Oncology nurse navigators can advance population health in a variety of ways and create value in the process, said Sharon Gentry, RN, MSN, CBCN, CBEC, a nurse navigator at Novant Health Derrick L. Davis Cancer Center.
The drivers of population health are several. Pressure to increase revenue and decrease utilization is mounting, as is sustained pressure on operating and financial performance. In today’s market, payment mechanisms are emerging that focus on value, driving providers to take accountability for costs and quality.
To survive, nurse navigators must look outside their own institutions. “We’ve got to look outside the walls,” Ms Gentry said, emphasizing building partnerships throughout the healthcare system.
Population health is a mandate to promote health and prevent disease to create “an epidemic of health and wellness.”
It is guided by the triple aim of improving population health and improving the individual patient’s experience while at the same time controlling the inflation of per capita costs. “Any time you interfere with 1 of these 3 sections, you can negatively or positively change another section,” she said.
A campaign from the American Society of Clinical Oncology called Choosing Wisely can be used for guidance in the oncology setting, she said. Choosing Wisely provides metrics to improve population health. For example, one item on the Choosing Wisely list is to withhold PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis because of a lack of evidence that such imaging increases survival. This recommendation accomplishes multiple aims (lowers cost and possibly improves individual patient experience).
Early palliative care to control symptoms is another example. “If you get palliative care involved early, you decrease medical procedures,” said Ms Gentry. “You decrease psychological stress for the patient, but best yet, you decrease the caregiver burden.”
Oncology has many roles in population health, including community assessment, setting benchmarks, and setting goals that are specific and measurable, action-oriented, and time-bound.
“There’s need to navigate patients across the systems of care because they remain very disconnected,” she said. “We know [patient navigation] requires coordination.”
Population healthcare strategies depend on the patient population. Three distinct populations are the high-risk patients, rising-risk patients, and low-risk patients.
High-risk patients are the 5% of patients with complex diseases and comorbidities who consume most of the healthcare resources. These patients tend to have high-acuity tumors and may need help with coping. Patients with advanced disease also fall under this category. High-risk patients tend to require more one-on-one navigation. The key to managing the high-risk patient is to be proactive, said Ms Gentry.
Rising-risk patients constitute 15% to 35% of the patient population. They tend to have a multitude of risk factors (ie, diabetes, obesity, heart disease) that need managing that, if left unaddressed, would propel them into the high-risk category. Again, being proactive to manage rising-risk patients can prevent hospitalizations and lower the acuity of their disease. This may mean calling in a diabetes educator when needed.
Sixty percent to 80% will be low-risk patients in whom minor conditions are easily managed. It is in this group that your survivorship care plans become critical, said Ms Gentry. “You need to keep them healthy and make them healthier than they were before,” she said.
Successful models in population health share 5 characteristics:
- They are multidisciplinary, with each discipline having an opportunity to influence decisions about the patient’s care. Successful teams often include nurses and pharmacists with clinical and behavioral skills
- They are data driven to identify avoidable cost opportunities across episodes of care. A gap analysis can pinpoint barriers to care delivery across the continuum and isolate them for targeted intervention
- Successful models are resource efficient; employing diet, exercise, and smoking cessation counseling; preventive medications and vaccinations; among others
- They are patient centered. Patient navigators know critical transition points to reduce the rate of emergency department visits and the rate of hospital admissions
- They are longitudinal and therefore take advantage of clinical pathways and survivorship plans
Imperatives for Value
An increase in the number of cancer survivors has translated into a growth in costs. These rising costs exacerbate concerns about value. Ms Gentry reviewed the 6 imperatives for driving value in cancer care.
Ensure Adherence to Evidence-Based Guidelines
Patient navigation programs have had many successes in improving adherence to evidence-based guidelines. The weight of evidence from the Patient Navigation Research Program indicates that patient navigation can reduce the time from abnormal findings to diagnosis in breast, cervical, colorectal, and prostate cancers.
In 2015, the new standard from the American College of Surgeons Commission on Cancer (CoC) established patient navigation programs in all CoC-accredited facilities.
Navigation can increase clinical trial participation. When the University of Southern California Norris Comprehensive Cancer Center placed a navigator in the community, working with African American women, 86% of the women she engaged entered into a clinical trial; the other 14% did not qualify.
