Why Collaboration Is Necessary to Advance the Oncology Navigation Profession

The phenomenon of collaboration is not a new concept to the oncology navigation profession. It is an essential part of integrated care that is characterized by close teamwork and communication between multiple healthcare professionals. Oncology navigators work in health networks where healthcare providers and hospitals plan contracts to provide medical care to its members. This environment of interprofessional collaboration leads to development of new clinical practices based on roles and division of labor, and interorganizational collaboration denotes a new division of system structure for coordinated care. The bottom line is that the benefits of collaboration allow professionals to achieve more together than they can individually, serve larger groups of people, and grow on individual and organizational levels.

The Oncology Navigation Standards of Professional Practice, the knowledge and skills all professional navigators should possess to deliver high-quality, competent, and ethical services to people impacted by cancer, speak to both interprofessional and interorganizational collaboration.¹ Standard 5 – Interdisciplinary and Interorganizational Collaboration – calls for all navigators to view the patient as the center of the focus and to build through interprofessional teamwork and communication improved organizational culture and care processes to enhance the best interests of patients. Standard 17 – Operational Management – addresses the healthcare systems level where strategic priorities, structure, and outside legislation, policy, and other influences impact patient care.

If the web around the patient is oncology navigators involved with interprofessional and interorganizational collaboration, where is the web around the professional oncology navigator? The answer is interprofessional collaboration among professional organizations involved in oncology navigation. The Academy of Oncology Nurse & Patient Navigators (AONN+) is the professional home to advance the role of patient navigation in cancer care across the care continuum by providing a network for collaboration, leadership, and development of best practices for the improvement of patient access to care, evidence-based cancer treatment, and quality of life.² The organization has multiple collaborative initiatives within its walls to solidify professional practice…our interprofessional collaboration.

The Leadership Council, consisting of experts encompassing the field of navigation, meets regularly to set strategic priorities, organizational planning, and evaluation of programs. This allows outside representation of membership to keep the organization focused on its purpose. In other words, paid employees of the organization are not driving their self-interests.

Policy and Advocacy Committee utilizes legislative, regulatory, and policy advocacy to protect and promote the practice of oncology patient navigation to best serve individuals and families impacted by cancer. The Metrics Committee support value-based cancer care initiatives utilizing national evidence-based metrics in the areas of patient experience, clinical outcomes, and return on investment—all showing value for all types of patient navigators. All the committees involve members in the development and delivery of services around navigation, represent member opinion in decision-making, and offer the opportunity for problem-solving. The committees are an avenue for presenting multiple points of view in the field of oncology navigation.

Education via annual and midyear conferences brings oncology’s most influential navigators, social workers, physicians, and administrators together to think boldly and enact change. The education accelerates the pace of change in navigation by imparting knowledge and best practices. In turn, attendees can take this back to their own communities to enrich effective navigation and quality cancer care coordination.

Successful, accredited certification supported by the portfolio of navigation reflects the individual commitment to high standards in what oncology navigators do daily. It is not best practice to take a course, pass a test and be recognized as a navigator. It takes knowledge, experience, and analytical skills—patients and families deserve that level of preparation.

The AONN+ website is reflective of the organization’s collaborative commitment with other professional organizations as resources from the American Cancer Society (ACS), National Navigation Roundtable (NNRT), Association of Community Cancer Centers (ACCC), George Washington University, Cancer Support Community and others are on the site.

As we look at the collaborative commitment beyond education, the AONN+ leadership is involved outside of its wall to promote and sustain oncology patient navigation. This is the interorganizational collaboration for AONN+.

Throughout the years, the ACS has and continues to have a cooperative relationship. The Table reflects the creative work.

Table | History of AONN+ and ACS

Since 2017, AONN+ has been involved and welcomed to participate in the National Navigation Roundtable. AONN+ actively has leaders on the Steering Committee, as well as the Workforce Development, Policy, and Evidence-Based Practice groups. This is an ACS initiative supported with organizational leadership and expert staff, but the NNRT Steering Committee chair and vice chair as well as the various committee chairs are not ACS employees. This group serves as a catalyst to initiate work on key issues around patient navigation, as well as to disseminate best practices and to overall enhance the field of navigation. A main premise is that collective action among member organizations will be more successful in advancing the field than if they worked alone.³ Members bring to the table their information, share their work, and the group collectively identifies needs and opportunities and addresses gaps relating to navigation. “The Navigation Roundtable is really about a collective action approach to focusing on gaps in sustainability for patient navigation, no duplication, and doing the work around the continuum and principles of navigation with a health equity lens,” said Andi Dwyer, chair of the NNRT Steering Committee at the May 2023 AONN+ Midyear Conference.

