Barriers to Developing and Sustaining Effective Navigation Programs: What's Wrong?

May 2019 Vol 10, No 5

Categories:

Commentary

Navigation programs have been in place in many cancer centers for several decades; other centers are just starting to look at creating their own programs. What I have seen across the country is that cancer center leadership needs to meet the Commission on Cancer (CoC) standards, including Standard 3.1 on having a navigation program, to meet or maintain accreditation status. How institutions have gone about doing this, however, varies widely. And there are some institutions that have simply hired a person to be their navigator as a marketing tactic, realizing that patients like the concept of having a navigator to help them along their journey. There are numerous barriers to developing a navigation program; however, there are also very effective solutions to these barriers.

Conducting a Needs Assessment

The most common approach to creating a navigation program has been for an individual, usually in a leadership position at the cancer facility, to decide that it is necessary to first hire or appoint a navigator. It is not unusual to merely convert a position that currently exists and call that person the navigator. This individual could have been an appointment scheduler, a clinical oncology nurse in the outpatient clinic, or someone elsewhere who may be doing some components of navigation already. Sometimes it is a person whose job is about to be eliminated via a reduction in force and who may have no knowledge or skill set tied to navigation. There is a lack of direction regarding what this navigator is now supposed to be doing, and a lot of people will want to direct the navigator in the hope that some tasks they want personally done can now be given to this person. The barrier here is poor planning. A needs assessment is the first step in determining what your navigation program should be. This includes compiling statistics about the volume of cancer patients seen and treated at the institution, their stages, the location of their homes, what volume is underserved, how many are not receiving treatment in keeping with the current National Comprehensive Cancer Network treatment guidelines, and the barriers that patients experience that result in a delay in diagnosis and/or treatment or result in patients falling through the cracks and not ever getting their treatments completed. Gathering information from the community is also needed. Turn to public health information to learn how large the population is in your local catchment area as well as whether they are getting cancer screenings, and where and when. Identify what the barriers are to consumers coming in for examinations or treatment. We know transportation and financial barriers for patients are huge. Cultural barriers also exist. These are just statistics, however. There is a lot more to a needs assessment.

Evaluating Operations Management

Commonly a new navigator will be asked to be the Band-Aid on a broken system, although it isn’t expressed that way. Whenever a patient has a delay in care or falls through the cracks in the system, a navigator may have a role to play. This can be wasted time, however. For example, a breast cancer patient has her breast cancer surgery and now has to be seen by a medical oncologist to discuss systemic treatment. An appointment cannot be obtained for the patient until 4 weeks from her post-op appointment. The navigator might be calling around to see if she can persuade a medical oncologist to take this new patient as an “add-on” to their clinic schedule. She may spend an hour or more on the phone, or text­ing and waiting, trying to get a more timely appointment for this anxious patient. The team thinks it’s great that the navigator is doing this task too. The barrier here is failure to perform operations management before hiring a navigator. This task should be part of the needs assessment. Study how a patient currently moves through the system, beginning with a cancer screening, then on to diagnosis, consultations after diagnosis, treatment initiation, and the patient going through each phase of treatment in an efficient manner, finally reaching survivorship or end of life. We shouldn’t be using navigators as Band-Aids. They should handle more important tasks such as empowering patients with educational information so they can actively and confidently participate in the decision-making about their treatment options. Therefore, in this scenario, as an outcome of performing operations management, it would have been noted that there are long wait times for patients to be seen by a breast medical oncologist. The solution would be to arrange in advance the medical oncology appointment at the same time the surgery date is arranged and not wait until the patient is in the clinic for the post-op appointment. The surgery date may have been 2 weeks after the surgical consultation. The OR scheduler should send an alert to the medical oncology scheduling office that this patient will need an appointment 4 weeks from the date of her surgery, so it is proactively scheduled. This results in the patient being seen by the breast surgeon, her OR date arranged for 2 weeks from then, her post-op appointment booked for a week after the surgery (when final pathology is back), and the medical oncologist seeing the patient 1 week later. This is an efficient method of scheduling the patient for the consultations she needs, when she needs them, and provides everyone the pathology information and test results needed to conduct a comprehensive consultation that results in decisions about her next phase of treatment. And if the patient has positive nodes, the breast surgeon can still get the patient in for scans between her post-op appointment and the medical oncology appointment. Again, all the information needed—who, when, where, what, and why—are in place. The navigator didn’t need to do anything to get this patient properly and efficiently scheduled.

