Delineating Roles in a Hybrid Nurse and Patient Navigation Model Can Reduce Care Variation

Navigation Program Models

When considering how to best align an oncology navigation program for success, many things need to be considered, including, but not limited to, the institution’s goals for patient care, the patient population they service, other available resources at the institution, and the funding source.¹

Why use patient navigation over another intervention or strategy? It is essential to identify the need that the navigation program will serve in your existing service delivery model and consider what is preventing your patients from accessing or completing care. These considerations have been the focus of previous articles in this series.²

Oncology navigation models can include nurses, social workers, nonclinical patient navigators, financial navigators, or organization-based navigators (ie, American Cancer Society [ACS] navigators). The need that your navigation program is aiming to meet will determine if your navigation team should consist of just one type of navigator or a combination of different types of navigators.

Nurse Navigator: An oncology nurse navigator is a registered nurse with oncology knowledge and skill who can assist patients with overcoming barriers to care, provide clinical education to support shared decision-making, and promote advanced care planning and palliative care.³

Patient Navigator: A patient navigator is a trained professional or volunteer who helps patients to identify and remove healthcare system barriers and access care. They conduct evaluations and connect patients with the appropriate resources, including transportation and housing.^4,5

In this article, we will review and share our experience with a hybrid approach to oncology navigation, including a combination of these roles.

A Hybrid Approach to Oncology Navigation

If you are in the process of creating an oncology navigation program, are reevaluating your program’s structure, or have a well-established navigation program in need of reinvigoration, the balance between existing services and what your program will add is important to consider. In addition to navigators, there may be several people on a multidisciplinary team who “navigate” patients through the care continuum, such as social workers and financial counselors, ambulatory care and infusion center registered nurses, medical assistants, medical secretaries or practice representatives, and medical records clerks. Clarifying roles is critical to ensure the most effective use of resources and maximizing benefit to the patients.

Role delineation is a well-established challenge that many navigation programs face. This point was highlighted by the Oncology Nursing Society (ONS) through their role delineation study in 2016, which was used to update existing core competencies for nurse navigators. During this study, researchers conducted a systematic literature review, consulted with expert oncology nurse navigators, and surveyed working oncology nurse navigators about their experiences with existing core competencies and with navigation. ONS found that extensive updating was necessary to reflect the ways in which navigation functions.⁶

In a hybrid navigation model, it becomes increasingly more important to distinguish the difference between roles. In our program at the Sidney Kimmel Cancer Center (SKCC) at Jefferson Health, role delineation is temporal as well as practical. Our patient navigators telephone new patients before their first visit with an oncology provider. During this call, a barrier assessment is completed and background information about the patient’s oncologic history is gathered. The patient navigator also reviews the electronic chart for the presence of imaging, pathology, and other documentation necessary for the formulation of a treatment plan. The purpose of this proactive call is 2-fold: to maximize the value of the new patient oncology visit for both patient and provider, as well as to identify psychosocial, economic, or other personal barriers the patient may face to start and complete the necessary treatment. Patients with identified barriers are referred to the nurse navigator for clinical concerns as well as the appropriate supportive medicine team member. In addition, the ACS navigator assigned to SKCC provides education to patients regarding ACS programs and resources and facilitates transportation and ACS Hope Lodge accommodations.

The nurse navigator, on the other hand, usually contacts the patient after the treatment plan has been formulated and treatment has begun. Patients are referred to the nurse navigators through a variety of mechanisms. Patient navigators, care team members, and supportive medicine team members can all refer a patient to a nurse navigator. In addition, nurse navigators identify high-risk patients who have not been referred by running a report of SKCC oncology patients with recent emergency department visits. By opening these patients to navigation, the hope is that they will use the navigator as a resource for triage or clinical advice to avoid unnecessary emergency department visits. It is critical to clearly communicate the expectations for both clinical and nonclinical navigators to all stakeholders to increase understanding of both roles.

The benefits of a hybrid model are that each navigator role can focus on specific aspects that are causing a patient to require navigation. Wells and colleagues recognized that patient navigation could be provided by a team including both lay and professional navigators to address both barriers to treatment and support throughout treatment.⁷ Nurse navigators were found to provide significantly more treatment support than other types of navigators, and patient navigators provided significantly more care coordination and basic navigation than nurse navigators in the same program.⁷ This concept is reflected in the SKCC oncology navigation program in which nurse navigators work up to their full licensure and focus on clinical aspects of the patient’s care, and patient navigators focus on preparation for an initial oncology appointment through scheduling and record collection. Each nurse navigator is paired with a patient navigator to facilitate active communication regarding patient needs and allow for handoffs between the 2 roles to maintain delineation of roles.

Setting Priorities for Navigated Patients

Whether nonclinical or clinical, navigators must set priorities for navigated patients to ensure that the patients receive the help they need in a timely fashion. For nonclinical navigators, factors may include timing of appointments and the need for records or imaging prior to appointments. For nurse navigators, clinical factors influence priority setting, such as patient acuity and likely toxicities of a given treatment regimen. Other professional members of the care team, such as social workers, who provide care coordination, may focus on psychosocial barriers to treatment. Prioritization of patients in navigation is necessary to “ensure manageable caseloads and justify the need for future expansion of navigation services.”⁸

In addition to determining clinical priorities, navigation programs need to be concerned about clearly defining the roles of navigators from those of other members of the care team. For instance, at SKCC, patients come in contact with a variety of nurses; in just the oncology ambulatory care area there are infusion nurses, oncology nurses, and nurse practitioners from the departments of medical oncology, radiation, and surgery; and if reporting an urgent symptom to the clinic over the phone, a patient may have contact with the triage nurse. Add the nurse navigator, and a lack of clarity can easily lead to role confusion and duplication of efforts. One way we overcame the role confusion between the medical oncology ambulatory care nurses and the nurse navigators was by convening ongoing collaborative meetings with representatives from each team. The collective members identified areas in which the nurse navigator could comanage a patient with the ambulatory care nurse, for instance, performing regular outreach phone calls to patients on oral oncolytics to monitor adherence, side effects, and understanding.

