When the landscape of healthcare shifted drastically about a decade ago, navigation had no choice but to evolve along with it. Initially driven by the Triple Aim of healthcare (focused on improving the patient experience of care, improving the health of populations, and reducing the per capita costs of medical care), national standards to adhere to value-based care propelled cancer programs to be accountable for measuring the quality-of-care delivery, as well as the cost.
“Suddenly, everything needed to be measured,” said Sharon Gentry, MSN, RN, HON-ONN-CG, AOCN, CBCN, program director at the Academy of Oncology Nurse & Patient Navigators (AONN+). “And we had to shift along with this sudden demand from insurance companies and government-based agencies.”
According to Ms Gentry, who spoke at the 2022 AONN+ Midyear Conference in Austin, TX, the navigation profession indeed kept up with the changing healthcare environment, leading to the development of navigation core competencies, as well as the only nationally recognized certifications for Oncology Nurse Navigator–Certified Generalist (ONN-CG) and Oncology Patient Navigator–Certified Generalist (OPN-CG).
Ms Gentry noted that these certifications are offered through the AONN+ Foundation for Learning, not through AONN+. “You don’t have to be a member of AONN+ to take the certification, and as a member of AONN+, you don’t have to take the certification. So there’s a firewall there,” she said. “Certification is a personal choice, but I’m excited to know that a lot of you have stepped up for that personal choice, because the research has shown that certification absolutely does make a difference.”
The changing landscape also led to the recognition that navigators need networking opportunities in the cities and towns in which they actually work. This spurred the development of AONN+ Local Navigator Networks—with 30 currently operating in the United States (and counting)—as well as Nurse Navigator and Care Coordinator Communities. The Journal of Oncology Navigation & Survivorship (JONS) also keeps navigators abreast of new networking opportunities while at the same time providing real, evidence-based tools that they can incorporate into their own practices.
Demonstrating Navigation’s Value
When administrators began to express concern over the value and sustainability of navigation—asking questions like “Who’s going to pay for this?” “How do we measure the success of our navigation programs?” and “What’s the return on investment of navigation?”—the field of navigation responded by developing standardized navigation metrics concentrating on return on investment, patient experience, and clinical outcomes.
These 35 baseline metrics can be used by all navigators in all institutions, regardless of the structure of their navigation programs, and serve to measure the impact of patient navigation across the continuum of cancer care.
“I don’t care if you’re community-based, advocacy-based, hospital-based, or academic-based, you can take these metrics and apply them to your program,” she said. “You’re not going to apply all 35 at one time, but pick the lowest hanging fruit and go for it.”
The AONN+ Metrics also coincide with many of the existing national standards, so AONN+ has also developed a crosswalk that identifies how the 35 standardized metrics align with national standards and indicators.
The Data Do Not Lie
A study of 8 sites that actually implemented the metrics showed that they did, in fact, demonstrate the value and sustainability of navigation programs. “This study also showed us that the more educated—the more certified—navigator made a difference in care,” said Ms Gentry. “We knew navigators made a difference in patient experience; we just had to prove it.”
The study demonstrated that navigators decreased the time to treatment for patients down to 11 days, and they also made a difference in terms of palliative and supportive care. “You pulled in dietitians, physical therapists, and occupational therapists,” she said. “You as navigators pull in a lot of people who bring dollars into your healthcare system.”
In 2020, AONN+, in collaboration with the American Cancer Society (ACS), launched the Navigation Metrics Toolkit. Navigators of all types—be they rookies or veterans—can now access the Navigation Toolkit on the AONN+ website, implement those metrics into what they do on a daily basis, and continue to demonstrate the value of navigation.
Ms Gentry emphasized the importance of oncology nurse and patient navigators understanding that active participation in data collection, analytics, and reporting outcomes are not added responsibilities but are already a part of their professional role.
“You’re analytical every day,” she said. “When you look at a patient and determine their barriers, you’re already thinking proactively about what you need to do to get that patient through treatment.”
Use the Existing Tools
Ms Gentry recommends that navigators of all kinds read Team-Based Oncology Care: The Pivotal Role of Oncology Navigation, published by Springer International Publishing AG. “This book will take you through any type of navigation that you’re doing, through screening, treatment, and up to the end of life, but it’ll also take you through taking care of yourself,” she noted. “When COVID hit, we saw the importance of that more than ever: taking care of yourself as a navigator.”
As the navigator role evolved, the need for an acuity tool became more and more evident. Oncology navigation acuity is defined as a measure of patient distress, medical and psychosocial barriers, complexity of illness, and social determinants that indicates the need for the intensity of the subsequent navigator intervention. In other words, how many patients can 1 navigator follow? Work is ongoing at AONN+ toward development of an evidence-based oncology navigation–specific acuity tool that will analyze and characterize the intensity of the navigation workload.
Ms Gentry noted that acuity is different for each navigator: one navigator might look at a patient’s transportation hurdle as an easy and quick fix, while another might see it as a daunting task.
“So this acuity tool has to be different for each of you,” she explained. “We have to capture your level of acuity, based on how you see that patient, from your subjective view, and with the resources that you have.”
Agreeing on Language
In March 2022, AONN+ released the Oncology Navigation Standards of Professional Practice, which provide clinical oncology nurse navigators, social work navigators, and patient navigators with clear information regarding best practices in the provision of professional care. These standards include the knowledge and skills all professional navigators should possess in order to deliver high-quality, competent, and ethical services to people impacted by cancer.
“This was a game-changer,” she said. “No more ‘nonclinical’ navigators; you’re all clinical. No more ‘lay’ navigators; you’re a navigator of some type. If we’re going to go forward and be sustainable as a profession, we have to start using the same language.”
To move forward with the building blocks already in place in the field of oncology navigation—including core competencies, certification, professional organizations, local navigator networks, etc—agreeing on the same language is crucial.
“We have beautiful building blocks in navigation,” said Ms Gentry. “And we want the federal government and private insurance to recognize what we’re doing every day. When we start getting into legislation, we have to make sure our language is correct, because if a bill is passed, it has to cover everyone.”
“We’re already walking the walk,” she continued. “It’s time we talked the talk.”
According to Ms Gentry, future issues in navigation will include developing standardized definitions for billable services (with the goal of achieving an oncology patient navigation Labor Code), a universal job description (work is underway with the ACS Patient Navigation Working Group on survivorship navigation), dealing with an oncology specialist shortage, expansion to other chronic diseases (already underway with the Association of Chronic & Complex Care Nurse Navigators), and, as always, continued efforts to demonstrate the value of navigation.