Novice Navigator: A Case Study on the Complexities of Care Coordination

May 2016 Vol 7, No 4
Kimberly Foster, MBA, BSN, RN
Marian E. Gilmore, RN, OCN
Pamela Goetz, BA, OPN-CG
Oncology Survivorship Navigator, Sibley Memorial Hospital, Johns Hopkins Medicine, Washington, DC
Barbara R. McHale, BS, RN, OCN, CBCN

The case study for this discussion highlights the complexities of care coordination when patients arrive unprepared physically or mentally for the recommended medical treatments as determined by guidelines. It also shows how navigators can assemble needed care team players to efficiently guide the patient through prehabilitation and preparation for medical treatment. Coordinating the collaboration of team members to establish and complete an individualized pathway of care for each patient is yet another way for navigators to demonstrate their value to the organization.

Case Scenario

During a routine follow-up with her gastroenterologist for hepatitis C management, SW, a 62-year-old widowed mother of a grown son, was found to have anemia. Further evaluation included a colonoscopy as well as an upper and lower endoscopy that revealed 2 polyps in the ascending colon. The pathology returned with a diagnosis of adenocarcinoma of the ascending colon. Staging studies included a chest, abdominal, and pelvic CT scan that showed no evidence of metastatic disease. SW’s carcinoembryonic antigen was within normal limits. Given her diagnosis and stage, the National Comprehensive Cancer Network guidelines recommendation was to commence with colectomy with en bloc removal of regional lymph nodes.

Lab results revealed that SW was in poor nutritional health and at risk for postoperative complications, healing issues, and mortality. Treatment for tonsillar cancer years ago resulted in dysphagia and xerostomia, contributing to her low nutritional status. A review of SW’s medical history identified unmanaged depression and obsessive compulsive disorder. In addition, the death of her husband in 2008 resulted in worsening depression, lack of motivation in performing activities of daily living, and social isolation. SW relied on Social Security Disability benefits for financial support and on her son for transportation, caregiving, and social contact.

The multidisciplinary gastrointestinal team, including the nurse navigator, dietitian, oncology social worker, medical oncologist, radiation oncologist, and surgeon, discussed SW at its weekly rounds. The initial goal was to get SW to surgery within 7 to 10 days per clinic protocol. However, the team members concluded that surgery would have to be postponed until interventions were employed to achieve a health status high enough to predispose a positive surgical outcome. The nurse navigator was instrumental in establishing and coordinating an appropriate plan of care that included prehabilitation to improve SW’s general function and independence, dietary counseling to address her nutritional status, and social work to support mental health and manage financial challenges.


  • Timeliness of care—measuring time from diagnosis to surgery
  • Psychosocial distress screening—documenting distress screening results and interventions to address problems
  • Identifying and addressing barriers to care

Physical (rehabilitation documentation)

  • Muscle strength
  • Functional status, greater strength and stamina
    • Timed Get Up and Go test
    • Stair climbing—ability to climb a flight of stairs
    • 6-minute walk test
  • Adherence to the prehab plan
  • Walking in/out of appointments with a walker

Nutritional (dietitian documentation)

  • Caloric intake
  • Protein intake
  • Appearance, including shinier hair, brighter skin, and eyes no longer sunken
  • Weight gain of 5 pounds

Psychosocial (social work documentation)

  • Coping skills
  • Interests outside of her home
  • Social contacts
  • Eye contact
  • Independence with scheduling appointments

Financial (social work documentation)

  • Wider support network, particularly for transportation
  • Access to patient assistance programs
  • Increased financial resources


  • Meals on Wheels:‎
  • CancerCare:, (800) 813-4673—free phone psychosocial counseling
  • Cancer Support Community: www.cancersupport—for psychosocial support and other programs
  • Local senior center: counseling for caregivers, and financial and transportation support
  • American Cancer Society referral program for financial support programs
  • State Department of Health and Human Services for transportation services
  • Church and/or community outreach support program for financial and food assistance
  • LIVESTRONG exercise program at a local YMCA for postsurgical rehabilitation care
  • Integrative care, such as Reiki, oncology massage, or acupuncture, within the cancer center or in the community
  • Genetic risk assessment, counseling, and testing at the cancer center


The nurse navigator plays a key role in helping patients access the care they require across the oncology specialty areas. Further, the navigator is key to assess and address patients’ challenges to receiving treatment. As in this case, to ensure the best possible outcomes, the primary treatment may at times be delayed while the navigator facilitates attention by supportive care specialists. In building collaboration among the care team members, coordinating execution of the plan, and working with patients to adhere to the plan, the navigator guides patients through the complicated steps in managing a cancer diagnosis, during active treatment, and in survivorship.

Additional Resources

Association of Community Cancer Centers. Cancer Program Guidelines.
Commission on Cancer. Cancer program standards: ensuring patient-centered care.
Garth AK, Newsome CM, Simmance N, et al. Nutritional status, nutrition practices and post-operative complications in patients with gastrointestinal cancer. J Hum Nutr Diet. 2010;23:393-401.
Isik O, Okkabaz N, Hammel J, et al. Preoperative functional health status may predict outcomes after elective colorectal surgery for malignancy. Surg Endosc. 2015;29:1051-1056.
Lohsiriwat V. The influence of preoperative nutritional status on the outcomes of an enhanced recovery after surgery (ERAS) programme for colorectal cancer surgery. Tech Coloproc. 2014;18:1075-1080.
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Colon Cancer. Version 2.2016.
Regenbogen SE, Veenstra CM, Hawley ST, et al. The personal financial burden of complications after colorectal cancer surgery. Cancer. 2014;120:3074-3081.
Tsimopoulou I, Pasquali S, Howard R, et al. Psychological prehabilitation before cancer surgery: a systematic review. Ann Surg Oncol. 2015;13:4117-4123.

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Last modified: June 10, 2018

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