Evaluating operations management across the continuum of care is an essential component of a needs assessment. The deficiencies that are discovered should drive fixing the system and patient flow rather than leaving things as they are. We need to work smarter, not harder, to implement changes that streamline this patient flow process. Someone might say, “Well, it has always been this way,” which is not acceptable. Think creatively. Find the right person or persons with the authority to help implement a change.

Conducting Team Interviews

The next component of the needs assessment is interviewing the various members of the multidisciplinary team: (1) Determine their current understanding of what navigation is and what a navigator is supposed to be doing; (2) Discuss the intended goals of the navigation program and get buy-in to establish agreed-upon team goals; (3) Discuss the importance of the navigator not being a Band-Aid for a broken system; share the findings of the operations management efforts to date and the steps being taken to fix what is broken; (4) Ask each team member if he or she feels there are other broken system processes that warrant leadership’s attention; (5) Talk about the reporting structure for the navigator and how her performance as well as the performance of the navigation program will be measured; and (6) Develop a policy that requires someone who wants the navigator to take on additional responsibilities to meet with the navigator’s supervisor and provide insight into how this request is linked to the navigator’s already established roles and responsibilities. The barrier here is quite obvious: people decide that the navigator is someone to do the grunt work others don’t want to do anymore. Without a clear vision of what navigation is and in what ways it is needed, the team may fail to include the navigator as a respected member and instead assign inappropriate tasks (printing, fetching, faxing, on hold on the phone, delivering, waiting, etc).

The solution is to get input and buy-in from the team members, especially the physicians, other clinical nurses, and social workers. There must be a clear delineation of responsibilities so the navigator isn’t stepping on someone’s toes. It can be helpful to develop a matrix chart that defines the roles and responsibilities of each staff member, including each nurse in the clinic, the social worker assigned to this patient population, appointment scheduler, financial counselor, and anyone else who will routinely be interacting with the patients. You don’t want someone feeling threatened by the addition of a new staff member or the conversion of an established position into this new navigator position. Also, the reporting structure must make sense. I have seen some navigators reporting to financial leaders, nurse managers, physicians, social workers, performance improvement leadership, and other individuals. What this supervisor’s understanding of navigation is will impact how effectively the navigator performs. Any bias will likely be noticeable. However, having a clearly measurable and agreed-upon role is vital to the success of the program, no matter to whom a navigator reports.

How Many Navigators Are Needed?

Leadership will determine the number of navigators who will likely be needed, but implement them one at a time. This is a mistake. The barrier here is that people aren’t using statistics and severity of illness/intensity of service to determine what that magic number might be. This is the most common question administrators ask: “How many navigators do I need?” AONN+ is currently working on the development of an actual navigation acuity scoring system that will provide a more systematic way to determine how many navigators are needed based on the population a given institution is taking care of at any given time. In the meantime, once you have ensured that the navigators aren’t there to Band-Aid a broken system, speak with leadership from other well-established and successful navigation programs and compare their structure with yours.

For example, on average, a breast cancer nurse navigator can navigate about 300 to 350 breast cancer patients per year from the point of diagnosis to completion of treatment if only about 50 are underserved and 10% have late-stage disease. A navigator for patients with advanced pancreatic cancer or advanced GI cancers likely can manage 200 to 225 patients per year because their patients’ clinical and personal situations are far more complex. If you have a small number of cancer patients (300 or fewer) within your cancer center, then you may be looking at having just 1 navigator who will navigate all cancer patients in need of her expertise and services. There must also be coverage for this individual so navigation isn’t hit or miss. Another key element to be determined is whether you want a patient lay navigator or a nurse navigator. This will depend on the specific tasks and functions that need to be performed. You want the individual working to the highest level of her education/licensure. Your needs assessment will once again drive the answer to this question.

