- B1. Addressing Patient Barriers to Adult Oncology Cancer Treatment in a Midwest Cancer Care Center: An Evidenced-Based Project
- B2. A Financial Toxicity Screening and Care Coordination Quality Improvement Program in a Gynecology Oncology Urban Practice
- B3. Assessing Outcomes of an Online Course on Health Literacy and Patient Communication
- B4. Major Adverse Cardiovascular Events Risk After Androgen Deprivation Therapy Initiation Is Higher for Older Patients and Underweight Patients
- B5. Navigating Cancer Patients to Improved Outcomes During COVID-19
- B6. Navigating ER Patients with an Incidental Finding Suggestive of/for Cancer with Cancer
- B7. Navigating the Patient Navigator: The Impact of Nonstandardized Workflows Among Patient Navigators Supporting Women with Breast Cancer
- B8. Partnering to Improve Access to Cancer Care for Diverse, Underserved Patients
- B9. The Impact of Navigation: Demonstrating Sustainability and Continued Improved Access, Timeliness, and Care Coordination in an Interdisciplinary Breast Program
B1 Addressing Patient Barriers to Adult Oncology Cancer Treatment in a Midwest Cancer Care Center: An Evidenced-Based ProjectSandra Harbort, MSN, RN, OCN, ONN-CG, CNE; Billie Madler, DNP, APRN, FNP, FAANP
Minot State University, Minot, ND
Background: Top barriers to receiving cancer care treatment identified by adult cancer patients in North Dakota were fear of treatment and difficulty understanding the treatment process, including the options, risks, and benefits. Literature revealed gaps in established methods for evaluating if patients are well-informed/satisfied with information received related to their cancer diagnosis and management plan. There is also a lack of standardized, effective communication utilized by providers in this area. The majority of the education and treatment recommendations are provided during the initial oncology visit. Effective communication during medical visits has been shown to positively influence patient satisfaction and treatment adherence.
Objectives: To increase patient satisfaction by addressing the identified barriers to care by promoting patient-centered communication in the immediate time frame surrounding the initial patient oncology encounter.
Methods: Mixed methods of qualitative and quantitative data screening methods were utilized. Project interventions promoting patient-centered communication in the immediate time frame surrounding the initial patient oncology visit were implemented: (1) a previsit National Comprehensive Cancer Network (NCCN) Distress Thermometer, (2) a postvisit summary of upcoming treatment planning activities, and (3) a magnet to highlight the primary contact information of the nurse navigator were implemented. Additionally, standardization of timing for distribution of the patient education manual and orientation to the facility was implemented during the initial oncology visit. The distribution of this information provided consistency to patient care surrounding the time of the initial oncology visit. Measurements of initial previsit and follow-up visit mean distress scores, as well as patient satisfaction scores, were obtained.
Results: Mean scores for distress decreased from 2.79 to 2.72 at the first follow-up oncology visit. Results were obtained by use of a t test and yielded a P value of .877 (CI = 95%), determining there was no statistically significant decrease in NCCN Distress Thermometer scores across the sample before and after. Outcome measurements included patient satisfaction with the addition of a postvisit summary and supplied refrigerator magnet using a Likert scale survey of responses. Of the 29 surveys provided to patients, 20 were returned. Across the sample, there was a modest decrease in the mean distress score from the time of the initial oncology visit to the first follow-up visit. Although not statistically significant, results have clinical significance. Improved patient communication and satisfaction were shown by analyzing the means of patient satisfaction scores and distress reported on first follow-up oncology visit.
Conclusion: Project outcomes demonstrate improved patient communication and decreased distress in the time frame surrounding the first oncology visit. Future implications indicate recommendations can be adjusted to further address patient fears/difficulty understanding treatment recommendations.
Alifrangis C, Koizia L, Rozario A, et al. The experiences of cancer patients. QJM. 2011;104:1075-1081.
Amalraj S, Starkweather C, Nguyen C, Naeim A. Health literacy, communication, and treatment decision-making in older cancer patients. Oncology (Williston Park). 2009;23:369-375.
American Cancer Society. The History of Cancer. www.cancer.org/cancer/cancer-basics/history-of-cancer.html. 2019.
