One of the top questions posed to members of the leadership team at the Academy of Oncology Nurse & Patient Navigators (AONN+) is: “What is the caseload that oncology navigators should be carrying?” According to Danelle Johnston, MSN, RN, HON-ONN-CG, OCN, when the leadership team ultimately realized they did not have a good answer to that question, they identified the need for a navigation acuity tool.
AONN+, in collaboration with Astellas US, LLC, has been working for over a year to develop an acuity tool for oncology navigation. The AONN+ National Navigation Acuity Team, comprising 11 women, report that “when finalized, the acuity tool is expected to help oncology navigators characterize the intensity of the patient navigation workload, aid in the allocation of resources, and measure the effectiveness of navigation on patient outcomes. The acuity tool may also support and enhance the effectiveness of oncology navigators through patient-centric evidence-based methods that may have the potential to decrease the overall cost of care.”
At the AONN+ 10th Annual Navigation & Survivorship Conference, Ms Johnston, Chief Nursing Officer and Senior Director of Strategic Planning & Initiatives at The Lynx Group, along with 2 other members of the National Navigation Acuity Team—Cheryl Bellomo, MSN, RN, OCN, HON-ONN-CG, and Wendy Latash, PhD—explained the rationale behind the development of such a navigation acuity tool and brought attendees up to speed on the team’s progress.
First Steps: Developing the Tool
“There are only so many of us in our institutions, and we know that patients are going to keep coming,” said Ms Bellomo, an oncology nurse navigator at Intermountain Cancer Center at Cedar City Hospital. “So how do we balance that workload while also remembering that not all oncology patients are the same?”
The answer, she says, is with a standardized acuity tool that assesses, addresses, and measures patient barriers and distress, improves access to safe, effective, and efficient care, and helps patients adhere to their treatment (in turn, improving patient experience and clinical outcomes and increasing return on investment).
“This initial body of work began when we identified the need to define acuity in navigation. We know this is important work, and it has been reinforced by the work we’ve been doing with our metrics study,” said Ms Johnston. “We have identified that this is a significant need.”
The team first conducted an exhaustive literature review to provide an evidence base for the development of a navigation-specific patient acuity tool. They wanted to ensure the tool could be implemented across all navigation settings and roles and be easily incorporated into existing practices by a navigation team (without creating any additional burden). They agreed the tool should also support sustainability for various navigation programs, while also supporting the national guidelines and the AONN+ navigation metrics.
Defining Patient Acuity
Acuity was defined by Brennan and Daly1 in 2009 as “a measure of the severity of illness of a patient and the intensity of the nursing care that the patient requires.” According to Ms Bellomo, “severity” and “intensity” are the words to remember here.
The acuity team applied that definition to the field of navigation and ultimately defined oncology navigation acuity as a measure of patient distress, medical and psychosocial barriers (ie, financial toxicity, comorbidities, lack of family support), and the complexity of illness and social determinants that indicate the need for the intensity of subsequent navigator interventions across the care continuum. Though related, acuity is not productivity, she pointed out. Productivity refers to how often the activities within a workload occur, whereas acuity refers to the appropriate assignment of navigation needs based on patients’ complexity.
“‘Distress’ in this definition equates to the ‘intensity’ in Brennan and Daly’s definition, while ‘barriers’ correlate to those severity factors,” said Ms Bellomo. “These can all serve to indicate the complexity and the workload of the navigator.”
Barriers to care are defined as obstacles that prevent a patient with cancer from accessing care, services, resources, and/or support. Common barriers to cancer treatment include insurance and out-of-pocket payments, transportation issues, issues coping (ie, fear about cancer), care for dependents, assistance with activities of daily living, and time away from work. All of these factors can influence a patient’s acuity score.
“Typically, the more complex the barrier, the greater the distress for that patient and their family, and the greater the intensity of their navigation needs,” she said.
Addressing Social Determinants of Health
The team identified one particularly complex set of barriers that pose significant hurdles for many patients: social determinants of health. The CDC defines social determinants of health as “conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes.” Differences in health are particularly striking in communities with poor social health determinants, such as unstable housing, low income, unsafe neighborhoods, or substandard education.
According to the CDC, by applying what we know about social determinants of health, we can not only improve individual and population health but also advance health equity.
“This is something that absolutely needs to be addressed,” said Dr Latash, Director of Patient Experience and Outcomes at Astellas. “So how can navigators address these with their patients?”
The first way, she said, is through education. “One of the main roles of a navigator is to help educate patients —making sure they understand their condition as well as the treatment pathway they have to go through, while also making sure you’re meeting them where they are from an educational standpoint,” she noted.
Second, navigators should address social determinants of health through community health needs assessments by providing services like community outreach, prevention, screening, and navigation programs to communities that need them.
Digging Deeper into Distress
Distress is defined as a multifactorial, unpleasant emotional experience of a physical, psychological (cognitive, behavioral, emotional), social, and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment. Distress is real and measurable; the National Comprehensive Cancer Network Distress Thermometer is a validated, patient-reported, patient-driven tool used to measure its extent in patients with cancer.
“So, in developing the AONN+ Acuity Tool, it was imperative that we included a validated measurement of barriers and distress,” said Ms Bellomo. “Barriers can lead to distress, and while distress is connected to barriers, distress in itself is a barrier for our patients, resulting in increased complexity, intensity, and acuity.”
Screening for distress is important to patient-provider communication, she said. It increases psychosocial referrals, contributes to enhanced patient quality of life and satisfaction with medical care, and, importantly, helps to combat the stigma associated with psychiatric/psychosocial problems.
According to Dr Latash, the task force recommends an approach that collectively evaluates barriers and addresses distress to arrive at an acuity score. Proactively evaluating these barriers and stressors can improve outcomes by allowing for timely access to care, increasing patient satisfaction and adherence to treatment, engaging and empowering patients, and improving the quality of care as a whole, she said.
“By screening for distress, we are assessing their barriers to care,” added Ms Bellomo. “By addressing those barriers to care, we are addressing their distress. And by addressing the barriers and the distress, we are addressing the intensity, the complexity, and the acuity of that patient.”
Reference
- Brennan CW, Daly BJ. Patient acuity: a concept analysis. J Adv Nurs. 2009;65:1114-1126.
