, the task force developed 35 standardized metrics that focused on:

AONN+ Navigation Knowledge DomainsCommunity Outreach and Preventionstandardized metrics that focused on:

• The AONN+ Certification Domains for navigation, which concentrated on return on investment, patient

Community Outreach and PreventionCoordination of Care/Care Transition

Patient Advocacy/Patient EmpowermentPsychosocial Support: Assessment & Services

experience, and clinical outcomes• Putting each metric through rigorous

criteria to ensure accuracy and

y ppSurvivorship/End of Life

Professional Roles & ResponsibilitiesOperations Management/Organizational 

soundnessThese are baseline metrics that all institutions can use, irrespective of the t t f th i i ti

Development/Healthcare Economics

Research/Quality/Performance Improvement

structure of their navigation programs.

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Core Competencies for Navigators:Core Competencies for Navigators: Metrics

• Operational Management: – Health care reform,– Utilization of resources

• Knowledge for Practice: – Demonstrate basic knowledge of health

system operations

Clinical Navigator Non-Licensed Patient Navigator

Utilization of resources– Work force shortages– Organizational development – Healthcare economics

• Quality and Performance Improvement:

• Practice-Based Learning and Improvement:

– Contribute to patient navigation program development, implementation and evaluation

– Use evaluation data (barriers to care, patient encounters, resource provision, population health

– Value/role of nursing research to validate practice and build evidenced based practices,

– Research, Quality metrics: (selection of metrics, develop measure, & create dashboards), Performance Improvement: (methodologies-PDSA, SMART Goals,

encounters, resource provision, population health disparities data and quality indicators) to collaboratively improve navigation process and participate in quality improvement.

– Incorporate feedback on performance to improve daily work.

– Continually identify, analyze and use new knowledge to mitigate barriers to carePDSA, SMART Goals,

– Role in identifying quality needs, areas of quality improvement, Role in improving the process

• Professional Roles and Responsibilities:

C iti l thi ki

knowledge to mitigate barriers to care.• Interpersonal and Communication

Skills– Communicate effectively with navigator

colleagues, health professionals and health related agencies to promote patient navigation services

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– Critical thinking– Problem solving– Tracking workloads

services

https://www.aonnonline.org/certification/nurse‐navigator‐certification https://www.aonnonline.org/certification/patient‐navigator‐certification

Value of NavigationValue of Navigation

8/7/2019 8https://aonnonline.org

Opportunities for Navigation in C G tiCancer Genetics

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American Society of Clinical Oncology (ASCO)American Society of Clinical Oncology (ASCO)

“Genetic testing can have implications for management of the cancer “Genetic testing can have implications for management of the cancer patients including: surgical treatment chemotherapy choices prognosis andpatients including: surgical treatment chemotherapy choices prognosis andpatients, including: surgical treatment, chemotherapy choices, prognosis and patients, including: surgical treatment, chemotherapy choices, prognosis and

risk for additional cancers. It is risk for additional cancers. It is therefore important to assess the risk of a therefore important to assess the risk of a hereditary syndrome at diagnosis, at decision points along the cancer hereditary syndrome at diagnosis, at decision points along the cancer

treatment trajectory and again when entering survivorship or surveillance.treatment trajectory and again when entering survivorship or surveillance.”” 11

1 http://www.asco.org/practice‐guidelines/practice‐management‐issues/genetics‐toolkit/genetic‐testing

What is in the Genetic Toolbox?

• Family History• Family History• Physical Assessment• Risk Assessment• Genetic Testing• Tumor Profiling• Targeted Therapy

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Review: Germline & Somatic TestingTesting

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1. National Cancer Institute. The Genetics of Cancer. https://www.cancer.gov/about-cancer/causes-prevention/genetics. Accessed December 5, 2018.

2. Martincorena I, et al. Science. 2015;349:1483-9. 3. Cancer.net. The Genetics of Cancer. https://www.cancer.net/navigating-cancercare/cancer-basics/genetics/genetics-cancer. Accessed

December 7, 2018.

Difference between Germline & Somatic Testing

Organizational Checklist: What is your process for

identifying patients forg

Germline Test

identifying patients for germline testing?

Is DNA sequencing done using tumor and/or normal match in

Genetic Counseling Genetic Counseling

and/or normal match in appropriate lab?

Somatic mutations that may have implications in the germline testing?

Somatic Test

the germline testing? Are results of germline

testing concordant? Should we send the

point mutation vs a

Genetic Tumor Boards

point mutation vs a panel to confirm germline mutation?

Was appropriate counseling provided for

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co se g p ov ded ogermline testing?