American College of Surgeons. Commission on Cancer. Standards and Resources. www.facs.org/quality-programs/cancer/coc/standards. 2016.
Bailo L, Guiddi P, Vergani L, et al. The patient perspective: investigating patient empowerment enablers and barriers within the oncological care process. Ecancermedicalscience. 2019;13:912.
Beach WA, Dozier DM. Fears, uncertainties, and hopes: patient-initiated actions and doctors’ responses during oncology interviews. J Health Commun. 2015;20:1243-1254.
Berger O, Grønberg BH, Loge JH, et al. Cancer patients’ knowledge about their disease and treatment before, during and after treatment: a prospective, longitudinal study. BMC Cancer. 2018;18:381.
Blayney DW. Strengths, weaknesses, opportunities, and threats. J Oncol Pract. 2008;4:53.
Brand SR, Pickard L, Mack JW, Berry LL. What adult cancer care can learn from pediatrics. J Oncol Pract. 2016;12:765-767.
Chan RJ, Webster J, Marquart L. Information interventions for orienting patients and their carers to cancer care facilities. Cochrane Database Syst Rev. 2012;12:CD008273.
Chua GP, Tan HK, Gandhi M. What information do cancer patients want and how well are their needs being met? Ecancermedicalscience. 2018;12:873.
Coronado A, Tran K, Chadder J, et al. The experience of patients with cancer during diagnosis and treatment planning: a descriptive study of Canadian survey results. Curr Oncol. 2017;24:332-337.
de Calvo A, Sepulveda-Carrillo LU, Judith G. Care needs of cancer patients undergoing ambulatory treatment. Enfermeria Global. 2017;16(1):353-383.
Elston Lafata J, Shay LA, Winship JM. Understanding the influences and impact of patient-clinician communication in cancer care. Health Expect. 2017;20:1385-1392.
Ferrell B, McCabe MS, Levit L. The Institute of Medicine report on high-quality cancer care: implications for oncology nursing. Oncol Nurs Forum. 2013;40; 603-609.
Foster J, Idossa L, Mau LW, Murphy E. Applying health literacy principles: strategies and tools to develop easy-to-read patient education resources. Clin J Oncol Nurs. 2016;20:433-436.
Fulcher C, Gosselin-Acomb TK. Distress assessment: practice change through guideline implementation. Clin J Oncol Nurs. 2007;11:817-821.
Gilligan T, Coyle N, Frankel RM, et al. Patient-clinician communication: American Society of Clinical Oncology Consensus Guideline. J Clin Oncol. 2017;35:3618-3632.
Gross SE, Nitzche A, Gloede TD, et al. The initial clinical interview – can it reduce cancer patients’ fear? Support Care Cancer. 2015;23:977-984.
Hendren S, Chin N, Fisher S, et al. Patients’ barriers to receipt of cancer care, and factors associated with needing more assistance from a patient navigator. J Natl Med Assoc. 2011;103:701-710.
Hummel J, Evans P. Providing Clinical Summaries to Patients after Each Office Visit: A Technical Guide. www.healthit.gov/sites/default/files/measure- tools/avs-tech-guide.pdf. 2012.
Katz A. Health literacy: what do you know? Oncol Nurs Forum. 2017;44:521-522.
McMullen L, Banman T, DeGroot JM, et al. Providing novice navigators with a GPS for role development. Clin J Oncol Nurs. 2016;20:33-38.
McMullen S, Szabo S, Halbert RJ, et al. Tools for communication: novel infrastructure to address patient-perceived gaps in oncology care. Clin J Oncol Nurs. 2017;21:E38-E48.
Mick J. Factors affecting the evolution of oncology nursing care. Clin J Oncol Nurs. 2008;12:307-313.
National Institutes of Health. State Cancer Profiles. https://statecancerpro files.cancer.gov/quick-profiles/index.php?statename=northdakota. 2017.
National Institutes of Health. Cancer Statistics. www.cancer.gov/about-cancer/understanding/statistics. 2018.
North Dakota Cancer Coalition. Data and Reports. www.ndcancercoalition.org/about-us/data-and-reports/. 2017.