Along with its member organizations that include academia, public health, advocacy and survivor groups, professional societies, industry, training, and state and federal agencies nonprofits, the NNRT aims to:

• Disseminate evidence that patient navigation reduces disparities and demonstrates effectiveness, value, and return on investment
• Standardize outcome metrics and demonstrate defined professional roles/responsibilities of the navigator
• Ensure a development path forward for professional and clinical/licensed navigators.
• Create a sustainable model for navigation funding

Dr Linda Fleischer, Vice Chair for the Steering Committee, also commented on the collaborative work at the 2023 AONN+ Midyear meeting. “We have the building blocks for navigation, we have professional standards, consensus metrics, training and certification programs.” She continued, “We’ve got the structures in place for sustainability. Now it’s about the implementation of these building blocks and looking at how we can achieve sustainability for navigation.”

And oncology patient navigation sustainability is also a goal in the AONN+ Leadership Council proposal from 2020. So how have the two used interorganizational collaboration to promote this common goal? It has been a multipronged approach with multiple presentations and publications among the groups with the basis around Patient Navigation Sustainability Assessment Tool Model (PNSAT).⁴ This model developed by Washington University in St. Louis measures the capacity of programs to sustain themselves beyond solely funding. It consists of internal and external domains that affect the likelihood that a program will be sustained. The NNRT, along with AONN+ Leadership Council, recognizes the importance of the domains and definitions listed in the Figure as vital to the sustainability of this profession, and both have voiced public support of this model and agreed to and work alongside other organizations to take it forward.

Figure⁵

One avenue to promote the model has been through the Association for Value-Based Cancer Care (AVBCC), an organization dedicated to the education and exchange of knowledge among all participants in the cancer care ecosystem responsible for patient care, to ensure optimal care is delivered to patients with cancer.⁶ The main mission is to provide a forum for payers, providers, and the entire oncology team to enter into conversations and evaluate value in terms of impact, quality, and cost on patient care and outcomes. Since 2021, NNRT and AONN+ have been in this arena copresenting to the many payers on “Navigation: A Critical Long-Term Investment in Patient Care,” “Leadership for Navigation: How Leadership Promotes Values of Navigation for Sustainability,” and interacting with private payers in 2023 on “A Case for Sustaining Navigation: the Economic Value and Metrics Behind Improving Outcomes and Quality of Life.”

Through cooperative planning with an aim to educate, and in the arena of sustainability with this model, presentations at the AONN+ conferences have taken place and will continue to be a topic. Also, to capture the practicing navigator voice, focus groups provided the opportunity for all types of navigators and managers to engage in a discussion to review the characteristics and activities, challenges, and opportunities that support the development and sustainability of patient navigation programs, including reimbursement, champions, and workflow processes. This vital information will lead to joint publications as well as planning to meet the gaps relating to navigation. “NNRT is kind of the coalition of navigation,” Dr Fleischer commented, “It’s way too much for any one organization, and AONN+ and other partners are really taking the lead on various aspects. We’re not doing all of this work alone.”

The NNRT made major strides toward its sustainability goal by publishing a supplement in the journal Cancer, titled, “A Decade Later: The State of Patient Navigation in Cancer Care.”⁷ AONN+ leaders and members supported this effort through best practice peer discussions, individual and group interviews, sharing treatment and outcome patient data, and even coauthoring on specific articles. “We have enough evidence to show that navigation is an effective intervention to help patients,” Dr Fleischer said. “And I think this supplement really highlights that.” However, she pointed out that it’s one thing to publish articles about the benefits of navigation, but it’s another to apply that evidence at work out in the field.

To answer that call, the NNRT also launched a virtual call-to-action series and used research from the Cancer supplement to create educational webinars. Through these, navigators could learn how to apply the research to their own work, and the series highlights critical pieces of the sustainability model. Utilizing the Oncology Navigation Standards in Professional Practice, Examples from the Field and Creating Workforce Development Path are archived on the NNRT website. The Evidence Panorama and Pursuing Patient Navigation Policy Landscape will be future topics. All the presentations examine barriers, standards, and sustainability of oncology patient navigation and are led by a diverse group of key oncology experts in the field. This is an example of interorganizational collaboration that speaks to NNRT’s aim for collective action.

In May 2023, The ACS Cancer Action Network’s 12th Annual National Forum on the Future of Health Care focused on how patient navigation improves access to care and healthcare outcomes. Speakers from NNRT, AONN+, and other champions of oncology patient navigation highlighted how patient navigation advances health equity, the return on investment patient navigation provides to the larger healthcare system, and how public policies can ensure access to patient navigation coverage and reimbursement for cancer. This gathering of over 500 people in person and virtually was a strong voice in Washington, DC for supporting the impact of oncology navigation on a range of patient-related outcomes across the cancer continuum.