By using navigators, Ms Gentry’s institution led the nation in enrollment in the phase 3 B40 clinical trial to examine the impact of neoadjuvant chemotherapy in women who have undergone resection for relapsed breast cancer. “We also changed our process in 2013, and had a navigator sit down with a woman at diagnosis” to ensure that appropriate breast cancer patients are considered for neoadjuvant chemotherapy, she said.
Gap analysis can identify bottlenecks in the healthcare continuum. A navigation team working with the Intermountain – Southwest Cancer Center identified a 7-day increase in the time for a medical oncology appointment. They developed a navigation pathway for newly diagnosed breast cancer patients, and the interval between the medical oncologist referral and treatment initiation was reduced by 10 days.
“By the time the patient got to the medical oncologist, they had shaved off 24 minutes of that medical oncology visit,” she said. “This turned into more than $485,000 in 1 year.”
Henrico Doctors’ Hospital used a gap analysis when it discovered that 240 women left their system in 1 year after receiving a breast cancer diagnosis. “They moved a nurse navigator to the front to be with the patient at the time of an abnormal finding,” Ms Gentry said. “ In 1 year, they took that number down to 28.”
Reduce Unnecessary Emergency Department and Inpatient Admissions
Engaging patients in an oncology patient-centered medical home, which emphasizes coordination of care and avoidance of potential patient complications, can improve patient satisfaction while lowering costs. By empowering patients to report concerns before an emergency department or clinic visit is necessary, and using a nurse-based phone triage with symptom management algorithms, emergency department visits decreased by 50% despite an increase in patient volume.
At Cleveland Clinic Lakewood, Medicare patients who received navigation services experienced a 30-day readmission rate that was 4% lower than that seen in patients who did not receive navigation services. Self-pay patients experienced similar results. Of the 1531 patients who worked with the patient navigator, only 3.16% were readmitted. With a salary of $35,000, and a combined savings of $156,000 in the first 6 months, the navigator paid for her salary in less than 2 months.
Focus on Services That Increase Quality
Patient navigation is designed to reduce health disparities by addressing specific barriers to obtaining timely, quality healthcare. With navigation, the continuity of care improves and patients report higher satisfaction.
A one-time navigation for screening colonoscopy was estimated to be cost saving. The effects of patient navigation on mammography were to improve timely diagnostic resolution, decrease anxiety, and increase patient satisfaction among urban minority women with abnormal mammograms.
In patients with head and neck cancers, navigators have been found to improve continuity of care while also leading to better body image and better emotional quality of life.
Navigators have also been shown to decrease delays in chemotherapy and improve adherence to diagnostic services after an abnormality. Even in palliative care, navigators can address cancer rehabilitation needs.
Enhance Patient-Provider Communication
Patient navigator programs help to facilitate direct contact between the navigator and the patient’s medical team, as well as full disclosure of relevant training, experience, credentials, and potential conflicts of interest to patients they serve.
Hospitals in the Denver Health system employ navigators to help low-income Latinos access medical care. These navigators accompany patients on physician visits, remind them about upcoming appointments, and help patients explore options to pay for costly procedures. The no-show rate for screening colonoscopy declined from 57% to 17% after the health system hired navigators.
Engage Patients and Families in End-of-Life Planning
Many oncologists delay discussions with cancer patients about advance directives until chemotherapy options are exhausted. Navigators can help patients make informed decisions concerning the use of hospice care for advanced illness and eliminate the use of ineffective chemotherapy in advanced stages of disease. An increase in hospice use by Latinos in eastern and central Massachusetts was the result of expanding outreach to the Latino community through navigator-led programs.
Advance Cost Goals
In a cost-benefit analysis conducted at Intermountain – Southwest Cancer Center in Utah, medical oncologists experienced a 24-minute reduction in clinical visit time with a newly diagnosed breast cancer patient when the patient had received an educational visit with a nurse navigator, at a cost savings of $277,953 annually to the system. The educational intervention allowed the medical oncologist to see an additional clinic patient each day. The additional revenue of $207,360 plus the decrease in time had the potential to bring in $485,312 to the system annually.
In 2011, Novant Health Derrick L. Davis Cancer Center published a report showing that the annual revenue captured from breast nurse navigation decreasing outmigration was $436,000.