North Dakota Cancer Coalition. Resources. www.ndcancercoalition.org/image/cache/2018-2022_ND_Statewide_Cancer_Plan_1-9-2019.pdf. 2018.
Patel MI, Periyakoil VS, Blayney DW, et al. Redesigning cancer care delivery: views from patients and caregivers. J Oncol Pract. 2017;13:e291-e302.
Portz D, Johnston MP. Implementation of an evidence-based education prac tice change for patients with cancer. Clin J Oncol Nurs. 2014;18(suppl):36-40.
Richter D, Ernst J, Lehmann C, et al. Communication preferences in young, middle-aged, and elderly cancer patients. Oncol Res Treat. 2015;38:590-595.
Schofield PE, Butow PN, Thompson JF, et al. Psychological responses of patients receiving a diagnosis of cancer. Ann Oncol. 2003;14:48-56.
Thorne S, Hislop TG, Kim-Sing C, et al. Changing communication needs and preferences across the cancer care trajectory: insights from the patient perspective. Support Care Cancer. 2014;22:1009-1015.
Truccolo I, Ciplat Mis C, Cervo S, et al. Patient-centered cancer care programs in Italy: benchmarking global patient education initiatives. J Canc Educ. 2016;31:405-412.
Vaartio-Rajalin H, Huumonen T, Iire L, et al. Patient education process in oncologic context: what, why, and by whom? Nurs Res. 2015;64:381-390.
Vaartio-Rajalin H, Leino-Kilpi H. Nurses as patient advocates in oncology care: activities based on literature. Clin J Oncol Nurs. 2011;15:526-532.
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B2 A Financial Toxicity Screening and Care Coordination Quality Improvement Program in a Gynecology Oncology Urban PracticeTina Harris, DNP, NP-C, AOCNP
University of North Georgia, Chattanooga, TN
Background: Research links financial toxicity (FT) to cancer patients’ nonadherence to treatment, worsening quality of life (QOL), and increased mortality rates.1,2 Esselen et al found that 52% of stage III and IV gynecologic cancer patients had FT, with 49% reporting high FT, correlating to a poor QOL.1 Studies show that healthcare organizations recognized the need for these conversations and were willing to incorporate cost conversations in the workflow to address immediate financial hardships that would minimize financial burdens.3-7 Barriers remain, such as the lack of FT screening (74%), clinician time constraints (67%), and no staff training (66%), leaving critical gaps in care, with 59% showing a multicomponent implemented program could improve outcomes.3 Educating a multidisciplinary team on FT risk, screening, and care coordination is an approach to addressing gaps in care when identifying newly diagnosed patients with stage III or IV gynecological cancer who may be experiencing FT.
Objective: The goal of the Quality Improvement Project (QIP) was to supply an education program for the multidisciplinary team, providing insights for the following objectives:
- Increase the rate of FT screening where there was no baseline screening.
- Increase referrals for resource care coordination among patients experiencing FT.
- Evaluate the relationship between FT and selected demographic identifiers during the 8-week project.
Methods: The Plan-Do-Study-Act (PDSA) model was adopted for learning and leading the change during the QIP, focusing on the Comprehensive Screening Tool (COST) score and resource care coordination for newly diagnosed participants with stage III or IV gynecological cancer.
Results: Of a total of 52 patients, 42 (80.75%) consented to the QIP; 61.90% had COST scores below 23, with 100% (26) of the participants receiving referrals for resource care coordination. On average, 6.50 patients a week enter the practice for care, with 50% (3.25) reporting FT. At this rate, 162.50 patients were experiencing FT in a 50-week year and were not receiving resource care coordination. However, because some patients did not consent to the QIP, the average FT (Yes) count could potentially be between 199.50 and 225.00 patients in a 50-week year, potentially leading to 62.50 with FT (or 28% of 225.00) not receiving referrals for care coordination.
Age was the main driver for the FT-COST Score in this QIP. Many variables were unobserved in this QIP and could impact the FT-COST Score. However, separate modeling reveals that age alone explains approximately 15% of the observed changes in the FT-COST scores. Controlling for more variables may refine the model, but it seems unlikely by the data analysis that age would disappear as a driver of change in the FT-COST Score.
