Cancer Collaboration: Incorporating a Multidisciplinary Team in Developing a Comprehensive Survivorship Navigation Program

November 2019 Vol 10, No 11
Jordan Henderson, BSN, RN, OCN, ONN-CG
Director of Program Development, AONN+
Katie Narvarte, LMSW, OSW-C, OPN-CG
Sarah Cannon Cancer Institute at Medical City Healthcare

Background: Research shows that multidisciplinary meetings/conferences reduce time to treatment and improve patient outcomes, but what about utilizing a multidisciplinary survivorship team? Through a literature review, we found that research supports this idea. Oncology social workers provide a number of vital supports to those coping with cancer—patients, of course, but also the local community and other healthcare workers. They also help patients cope with their cancer diagnosis all along the disease continuum, reduce anxiety, manage support groups, and assist the transition to survivorship or palliation. The oncology nurse navigator has a positive impact on both the patient and the cancer team by providing continuity of care and improved communication.

Objective: To illustrate the necessity of developing a survivorship navigation program with a multidisciplinary social worker/oncology nurse team through showcasing both interpersonal benefits and programmatic accomplishments of our team.

Methods: Our methods begin with a literature review of effectiveness of oncology nurse navigators and oncology social workers. We will present a case study example highlighting the partnership between nurse and social worker to meet a patient’s complex barriers. The social worker completed a distress/suicide assessment, and connected the patient to counseling resources for both distress and hoarding. The nurse completed a clinical assessment and gave resources for clinical barriers. The survivorship team also implemented a variety of programmatic developments. Clinically, the nurse navigator has developed clinical pathways for survivorship within our healthcare system, a wallet-sized card listing patient treatment history and current medications, and a clinical evidence base for survivorship navigation by implementing a survivorship needs assessment. Psychosocially, our social worker has developed behavioral health research, which has identified gaps in holistic care; a multidisciplinary committee to oversee psychosocial programmatic development in our division; a psychosocial conference/committee, which reviews difficult psychosocial cases in our healthcare system; and a professional quality-of-life survey to monitor the health of our navigation team. Together the survivorship team has increased digital programming, strengthened community partnerships, and engaged patient alumni in hospital-related programming.

Results: Our program accomplishments illustrate that creating a multidisciplinary oncology navigation team increases patients’ access to care and develops closer community connections, improved clinical care, and overall more holistic survivorship care than having a sole-discipline team.

Conclusion: As cancer patients and cancer healthcare professionals are fully aware, psychosocial issues and distress are common in the survivorship phase of a patient’s cancer journey. While registered nurses and oncology trained nurse navigators are equipped to assess and intervene on clinical matters such as late side-effect management, education on diagnosis and treatment overview, and signs and symptoms of recurrence, they are not trained mental health specialists like an oncology certified social worker. Oncology social workers are able to fill that psychosocial gap in cancer care that is often missed or not discussed in the survivorship phase. They also have the capacity to screen for distress and suicidal ideations in this vulnerable survivorship population, implement behavioral health research, and develop psychosocial programming. By partnering an oncology trained nurse navigator and oncology social worker, both clinical and psychosocial issues can be identified and addressed quickly and precisely as both are experts in their respective fields, ultimately providing the holistic comprehensive cancer care that is often sought after.

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Last modified: August 10, 2023

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