When patient navigation became a hot topic, a Commission on Cancer (CoC) accreditation standard, or a marketing campaign, some assumed it was trendy. Rename an existing role and say you have navigation. Not so simple. Patient navigation is not a trendy new title—it is a highly skilled and important role that influences patient outcomes and patient experience. It takes many steps to create a successful program. One of the most essential barriers it tackles is the fragmentation between multiple providers, often within the same system.
Whether the role is clinical or nonclinical, adding a new role to address the silos and gaps is daunting without support from leadership. Uncovering gaps in services or areas where outcomes could be improved will need administrative buy-in to adopt proposed solutions or a shift in existing workflow. A patient navigator seeks to connect all the parts, pieces, and players. If the issues are systemic or policy-based, then the solutions will involve departments that may not be in oncology’s vertical.
Another of the key factors in its success is a multidisciplinary and well-integrated approach. Gathering a team to create goals for the program will ease the path and identify champions early in the role.
A specific job description (while evolving) is needed to maximize impact.
When creating the role, a comprehensive gap analysis is needed to identify the target patient population.
What is the mission of your patient navigation program? Although it will impact many facets of patient care, which one is your target? Do your head and neck patients have higher utilization of the emergency department? Do your esophageal patients have higher readmission rates than average? Is there a population that is being diagnosed at a later stage than your CoC counterparts? Are you losing patients to a competitor because of long wait times for consults? Are patients missing appointments because they don’t have transportation? Closely analyze your “pain points”—and identify a specific issue that could be improved.
Once you have a quality improvement goal or measure in mind, consider what resources are needed. If you are seeking to reduce hospitalizations, carefully analyze what issues are leading to hospitalization; is it dehydration due to vomiting or diarrhea? Is outpatient infusion available? Is there consistent follow-up posttreatment to assess for risk? Are patients utilizing medications to minimize side effects? Do patients know what symptoms should trigger a call to their provider?
What resources are available to the patient navigator? Are there available seats in the treatment room? Who needs to place the order? Does the emergency department “flag” the oncology practice when someone seeks treatment?
What databases/electronic medical records or other records will they need access to? Who are they working with? Who are their go-to people? Who is the champion or door opener? Without investing time in the basics, your navigator may run into barriers or challenges to effectiveness.
Choose a target patient population that for some reason or another is challenging. Is it patients without a social support network? Is it those for whom English is not their primary language? Are there too many missed appointments in radiation oncology?
As an example, let’s consider this experience in which the patient had support from a nonclinical navigator:
An elderly patient who speaks only Haitian Creole was scheduled to start his daily radiation treatment. Daily transportation was arranged through the Senior Shuttle, a free service that has scheduled pickup times from home and the hospital. The patient navigator set up a daily 10:00-10:30 am pickup from home and a 12:30 pm return ride from the hospital.
The patient completed the first day of treatment with no issues. The next day he was dropped off but did not get his radiation treatment. The patient navigator soon discovered that he had gone to the pharmacy to pick up his chemotherapy pills and had taken the Senior Shuttle back home instead of going to radiation. The patient navigator coordinated a Lyft ride to pick him up to bring him back to the hospital because daily treatment was important. It was challenging relaying the driver/vehicle information through a phone interpreter, but the patient eventually found the car and was able to come back for treatment.
On the third day, he was dropped off around 10:30 am and called the Senior Shuttle around 10:40 am requesting a ride home. The Senior Shuttle contacted the patient navigator, knowing there had not been enough time for him to have been treated. Despite not being driven home, the radiation department reported to the patient navigator that he was not there. Eventually, the patient was located sitting in the radiation waiting room. Despite previous instructions, he had not followed procedures upon arrival to check in.
The patient navigator coordinated several calls back and forth between the Senior Shuttle, radiation department, the patient, and his daughter. She reviewed with the patient and his daughter how to use the transportation service and how to check in for radiation treatment. She worked with the shuttle service, which had become wary of working with this patient due to the recent difficulties. The patient eventually understood the process and completed treatment. Without the one-on-one care and assistance, it is unlikely that he would have properly followed through with his treatment.
You can all imagine many other endings to this patient story.
For the first year, what is a reasonable goal? How will you identify which patients to refer to the patient navigator? Who does the initial screening or identification of barriers? What if the patient has barriers in multiple areas? Without a workflow and multidisciplinary team, you will have scope creep or nurses spending time on hold seeking rides.
Operationalize: Clinical Protocol/Administrative Workflow
Every individual should be working to the top of their license, and procedure should be standardized. A process map is essential, and as growing pains occur, you must reevaluate. Is a registered nurse needed to gather scans and pathology for tumor boards? Does an MD have to order every procedure? Everyone should be working to the top of their skill sets, and everyone should learn to ask: what is best for the patient?
Providers, patients, and all patient-facing staff should be able to articulate at least the basics of what navigation does for patient experience and outcomes.
What internal and external resources are needed? Is there anyone in the community addressing the barriers you are tackling? Can you partner or build relationships with the American Cancer Society, Meals on Wheels, or a Food Pantry? What resources exist to help with medication assistance or free care? How do the programs your systems have work? Are they accessible?
Can communication be improved between primary care and oncology? Are you notified when lab results are ready, or do you need to remind yourself to check? What tasks are operationalized to be efficient, and which are vulnerable to human error or oversight?
Once you feel you have made an impact, how can you demonstrate it? Are you documenting your actions, and are others reviewing your notes? If no one is aware what the patient navigator is contributing to the care coordination and experience, you are easily eliminated.
What data points can you collect that demonstrate the added value? Counting encounters demonstrates that you are busy—not that you add value. Adopt the Academy of Oncology Nurse & Patient Navigators metrics, or have a quality improvement project that looks at 1 pain point. Did you reduce time between initial diagnosis and initiation of treatment? Did no-shows or cancellations get reduced? Identify the impact you can point to.
With demonstrated success, you know which components need to be included to replicate it in another disease site or patient population.
Tell your successes—have patient exemplars collected throughout the year. Share how a simple intervention prevented complex problems. Tell how patients with complex problems were navigated through the care continuum without unnecessary tests, visits, or with few complications.
The benefits of patient navigation are countless. In this resource-strapped and increasingly challenging financial climate, it is vital that each full-time employee be able to justify their employment. Support from leadership is imperative for creation, continuation, and expansion of patient navigation.