Category IV: Original Research on Navigation Programs

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• E1. A Community-Centered Approach to Early Breast Cancer Treatment Through Patient Navigation
• E2. Development of a Tool for Assessing Patient Barriers to Care
• E3. Utilizing a Nurse Navigator to Improve the Outcomes of Patients with Amyloidosis

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E1 A Community-Centered Approach to Early Breast Cancer Treatment Through Patient Navigation

Mary Bowen, RN, MSN, OCN, CBCN

St. Peter’s Health Partners, Albany, NY

Background: One in 8 women will develop breast cancer in her lifetime, and survival disparities exist according to race and ethnic background. In New York State, approximately 14,500 women are diagnosed with breast cancer annually. During the past 20 years, cancer detection rates have increased and mortality rates have decreased as a result of improved screening methods, accessibility to care, awareness of cancer risk factors, and effective treatments. In spite of these facts, there is still a portion of the population that has difficulty accessing care because of a lack of health insurance coverage, and other socioeconomic barriers. It is considered best practice to use breast cancer navigators to reduce disparities in cancer care, particularly for underrepresented populations. The St. Peter’s Health Partners breast cancer navigation program in Albany, NY, provides patient navigation through the breast cancer continuum of care.

Objectives: To describe the breast cancer navigation program and the role of nurse navigators, which includes (1) reducing delays in access to the full spectrum of cancer care services, with an emphasis on diagnosis and treatment completion and in reducing the number of patients lost to follow-up; (2) effecting positive change by providing emotional support, information, problem solving, and expertise in logistic management that allows patients to focus on their personal health and their family’s well-being, leading to an increased quality of life throughout treatment; (3) guiding women through the breast cancer care continuum; and (4) to increase their service satisfaction by reducing frustrating tasks for patients and their significant others, especially when a potential or actual new breast cancer diagnosis has emerged.

Methods: Once a diagnosis has been made, the navigator generally waits 1 week before contacting a patient to allow for the news to come from the referring provider. The optimal timeliness rate was determined to be 90% completion of recommended staging and follow-up consultations within 1 month of diagnosis. Prenavigation figures were compared with postnavigation figures through monthly audits. To measure adherence, the number of patients initiating navigation services was compared with the number of patients remaining on service through to the established program end point. Guiding women through the breast cancer care continuum, the navigator reduced barriers to care by linking patients to contacts within the community for services such as financial assistance, transportation, education, and support groups, while being mindful of cultural influences. By obtaining feedback from patients, navigators increased their service satisfaction by reducing frustrating tasks for patients and their significant others, especially during breast cancer diagnosis. Each patient completing the navigation program received a satisfaction survey containing 10 simple questions about factors influenced by navigation. Patient satisfaction was measured for January and February 2015. The survey consisted of 10 questions using a Likert scale with areas for the responder to write a narrative and their name if they so desire. The survey was mailed with a stamped, addressed return envelope.

Results: All women included in the breast cancer navigation program who needed a biopsy were scheduled for the procedure to be completed within 1 week, unless it was delayed by patient preference. Of the 220 total women with a cancer diagnosis in the 4-month study period (2 months pre- and 2 months postnavigation), only 3 did not have a surgical referral and visit within 2 weeks of diagnosis after initiating the navigation program. The average wait time for initial medical oncology visits for all patients studied from November 2014 to February 2015 was 3 to 4 weeks. Since the navigator personally consulted with the nurse manager and the new patient coordinator in the oncology office, the average wait time was reduced to 2 to 3 weeks. A total of 61 patients newly diagnosed with breast cancer in January and February 2015 chose to remain in the St. Peter’s Health Partners system and were included in the breast cancer nurse navigation program. This number represents 55% of the total number of women diagnosed with breast cancer during that time period. None were lost to follow-up and none discontinued treatment prematurely. Only 28% of newly diagnosed patients stayed within our system before nurse navigation. Since initiating the navigation program, 80% of patients have been given referrals to community agencies for support groups, transportation assistance, wigs and prosthetics, cleaning services, massage and physical therapy, nutritionists, and genetic counselors, and 1 patient was ecstatic after a referral to a nurse who performs micropigmentation on reconstructed breast areola, nipples, and scars. Participation in a free breast and cervical cancer screening program for the uninsured yielded 5 women with abnormal clinical breast exams that were performed by the navigator who were referred for more in-depth imaging; 1 woman had a negative biopsy. A 50% patient satisfaction survey return rate was considered to be optimal; a 75% return rate has been accomplished. All categories overwhelmingly scored a high of 10 points for each question equating to a response of “strongly agree” with some scoring 5 points for the response of “neutral.” No negative comments or scores of zero have been received thus far.