Conclusion: Developing a multidisciplinary education program focusing on a structured QIP-PDSA plan can be an example of standardizing an FT screening and a care coordination program. The QIP team successfully incorporated a PDSA model roadmap screening program to identify the participants experiencing FT and promptly referred 100% for resource care coordination.
- Esselen KM, Stack-Dunnbier H, Gompers A, Hacker MR. Crowdsourcing to measure financial toxicity in gynecologic oncology. Gynecol Oncol. 2021; 161:595-600.
- Klein J, Bodner W, Garg M, et al. Pretreatment financial toxicity predicts progression-free survival following concurrent chemoradiotherapy for locally advanced non-small-cell lung cancer. Future Oncol. 2019;15:1697-1705.
- Fradgley EA, Byrnes E, McCarter K, et al. A cross-sectional audit of current practices and areas for improvement of distress screening and management in Australian cancer services: is there a will and a way to improve? Support Care Cancer. 2019;28:249-259.
- Henrikson NB, Banegas MP, Tuzzio L, et al. Workflow requirements for cost-of-care conversations in outpatient settings providing oncology and primary care. Ann Intern Med. 2019;170(suppl):S70-S78.
- Khera N, Kumbamu A, Langer SL, et al. Developing an educational intervention to address financial hardship in cancer patients. Mayo Clin Proc Innov Qual Outcomes. 2020;4:424-433.
- Perez SL, Weissman A, Read S, et al. U.S. internists’ perspectives on discussing cost of care with patients: structured interviews and a survey. Ann Intern Med. 2019:170(suppl):S39-S45.
- Yabroff KR, Zhao J, Han X, Zheng Z. Prevalence and correlates of medical financial hardship in the USA. J Gen Intern Med. 2019;34:1494-1502.
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B3 Assessing Outcomes of an Online Course on Health Literacy and Patient Communication
Maya Sanford1; Christina Mangir, MS1; Sandy E. Kurtin, PhD, ANP-C, AOCN2; Cardinale B. Smith, MD, PhD3; Elana Plotkin1; Lorna Lucas, MS1
1Association of Community Cancer Centers; 2University of Arizona Cancer Center; 3Icahn School of Medicine at Mount Sinai
Background: Clear communication between providers and cancer patients is essential to patient understanding, decision-making, and continuation of care.1 Inadequate patient health literacy can lead to lower overall health, reduced disease comprehension, and lack of medication adherence.2 In a 2021 survey of Association of Community Cancer Centers (ACCC) membership, 45% of multidisciplinary cancer care team respondents identified limited health literacy as a barrier to effective, shared decision-making.3 Nurse and patient navigators play an essential role in patient communication and comprehension.
Objectives: Assess learning outcomes of a self-paced, online education course on communication and health literacy to determine the ability of multidisciplinary care team members to apply knowledge and skills to their cancer program.
Methods: ACCC worked with a multidisciplinary advisory committee to develop the Clear Communication and Health Literacy eCourse, an online education course designed to build awareness and skills for the whole care team. Users accessed the interactive, self-paced course on the ACCC Learning Management System. An exploratory analysis was performed on pre/postassessments to evaluate the outcomes and effectiveness of this education program. In an initial pilot, 70 learners registered for the course from 3/17/22 to 6/16/22, and 29 learners completed the postassessment, including nurse/navigators (43%) and financial/patient navigators (28%). In the pre/postassessments, each learner rated their level of proficiency for each learning objective: clear communication with patients, evidence-based application of health literacy practices, explanation of complex oncology concepts in plain language, use of the teach-back method, and assessment of patient materials.
Results: After completing the course, the percentage of learners reporting “excellent” or “good” proficiency increased for each learning objective: clear communications with patients from 78% to 96%, evidence-based application of health literacy practices from 36% to 82%, explanation of complex oncology concepts in plain language from 47% to 79%, and use of the teach-back method from 43% to 90%. Eighty-seven percent of learners responded that they were likely to recommend the course to a colleague, and 69% were likely to implement the course in their program.
