Background: Multidisciplinary care is recognized as a sign of quality cancer care according to several organizations, including the American Society of Clinical Oncology, the Institute of Medicine, the National Cancer Institute Community Cancer Centers Program (NCCCP), and the Oncology Roundtable. Navigators are identified as an effective strategy for promoting care coordination. The NCCCP developed an assessment tool to measure maturation and quality improvement of multidisciplinary care. This tool was used for measuring baseline and improvement in developing multidisciplinary clinics (MDCs) at Lehigh Valley Health Network (LVHN). Assessment areas associated with nurse navigators include case planning, treatment team integration, integration of care coordinators, clinical trials, and quality improvement. In 2011, LVHN implemented nurse navigator–coordinated MDCs utilizing the NCCCP Navigation Assessment Tool. Navigators provide individualized needs assessment and ancillary service referrals for all MDC patients, which promote quality care coordination (Friedman et al, 2014). Presently, we have disease-specific MDCs for patients with thoracic, gastrointestinal, skin/soft tissue, breast, and genitourinary cancers. The need was recognized for an MDC workgroup to identify and discuss operational challenges for MDCs and implement process improvements.
Objectives: Workgroup objectives include identifying MDC operational challenges, tracking referrals, volumes, clinical trial accrual, patient outmigration, and implementing and evaluating process improvements.
Methods: Monthly meetings are attended by navigators, a physician champion, cancer center leadership, oncology practice managers, and schedulers. An Excel spreadsheet is used to track MDC data. The navigators enter and report the data for each respective MDC, including number of referrals, total number of visits, and target referral volumes. Reasons for discrepancies between referral target volumes and actual visits are discussed. Trends in referral volumes help determine the need for and frequency of MDCs and optimal patient volumes. Operational challenges encountered within the MDCs are discussed, as are reasons for patient outmigration. Navigator referrals for patients with head and neck cancer are tracked in anticipation of the development of an MDC for this population.
Results: All MDCs have increased from a baseline score of Level 1 to Level 5 based on the NCCCP Navigation Assessment Tool for the areas associated with the navigator role. All MDC patients are screened for clinical trials, with an average annual accrual of 25 patients. Referrals increased from 379 in FY14 to 608 in FY17. Visits increased from 260 in FY14 to 412 in FY16. Operational process improvement included designation of physician backup to avoid cancellations due to lack of physician availability. Annual review of skin/soft tissue volume data has resulted in decreasing the number of appointment slots by 1 appointment per MDC. Improvement in timely scheduling of patients for post-MDC appointments has occurred through increased involvement of navigators in identifying and facilitating appointments. Head and neck cancer patient referrals support development of an MDC for this population, and planning is under way.
Conclusions: The navigator-coordinated MDC work-group provides a forum for process improvement. Utilizing the NCCCP Navigation Assessment Tool provides a baseline and pathway for MDC improvement. Outmigration data collected in FY17 will serve as a baseline as we focus on patient retention in FY18.