Conclusion: Patient navigation has been used as a tool to help reduce disparities in cancer-related care for the underrepresented and can be considered best practice. The population identified for inclusion in this breast cancer navigation program resides in St. Peter’s Health Partners’ “mission zip codes” in the county of Albany, NY. These zip codes have a high percentage of black and Hispanic women, low-income neighborhoods, and a greater than usual concentration of uneducated people. These residents are less likely to have adequate health insurance coverage, they have less access to care and screenings, and they tend to be diagnosed at more advanced stages. The breast cancer nurse navigation project in the imaging area is in the infancy stage of what is projected to become an expanded program.

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E2 Development of a Tool for Assessing Patient Barriers to Care
Serena Phillips RN, MPH¹; Mandi Pratt-Chapman, MA¹; Anne Willis, MA²; Elizabeth Hatcher, RN, BSN, NP¹; Adrienne Thomas, LGSW<sup>3

1</sup>George Washington University Cancer Institute, Washington, DC; ²Patient-Centered Programs, George Washington University Cancer Institute, Washington, DC; ³Patient Navigation and Community Outreach, George Washington University Cancer Institute, Washington, DC

Background: New patient care standards have quickly spurred the implementation of many patient navigation programs. Because of this rapid growth, however, key research is needed to help guide the field as patient navigators become critical members of the healthcare team. For example, patient navigation programs are customized to a particular institution or organization and its patient population, and there is currently a lack of standardization in terms of what patient navigators do and how they perform their role. As a result, it is difficult to compare patient navigation programs across a number of variables.

Objectives: To create a tool that could be widely used to assess patient barriers to care by creating more standardization; a way of capturing common measures relevant to a wide variety of stakeholders is needed that will lead to consistency in how barriers are assessed.

Methods: We started with a literature review to identify patient barriers to care. We identified 59 articles for review. Based on the literature and on our experience with patient navigation programs, we drafted a barriers assessment tool. We then held 3 focus groups with patient navigators to gather their feedback about the tool.

Results: Major themes from the focus groups will be presented after the completion of the analysis, along with the final barriers assessment tool.

Conclusion: With a standardized measurement tool, individual programs will be able to better describe patients’ needs, which will help institutions meet the new Commission on Cancer standards. Moreover, the tool will make it possible to gather data through a large-scale study to better understand in a systematic way what patient navigators do and how they help patients. The creation of a barriers assessment tool is needed to guide research and practice to ensure that patient navigators are equipped to reduce barriers to care for patients with cancer.

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  E3 Utilizing a Nurse Navigator to Improve the Outcomes of Patients with Amyloidosis
Margaret Rummel, MHA, OCN, NE-BC¹; Colleen H. Erb, MSN, CRNP, ACNP-BC, AOCNP¹; Adam D. Cohen, MD²; Brenden M. Weiss, MD<sup>2

1</sup>Abramson Cancer Center, Penn Medicine, Philadelphia, PA; ²Hospital of the University of Pennsylvania, Philadelphia

Background: In 2013, the multiple myeloma team at the Abramson Cancer Center, Penn Medicine, embarked on the development of a multidisciplinary amyloidosis center. Amyloidosis is a rare and complex plasma cell disorder that causes organ damage from protein deposits and affects patients’ quality of life. Patients with this disease are treated similarly to patients with multiple myeloma. Because of the complexity of the disease, it was decided to have the hematology oncology nurse navigator serve as the point of contact for all patients entering the program.

Objectives: To provide easy access for patients with amyloidosis to the program and to coordinate the multiple providers needed to provide seamless care for this rare disease. In addition, it was important for patients to receive education regarding this disease because there is a large knowledge gap related to amyloid disease in the medical community.

Methods: Over a 6-month period, the amyloid team met to review and discuss the plan for the program. Key providers in hematology, cardiology, renal, and other specialties who had an interest in the disease were identified and recruited into the program. It was identified that all patients would be triaged by the nurse navigator and would have their records reviewed to get the patients seen in a timely manner. Patient education packets were developed and reviewed with patients at their initial appointment. Weekly conference calls were initiated to discuss all new patients and to provide updates on existing patients. Research was done regarding community resources, and the program partnered with the Amyloidosis Support Community to become a partner in the regional educational programs that are conducted twice annually.

Results: The nurse navigator’s involvement has improved the coordination of care for patients with amyloidosis. Patients are now able to see 3 or more providers in the same day as a result of the navigator’s role in coordinating care with providers, diagnostic testing, and appointments. The navigator also ensures that patients who live far away are connected with community providers and are being followed by their primary providers in the Penn Medicine amyloid program. Since its inception, the program has seen more than 100 new patients from many geographic areas. In partnership with the Amyloidosis Support Community, attendance at the regional program has tripled.

Conclusion: The nurse navigator played a significant role in improving access to care for patients with amyloid disease. In addition to the improved coordination of care for this population, there has also been a significant increase in patient volume, and Penn Medicine has become a major amyloidosis referral center. The program continues to grow and the navigator’s involvement remains instrumental.

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