I i N i i iIntegrating Navigation into the Genetics Workflow

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Integration Into Practice

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© Cancer Resource Partners, LLC 2017

Establishing a Work Flow for Genetic TestingTesting

How will you triage patients for testing?• Time until surgery

Adequate Family History to capture unaffected individuals for testing?• Time until surgery

• Age at diagnosis• Cancer survivors• Affected vs Unaffected 

unaffected individuals for testing?• Is it documented?

Who is counseling patient/family on genetic testing?

How would you build genetic education, counseling, and testing into a clinic visit?

What resources for genetic How do you bill for genetic testing andWhat resources for genetic counseling and testing do you have for your patients?

How do you bill for genetic testing and what is insurance covering for genetic testing?

One Size Does Not Fit All

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Germline Testing is a Biomarker

G li t ti i f ti i f• Germline testing information informs…– cancer risk– cancer screeningg– cancer prevention– cancer treatment

Example: The overall mutation prevalence in unselected mBC patients is 8.4%, and the rate appears p , ppto be higher in triple‐negative breast cancer (12.4%)1

MBC patient may be a good candidate for a PARP inhibitorinhibitor.  

1 Frauenheilkd et al.Biomarkers in Patients with Metastatic Breast Cancer and the PRAEGNANT Study Network. 2015 Jan;75(1):41‐50.2 Riely GL. What, when, and how of biomarker testing in non‐small cell lung cancer. J Natl Compr Canc Netw. 2017;15(5S):686‐688.

National Comprehensive Cancer Network® (NCCN®)National Comprehensive Cancer Network (NCCN )Guidelines for Genetic Testing in Breast Cancer

NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) 1.2019 for BRCA‐Related Breast &/or Ovarian Cancer Syndrome/ y

1. NCCN Clinical Practice Guidelines in Oncology

NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Breast Cancer1

Guidelines in Oncology (NCCN Guidelines®) for Breast Cancer. Version 1.2019. http://www.nccn.org. Updated July 11, 2018.  . Accessed July 13, 2018. 2. NCCN Clinical Practice Guidelines in Oncology

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• For patients with HER2-negative tumors eligible for single-agent therapy, strongly consider germline BRCA 1/2 testing

• Genetic counseling if patient is high risk for hereditary breast cancer

Guidelines in Oncology (NCCN Guidelines®) for Genetic/Familial High‐Risk Assessment: Breast and Ovarian. Version 1.2018. http://www.nccn.org. Updated October 3, 2017. Accessed May 2, 2018. 

CC G id li V i 3 2019NCCN Guidelines Version 3.2019Generalized Summary & Triggers for Assessment

• Personal history of breast cancer at any age with >1 affected close family member  

• <50y/o (regardless of family history)• <60 y/o with TNBC• At diagnosis of Her‐2 negative metastatic disease• Personal history of ovarian, metastatic prostate, pancreatic• Ashkenazi Jewish Ancestry• Reflex testing after mutation found during molecular 

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g gprofiling

https://www.nccn.org/professionals/physician_gls/pdf/genetics_screening.pdf

Online Personal & Family History ToolTool

8/7/2019 22https://ww5.komen.org/BreastCancer/FamilyHistoryofBreastOvarianorProstateCancer.html

Genetics Across the Cancer Continuum

G i i i f i dj h d dGenomic testing can inform prognosis, adjuvant therapy, and targeted treatments

Germline testing can impact future cancer screening and prevention

1. Ford D, et al. Lancet 1994 2 Nielsen M et al

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2. Nielsen M, et al3. Baglietto L, et al. J Natl Cancer Inst 20104. Begg CB, et al. J Natl Cancer Inst 20055. Provenzale D, et al. 6. Pharoah PD, et al. Gastroenterology 2001 7. Tai YC, et al. J Natl Cancer Inst 2007

Shared Decision Making

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Efficacy of Point Of Service Testing – Breast Cancer ( POST BC)(ePOST-BC)• 5 one-hour Project ECHO sessions

– ~10-15 minutes of didactic– 40-45 minutes of case study discussion

surrounding genetic and genomic testing in practice

– implementation, testing, interpretation, management (treatment, screening, prevention)

• Team participation (MD, AAP, BSN/RN, Navigation, Registry, SW, Genetics, etc…)Registry, SW, Genetics, etc…)

• Practice incentive and quality improvement• CEU for participation• Provide cases and be active in case discussion

Funded by: ACCC/Pfizer

Thank You

Jennifer R. Klemp, PhD, MPH, MAjklemp@kumc.edu

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