The responsibilities of patient navigators can be similar to the responsibilities of other roles in the ambulatory clinic. In an effort to overcome possible duplication of effort between the patient navigators and medical rec­ords clerks, operations, medical records, and the navigation teams worked together to outline an algorithm of responsibility for obtaining new patient medical records and a communication pathway.

The Future State of Navigation

As research continues to advance cancer treatment, the number of survivors is growing, and the strain on the healthcare system is becoming greater. As a result, oncology care in the United States is being shaped by the need to reduce care variation. This has become the focus of demonstration programs, such as the Oncology Care Model (OCM) administered by the Center for Medicare & Medicaid Innovation (CMMI). At the heart of the OCM program and many other value-based models is care coordination, which is a key strategy to reduce care variation and achieve success in these models.⁹

Reducing care variation requires a lot of coordination, and the team at the center of those efforts is navigation. Navigators are continuously assessing, identifying, and monitoring high-risk patients who often contribute to the majority of the variation and cost. They are the hub of the care team, and a support system for patients throughout their care. Navigators facilitate communication with patients, serve as educators, and connect patients to the appropriate care team and resources to reduce barriers to efficient and effective care. Among the benefits that a clearly defined navigation program aligned with the goal of reducing care variation can provide are improved care coordination and symptom management, ultimately reducing costs.¹⁰ At the University of Alabama at Birmingham, emergency department visits declined 6% and hospitalizations 7.9% for navigated patients, resulting in a $781 saving per patient.¹¹ Another institution was able to reduce acute care utilization 12% by connecting patients with navigators. Reducing avoidable emergency department and hospital use is a critical element in achieving cancer care transformation by reducing care variation, and patient navigation is the key to success.¹⁰

The value of navigation has been well-recognized and integrated into requirements set by the Commission on Cancer and CMMI, but financial models to support navigation programs are uncertain.¹¹ Reducing care variation does not support an organization’s financial goals, but when a patient is supported by a navigator, they are much more likely to be retained within the system, which has financial benefits in a fee-for-service payment system. In bundled payment models, reducing care variation may be rewarded with an additional payment, but this benefit is program dependent.¹¹ It is a fine balance, especially because neither source of revenue is likely to be reliable enough to support the navigation infrastructure long-term.

As cancer care programs ready for future payment models that will likely include some level of risk, navigation will be critical to their success. Although payment structures do not currently value the benefits of navigation services entirely, it is a worthwhile investment as evidenced by the benefits described. Each of the articles in this series has provided guidance on the development of a navigation program and how to make it successful with clearly defined goals as well as delineated roles and responsibilities and a mechanism to evaluate the impact of the navigation program. If you are just beginning to develop a navigation program, have one in place that requires a reset, or have a well-established program, this article can serve as a checklist to help you prepare for the next phase of cancer care and reimbursement.

References

1. Patlak M, Trang C, Nass SJ. Establishing Effective Patient Navigation Programs in Oncology: Proceedings of a Workshop. Washington, DC: National Academies Press; 2018.
2. Ciccarelli H. Why are some navigation programs so successful and others never get off the ground? Journal of Oncology Navigation & Survivorship. 2019;10(2):55-56.
3. Oncology Nursing Society. 2017 Oncology Nurse Navigator Core Competencies. www.ons.org/sites/default/files/2017ONNcompetencies.pdf. Accessed November 1, 2019.
4. Willis A, Reed E, Pratt-Chapman M, et al. Development of a framework for patient navigation: delineating roles across navigator types. Journal of Oncology Navigation & Survivorship. 2013;4(6):20-26.
5. American Cancer Society. Patient Navigator Job Description. https://jobs.cancer.org/job/boston/patient-navigator/79/13611818. Accessed November 4, 2020.
6. Baileys K, McMullen L, Lubejko B, et al. Nurse navigator core competencies: an update to reflect the evolution of the role. Clin J Oncol Nurs. 2018;22:272-281.
7. Wells KJ, Valverde P, Ustjanauskas AE, et al. What are patient navigators doing, for whom, and where? A national survey evaluating the types of services provided by patient navigators. Patient Educ Counsel. 2018; 101:285-294.
8. Baldwin D, Jones M. Developing an acuity tool to optimize nurse navigation caseloads. Oncology Issues. 2018;33(2):17-25.
9. Csik VP. Value-Based Models Entering Specialties – the Oncology Care Model. Population Health Matters. Published Spring 2019. https://files.constantcontact.com/b26af31a201/39b88fe9-f65c-47f9-aac5-839228977614.pdf.
10. Advisory Board. Launch cancer care transformation. Three goals to improve quality and decrease costs. www.advisory.com/research/oncology-roundtable/multimedia/infographics/2017/launch-cancer-care-transformation. Accessed November 1, 2019.
11. Kline RM, Rocque GB, Rohan EA, et al. Patient navigation in cancer: the business case to support clinical needs. J Oncol Pract. 2019;15:585-590.