Background: Community Care Physicians (CCP) is a practice located in Upstate New York that comprises 430 providers and 30+ subspecialties.
In spring 2017, the Board of Directors approved the first oncology nurse navigator for their system. The primary goal of this position was to reduce referral leakage outside the practice network and increase internal resource utilization. Providing 1 point of contact through diagnostic workup for suspicious cancers and coordination among disciplines for a new cancer diagnosis were also identified as critical factors for the navigator role.
Objective: Creation of a workflow within a primary care network for oncology navigation referrals through EMR redesign, physician collaboration, and metric development was implemented in the first year of the program. Increase internal resource utilization in oncology services within community care practice.
Method: Implementing a navigation model at CCP was intended to address several factors: 1 point of contact for patients to access when dealing with a diagnosis of cancer, increasing internal utilization of services within the practice, and timely access to clinicians for care. When the program was initiated, there was a lack of data about how referrals were processed at the practice level and how decisions were made to refer patients internally or to other oncology services outside the practice system.
The initiative addressed both qualitative and quantitative methods of research.
Data were collected monthly to identify the number of referrals both in and out of the network. A patient satisfaction survey was developed to obtain patient input on navigator accessibility, ability to respond to questions, and relieve anxiety. Direct physician feedback was obtained through monthly visits to targeted practice sites.
Results: Referral order in EMR was created so 100% of oncology orders go directly to navigator work list. Development and creation of a system to monitor oncology referrals were built into EMR. Care management software was modified for use in tracking and reporting referrals monthly. A navigation brochure was developed and is now utilized by physicians for patient education on navigator role. Internal medical oncology referrals increased in 2018 versus 2017 by 32%. Relative value units (RVUs) for medical oncology increased in 2018 versus 2017 by 10%. RVUs for CCP radiation oncology increased in 2018 versus 2017 by 7.5%. Average number of navigator referrals per month has increased 60% since EMR referrals were initiated in 2018.
Conclusions: Primary care practitioners (PCPs) have initiated calls for the navigator to see patients jointly in the office at the time patient is given information about a new or suspicious diagnosis. The navigator joins PCP with next steps for consultations or workup. Annual face-to-face meetings with physicians reinforce the value of the navigator function and address continued opportunities.
Sixty percent of oncology referrals from PCPs to navigator are for breast cancer diagnosis. This has identified the need for a specific breast navigator role. Additional navigators will be requested in annual budget planning in fall 2019.
The workflow change of all referrals going to the navigator’s work list created a high volume of orders to address. A review of orders found that many were in the oncology category, but patients did not require navigation support. EMR modification was completed to specify order types that clerical staff could receive, primarily scheduling tasks. Improved workflow has facilitated internal referrals as noted in results section.
- Shockney LD (ed). Team-Based Oncology Care: The Pivotal Role of Oncology Navigation. Springer International Publishing AG; 2018.
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- Centers for Medicare & Medicaid Services. Oncology Care Model. https://innovation.cms.gov/initiatives/Oncology-Care.