The continued collegiate enrichment of the navigation profession, with a push for sustainable practices through interorganizational collaboration, has led to The Center for Medicare & Medicaid Services (CMS) to propose for Calendar Year 2024 Medicare Physician Fee Schedule coding changes to allow for reimbursement for patient navigation services only provided during active cancer treatment. It is a small start to support the funding part in the PNSAT model, but not to the point where it will support full-time positions. But it is an important first step laying the foundation for all types of patient navigation services to be sustainable, scalable, and broadly accessible in the future. The proposal calls for Principal Illness Navigation (PIN) services to include 60 minutes per calendar month, and that only 1 practitioner per beneficiary per calendar month can bill for PIN services, and that each additional 30 minutes per calendar month is then billed separately under a different billing code. NNRT, AONN+, and others signed the ACS CAN Consensus CMS Letter communally as comments were posted on the PIN provisions and others as a push to recognize navigation services being instrumental throughout a patient’s cancer journey from prevention through survivorship and not just active treatment. AONN+, AONN+ Policy and Advocacy Committee, as well as other organizations involved in patient navigation, sent in separate letters, but a strong interorganizational voice was submitted to CMS. As a result, on Nov 2, 2023, CMS issued a final rule that announced finalized policy changes for Medicare payments under the Physician Fee Schedule and other Medicare Part B issues, effective on or after January 1, 2024, that aligned with the Health and Human Services Social Determinants of Health Action Plan and help implement the Biden-Harris Cancer Moonshot goal of every American with cancer having access to covered patient navigation services. PIN services are to account for resources when clinicians involve certain types of healthcare support staff, such as community health workers, care navigators, and peer support specialists in furnishing medically necessary care.

AONN+ engages in interorganizational collaboration with its membership in the Commission on Cancer (CoC). AONN+ serves on the Accreditation Committee that writes, revises, and discusses the standards set by the CoC among professional organizations involved in oncology navigation. The navigation voice was instrumental in the revisions to the standards on survivorship, and it will be key to any new patient navigation standard in the future. The CoC Quality Improvement (QI) Committee, which improves the quality of cancer care through focused QI efforts on cancer care delivery, also uses the navigation expertise. Operations management, organizational development, healthcare economics, research, evidence-based practice, and quality/performance improvement are knowledge concepts that reflects current navigation practice and are supported by the Oncology Navigation Standards of Professional Practice.¹

A recent opportunity to represent the voices of the AONN+ membership came by an invitation to participate in an in-person meeting of the President’s Cancer Panel that took place in October. This was a first meeting of a series—Reducing Cancer Care Inequities: Leveraging Technology to Enhance Patient Navigation—and focused on opportunities for enhancing patient navigation. The panel is an advisory committee and relies on stakeholders such as AONN+, NNRT, ACS, National Cancer Institute, academia, community, state, and advocacy organizations to have authority to discuss recommendations, and then the findings are presented to the President of the United States.⁸ This collective group highlighted and educated the federal government representatives on the evolution of oncology patient navigation and its basis of defined roles, competencies, formal training, metrics, certification, and standards, as well as the current state of technology in the profession. “I looked across the room as professional colleagues commented on the collaborative work completed as well as the work being planned to take navigation forward. I visualized a thick web woven by the pooled comments as participants supported the interorganizational work. It was a true safety net for navigators working with patients and families daily.”

Collaboration is necessary to advance the profession of oncology navigation. This article is not inclusive of all the AONN+ interprofessional or valuable interorganizational collaboration that goes on daily. We will continue to build and grow interprofessional collaboration within the organization to provide the tools, resources, education, and connections so patient outcomes, quality of care, and cost of care delivery can be optimized by the expertise of oncology navigators working together. We will also continue and expand interorganizational collaboration among professional organizations involved in oncology navigation to take navigation forward with a focus on the 8 domains of sustainability in the future and other identified gaps.

References

1. Oncology Navigation Standards of Professional Practice. Journal of Oncology Navigation & Survivorship. 2022. www.jons-online.com/issues/2022/march-2022-vol-13-no-3/4399-oncology-navigation-standards-of-professional-practice
2. Academy of Oncology Nurse and Patient Navigators (AONN+). https://aonnonline.org/
3. National Navigation Roundtable. https://navigationroundtable.org/
4. Dwyer AJ, Staples ES, Harty NM, et al. What makes for successful patient navigation implementation in cancer prevention and screening programs using an evaluation and sustainability framework. Cancer. 2022. https://doi.org/10.1002/cncr.34058
5. Dwyer A, Weltzien E, Harty N. Patient Navigation Sustainability Assessment Tool for Preventive Cancer Screening. Colorado School of Public Health and University of Colorado Cancer Center, Aurora, CO. 2019.
6. Association for Value-Based Care. www.valuebasedcancer.com/avbcc/about
7. A Decade Later: The State Of Patient Navigation In Cancer Care. https://acsjournals.onlinelibrary.wiley.com/toc/10970142/2022/128/S13
8. President’s Cancer Panel. https://prescancerpanel.cancer.gov/about/