At a recent cancer committee meeting, the hospital’s chief oncology physician stated that the current flow process for patients attending all of their required appointment and tests was in need of serious repair. He had noticed that the percentage of missed appointments among newly diagnosed cancer patients was increasing and costing the hospital system money. The navigator can help to reduce the number of cancellations and no-shows through direct contact with patients and their families.
It is important for navigators to have an understanding of healthcare costs and identify barriers to care that can cause an increase of missed appointments. Karen, the senior nurse navigator, decided to conduct a patient needs assessment (PNA) to identify possible barriers that would prevent a newly diagnosed patient from attending her scheduled appointments. Karen developed a simple survey to be given, along with all the other important paperwork to fill out, to new patients at their first consult with the oncology physician.
The results from the PNA showed that for newly diagnosed cancer patients, the number 1 barrier to care was transportation. Karen decided to share the results of her survey with the rest of the cancer committee to develop a solution that would remedy this barrier to care and decrease the percentage of missed appointments.
The navigation team, along with the Oncology Social Work Department (SW), researched the cost involved with the hospital paying out of pocket to cover “free” transportation for newly diagnosed cancer patients requiring hospital assistance for transportation. The amount spent to cover the costs for providing public transportation to/from the cancer center was around $60,000 a year! The navigation team also figured the average monthly no-show rate and the cost for each appointment missed due to the patient not showing or canceling the appointment. The average no-show rate was 7 patients per month, and the hospital was losing roughly $1200 to $3000 per missed appointment, which equaled $8400 to $21,000 per month.
Karen researched safe alternatives to using public transportation (bus, commuter train, Council on Aging, Uber, etc) and was able to find a small, licensed and privately insured transport company. She contacted the company to obtain a price list and area covered. Once speaking with the owner, Karen was able to negotiate a reasonable price for transporting the cancer center’s patients, and the company was willing to provide service 24 hours a day. The driving service agreed to transport newly diagnosed patients to all of their appointments and tests, as well as provide transportation to other cancer patients in need.
The navigators and SW went back to the cancer committee to share their information about the company and the amount required to hire them and compared the cost against the amount the hospital was currently spending. After applying for and receiving a transportation grant from the hospital, the cancer committee decided to hire on the transportation company for 10 hours a week as a temporary trial to help determine if the needs of their cancer patients required more or less than 10 hours a week.
In looking to address the cancer center’s no-show rate, the navigation team utilized the standardized metric in regard to patient no-show rate, “number of navigated patients who do not complete a scheduled appointment per month.” This metric looks at patient experience in regard to addressing barriers to care, clinical outcomes in regard to treatment adherence by addressing barriers to care, and return on investment by promoting treatment adherence and enhancing downstream revenue by addressing the transportation barrier to care.
Metrics for Domain of Operations Management, Organizational Development, and Health Economics
As with any program, evidence-based metrics are essential to measuring success and sustainability. The Table shows the Academy of Oncology Nurse & Patient Navigators (AONN+) metrics created for the domain of Operations Management, Organizational Development, and Health Economics.
The identification of barriers, recognizing how barriers impact patient care, and providing interventions/resources to address barriers related to flow and processes of care are at the heart of operations management. As members of the multidisciplinary team, navigators are instrumental in assessing and recognizing the patient flow process and identifying efficient and effective ways to implement the flow process as well as determine changes. It is imperative for navigators to have a working knowledge of healthcare economics and an understanding of the barriers to care that can drive inefficiencies. By taking the time to observe the care process of patients, performing community needs assessments, and utilizing critical thinking and problem solving skills, navigators are able to identify barriers to care, ineffective processes, and communication gaps.
The authors remind all members of AONN+ to view the modules for the Professional Roles and Responsibilities domain on the website. The authors also encourage members of AONN+ to post items regarding the competencies and best practices for Professional Roles and Responsibilities on the AONN+ website discussion board.
The authors can be contacted as follows:
Cheryl Bellomo, MSN, RN, OCN, ONN-CG
Intermountain Southwest Cancer Center
Nicole DeLano, MSN, RN, ONN-CG
Tricia Strusowski, MS, RN