A first-of-its-kind navigation acuity tool is entering a critical new phase of its development: an Institutional Review Board (IRB) quality initiative that will span 6 sites and include a minimum of 200 patients. The primary goal, say the leaders of the AONN+ National Oncology Navigation Acuity Initiative, is implementation and validation of the navigation acuity web-based tool.
“Our goal is to validate the web-based navigation acuity tool within the clinical environment across settings, models of navigation, and roles to effectively characterize the intensity of the patient navigation workload, aid in the allocation of resources, and measure the effectiveness of navigation on patient outcomes,” said Tricia Strusowski, RN, MS, co-chair of the initiative.
The development of the navigation acuity tool began in earnest 4.5 years ago at the 2018 AONN+ Annual Conference.
Over the past decade, the need for navigation services has grown exponentially, according to AONN+. Navigators, it says, have become an integral part of a patient’s multidisciplinary team of healthcare providers, identifying and addressing specific barriers to timely diagnosis and treatment as a strategy to improve outcomes.
The delivery of value, quality, and outcomes drives today’s healthcare. For cancer programs to receive full reimbursement from payers, they must demonstrate that patients receive high-value, high-quality care and show improved patient outcomes.
Adding to the challenge are healthcare workforce shortages, diminishing financial resources, and an aging patient population.
It has been shown in the literature that navigation services are an essential component of quality oncology services that can address many of the challenges of providing patient-centered, value-based healthcare.1 The Commission on Cancer, the National Accreditation Program for Breast Centers, and the new Enhancing Oncology Model, starting in July 2023, have required that navigation processes be in place to achieve accreditation or receive reimbursement. The expectation of these organizations is that effective navigation services will impact clinical outcomes, patient experience, and return on investment. Yet, significant programmatic challenges exist for organizations trying to adequately staff navigation programs and provide services to all cancer patients throughout the continuum of care.
In 2018, AONN+ identified a gap regarding the lack of an available navigation-specific acuity tool and recognized the opportunity to develop a validated evidence-based tool to measure the intensity of navigation services. As the organization quickly discovered, one of the problems inherent to the study of acuity is that the term is often used without specifying an exact meaning or referencing which attribute of acuity is being examined.2 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.
How We Arrived Here
AONN+ identified 35 evidence-based navigation metrics that it says demonstrate the value and sustainability of oncology navigation. They were presented in The Navigation Metrics Toolkit, which was developed and published in collaboration with the American Cancer Society. Its purpose was to provide navigators and administrators with “guidance on how to select, implement, report, and utilize [the metrics] as they engage in quality/performance improvement and strategic decision-making.”
Establishing the navigation metrics also sparked discussions among AONN+ members about the need to more effectively manage caseloads. At the AONN+ 2018 Annual Conference, a group of 15 thought leaders was asked to begin exploring how the organization could develop an acuity tool. The group included Ms Strusowski and Danelle Johnston, MSN, RN, OCN, HON-ONN-CG, who would become the co-chairs of the AONN+ National Oncology Navigation Acuity Initiative.
First, the group turned to the available literature to help it answer some fundamental questions, such as how was acuity being measured in healthcare? And could it apply a current standardized, validated, evidence-based acuity tool to oncology navigation? The project team has examined the known navigation acuity scales found in the literature to provide the basic framework for the development of a standardized acuity measurement incorporating navigation core competencies, national oncology standards, and the AONN+ navigation metrics.
The group convened again at the Unlocking Navigation Retreat in Dallas, TX, in March 2019.
Ms Johnston said, “Barriers to care are many and varied. They can be categorized in a variety of ways, such as physical barriers, psychosocial barriers, systemic barriers, financial barriers, educational barriers, etc. If the work of the navigator is to facilitate the resolution of these barriers, then a patient with more barriers or more challenging barriers would be assigned a higher acuity score along with incorporation of the patient’s reported psychosocial distress score.”
The group recognized that the navigation acuity tool would need to be applicable to a variety of settings, Ms Johnston said. The more complex it was, the less likely it would be widely adopted.
At the AONN+ 2019 Midyear Conference, the group asked several focus groups to name the various barriers to care and weight them based on their expertise and experience; 106 barriers were identified. At the onset of the initiative, AONN+ entered into a collaboration with the pharmaceutical company Astellas Pharma US, Inc. Astellas biostatisticians applied principal component analysis (a technique that improves the interpretability of large data sets with a high number of observations) to the named barriers and pared them down to 33, a more feasible amount for a tool where simplicity is a priority.
Using the National Comprehensive Cancer Network (NCCN) Distress Thermometer, the group divided the 33 barriers into the following categories: physical, practical, family, emotional, and spiritual.