Developing Goals

The agreed-upon goals of the navigation program (note I did not say the navigator) should be driven by the outcome of the needs assessment. A navigation program is far more than having a navigator physically present. Nearly everyone who touches the patient in some manner has a component of navigation but may not even realize it. Appointment schedulers in particular have a key role in navigation because by their scheduling of tests, appointments, and other referrals, the patient is being shepherded to the next point along the cancer journey. A common barrier is the absence of developing goals and a plan to achieve these and measure success of accomplishing them within the time frame that was agreed upon. The solution is to document them, along with clear measurable elements that include why this is a goal for the program. Obtain an understanding and agreement among the team members so they share the vision and mission. What you don’t want is for a physician to say that a navigator is in the clinic so someone can put a check mark beside the CoC’s Standard 3.1 tied to having a navigation program. By the way, merely having someone you can refer to as a navigator will not enable you to meet this standard. Granted, there may still be a naysayer in the group who has his or her own bias or lack of belief that navigation is needed. This is someone you will want to be meeting with regularly to eventually win over. Success is a good way to do this. Getting his or her opinions can also help someone who feels insecure or has personal oncopolitical opinions to become more willing to play nice in the sandbox.

As time passes, more and more changes in the diagnosis and treatment of cancer patients will occur. New drug categories for better treatment. New surgical techniques for cancer. More outpatient care and treatment and less inpatient treatment taking place. These changes make it necessary to repeat the needs assessment every year or so looking at your local community needs, patients’ needs, and institution’s needs once again. Reassess how the patient is traveling along the diagnosis and treatment journey. Other changes that have occurred will need to be documented. Based on these new findings, changes once again will need to be made as to how navigation is performed, and improvements—again using operations management processes—will need to take place. Cancer care is never stagnant. In this case the barrier is failure to reassess the community needs, the institution’s needs, and the individual patient’s needs based on changes in diagnosis, treatment, community awareness, institutional structure, reimbursement of services, and market competition. The solution is to always remember that navigation is not a stagnant process. Although there are some basics, such as barrier assessments, patient education, psychosocial support, caregiver support, and coordination of care, there will be a need to acknowledge new barriers and remedies for these barriers, create new educational materials for patients, develop better methods for support, etc.

Finances

Finally, a topic that worries most institutions and has been identified as a primary barrier for an institution, facility, or even a rural oncology office to develop and implement a navigation program—money. Although some navigation positions are funded by grants and philanthropy, this is not a sustainable way to go about making sure that you have navigation in place and working for your patients long-term. This goes back to the goals of the program. One of the goals must be that the navigation program will be financially solvent and not need external funding to continue on into perpetuity. Outside funding may get the navigator position launched; however, there will be a need for metrics that demonstrate return on investment (ROI) to sustain the program. Using AONN+ metrics that measure the navigator’s impact on ROI, clinical outcomes, and patient satisfaction can be the solution you need here. Looking at your original statistics, you may have discovered that the team sees 350 newly diagnosed patients for consultations, but only 275 stayed to receive their treatments (surgery, and/or chemo, and/or radiation) with your team. A navigator who provides patient education and psychosocial support, is available to be the touchstone for patient questions, and serves as the patient advocate can greatly influence whether a patient leaves or stays. Comparing the number of retained patients last year to the number retained this year and converting that into dollars associated with the treatments they received can be an easy way to demonstrate ROI. It requires documentation and tracking on the part of the navigator, however. If there are additional reasons that are influencing why more patients are staying on for treatment, they too must be noted. You will want your data clean.

Concluding Thoughts

Something to consider, no matter where you are along your process for developing and implementing a navigation program or tweaking the one you have, is to communicate, communicate, communicate. Don’t assume that no noise means all is well. Keep the team informed. Meet regularly with your navigator(s) and request frank feedback on how things are going. Allowing something to fester is poor management. Conduct stewardship with those who may continue to be naysayers. Once a naysayer personally experiences a benefit from the navigation program, that person will become a supporter.

Developing a successful navigation program is complex, but it can and should be done. Take pride in what you build and the hundreds and hundreds of patients the navigation program supports. It is well worth your effort.

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Last modified: May 10, 2019

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