The group then embarked on an expansive scoping review “[to] investigate and analyze articles related to components of the oncology acuity tool, including age, race, ethnicity, diagnosis and stage, barriers, and treatment per NCCN guidelines or other national standards published in English from January 1, 2018, to December 31, 2021.”
From more than 1750 screened articles, 49 were identified as being directly applicable to the cause and were used to develop 10 evidence-based case studies. These case studies were then used to test the navigation acuity tool.
A diverse field of more than 70 navigators was selected to test the acuity tool during the 2021 AONN+ Annual Conference, which was held virtually that November. They applied the tool to the case studies, which were meant to simulate working with real-life patients.
“We looked at the entire continuum of care, from prediagnosis screenings, treatment, survivorship, and end of life,” Ms Strusowski said. “The case studies resemble how a patient would be presented at a cancer tumor conference at different phases of the continuum.”
Methodical as their process appeared to be, the testers reported that the acuity scores were too low, and key barriers to care were being missed. These insights were valuable to reevaluate and strengthen the tool.
In an effort to infuse the project with fresh perspectives, Ms Strusowski and Ms Johnston last year formed a think tank comprising AONN+ Leadership Council representatives who are researchers, as well as additional researchers and members of the NCCN Distress Management Panel.
Ms Johnston said, “The power of the think tank provided confirmation of the foundational acuity work and also provided new insights to strengthen the comprehensiveness of the acuity tool.”
The next phase of this work is to conduct a national IRB quality initiative. The quality initiative was announced at the 2022 AONN+ Annual Conference. The letter of intent was opened in November to begin recruiting candidates for the IRB quality initiative, which it has titled “National Oncology Navigation Acuity Tool: Multisite Exploratory Quality Initiative.” The purpose of the initiative, Ms Johnston said, is to examine the implementation and validation of the navigation acuity web-based tool.
The Last Steps to Adoption
Assuming the IRB quality initiative yields the desired results, AONN+ plans to repeat it, this time on a much larger scale. Should that study also have positive results, the navigation acuity tool would likely begin to be put into practice shortly thereafter.
The current IRB quality initiative is expected to conclude in August. If that timeline holds, the second one would be conducted in 2024, which would put the tool’s official launch in early 2025, more than 6 years after AONN+ began exploring the concept.
“I know that seems a little daunting, but having the tool rigorously studied and validated is critical to its long-term implementation,” Ms Johnston said.
“There are reports that some institutions have abandoned their home-grown tools because they did not, in fact, measure patient acuity. Most tools were designed specifically for a particular practice or purpose. None of the existing tools have been validated, and most cannot easily be replicated in other facilities,” Ms Johnston and Ms Strusowski wrote in the scoping review. “To build sustainable navigation programs, we must develop a standardized acuity tool specifically for oncology navigation.”
Once AONN+’s navigation acuity tool is made available to the public, it will be free and accessible worldwide.
The expectation is that a validated navigation acuity tool will allow navigators and administrators to define the impact of navigation with a level of specificity that, until now, has been elusive. And with that knowledge, they will be better equipped to allocate navigators’ time and the resources available to them and their patients.
“I often spoke to navigators across the country who asked, ‘Danelle, how do I know my caseload? What’s the appropriate caseload for a navigator?’” Ms Johnston said. “You might hear a breast navigator navigating 200 patients and thoracic navigator navigating 400 patients. With that case volume, I always wondered whether we’re truly navigating the way we define navigation across the cancer continuum.”
At a time when navigation services are not reimbursable, drawing into question whether such a program is fiscally prudent, the navigation acuity tool will enable healthcare administrators and executives to track their navigation program’s metrics, including return on investment.
As Lillie D. Shockney, RN, BS, MAS, HON-ONN-CG, wrote in the JONS April 2022 issue, “Oncology care is driven by value, quality, and outcomes. Institutions demand that patients receive the trifecta of high-value care, high-quality care, and improved patient outcomes. Considering current healthcare workforce shortages, limited financial resources, and an aging population, delivering this trifecta can be challenging.”
AONN+ gratefully acknowledges Astellas Pharma US, Inc. for its support of the Oncology Navigation Acuity Initiative. When finalized, the acuity tool is expected to help oncology navigators characterize the intensity of patient navigation workload, aid in the allocation of resources, and measure the effectiveness of navigation on patient outcomes. This initiative may support and enhance oncology navigators’ effectiveness through patient-centric, evidence-based methods that may have the potential to decrease the overall cost of care.
- Strusowski T, Sein E, Johnston D, et al. Standardized, evidence-based oncology navigation metrics for all models: a powerful tool in assessing value and impact of navigation programs. Journal of Oncology Navigation & Survivorship. 2017;8(5):220-243.
- Brennan CW, Daly BJ. Patient acuity: a concept analysis. J Adv Nurs. 2009;65:1114-1126.