Conclusions: Education programs such as the Health Literacy and Clear Communications eCourse can help nurses and patient navigators effectively communicate with patients. Navigators can use evidence-based health literacy practices such as the teach-back method and assessment of printed materials to explain complex oncology concepts to patients. Additional educational opportunities and analysis may include concurrent assessment of patient and caregiver perspectives to incorporate them into provider education and evaluation of health literacy training programs in clinical practice.
Funding: Provided by Lilly Oncology. Data from this research will be published in Oncology Issues in 2022.
- Holcomb J, Ferguson GM, Thornton L, Highfield L. Development of training curriculum to improve patient communication skills and social support among community health workers. Health Lit Res Pract. 2022;6: e142–e150.
- Liu C, Wang D, Liu C, et al. What is the meaning of health literacy? A systematic review and qualitative synthesis. Fam Med Community Health. 2020;8:e000351.
- Association of Community Cancer Centers. Shared Decision-Making: Practical Implementation for the Oncology Team. www.accc-cancer.org/docs/projects/sdm/shared-decision-making-publication_final.pdf?s fvrsn=994b7f55_0. 2021.
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B4 Major Adverse Cardiovascular Events Risk After Androgen Deprivation Therapy Initiation Is Higher for Older Patients and Underweight Patients
Rebecca Floyd, RN, CCRC1; Deborah M. Boldt-Houle, PhD2; Stuart N. Atkinson, MBChB2
1Clinical Research, Carolina Urologic Research Center, Myrtle Beach, SC; 2Medical Affairs, Tolmar Pharmaceuticals, Inc., Buffalo Grove, IL
Background: Patients with prostate cancer (PCa) treated with androgen deprivation therapy (ADT) may experience major adverse cardiovascular events (MACE).1,2 There is some debate as to how much of MACE is caused by ADT itself. Some risk factors that might influence MACE are increasing age and abnormally low or high body mass index (BMI). A study in the general population found that the rate of cardiovascular (CV) disease was approximately 15% higher for individuals 80 years and older compared with those 60 to 79 years old.3 Lee et al found a lower risk of MACE in patients with a high BMI than in those with a normal weight, and patients with a low BMI had a higher risk of all-cause mortality.4 Nurses can have a significant impact on patients’ CV health; advanced practice nurses achieved results equal to or better than general practitioners for the management of CV risk factors,5 and a nurse-led intervention for CV risk modification was effective.6
Objective: To evaluate MACE risk for PCa patients in different age-groups and BMI groups using real-world data.
Methods: Analyses of US electronic medical records (2010-2020) of PCa patients receiving luteinizing hormone-releasing hormone (LHRH) agonist and antagonist injections were conducted to calculate the risk of MACE since ADT initiation in the following age (n = 42,630) and BMI (n = 34,861) subgroups: <60, 60 to <70, 70 to <80, and ≥80 years old, and <18.5, 18.5 to <25, 25 to <30, 30 to <35, and ≥35 BMI. The database contained 178,388 LHRH agonist and antagonist injection entries and 7681 documented MACE events. Exclusion criteria included MACE within 6 months prior to ADT initiation. MACE was defined as myocardial infarction, stroke, and death from any cause. Kaplan-Meier event-free survival curves were constructed, and hazard ratios (HRs) were used to compare the MACE risk between age-groups and BMI groups.
Results: 6%, 25%, 39%, and 30% of patients were <60, 60 to <70, 70 to <80, and ≥80 years old, respectively. MACE risk following ADT initiation was higher for older patients compared with younger patients (increased risk per year increase in age: unadjusted [HR, 1.07; 95% CI, 1.06-1.07] and adjusted [HR, 1.07; 95% CI, 1.06-1.08]). Both the unadjusted and adjusted risks of MACE were higher for BMI <18.5 kg/m2 compared with BMI ≥18.5 kg/m2 (unadjusted [HR, 2.22; 95% CI, 1.77-2.79] and adjusted [HR, 1.90; 95% CI, 1.29-2.80]).
Conclusions: Consistent with previous studies in general populations,3,4 MACE risk after ADT initiation was higher for older patients and underweight patients. Our analysis of data over the most recent decade from ~45,000 PCa patients is likely an accurate reflection of the real world. Nurses should help clinicians identify CV risk factors and ensure that patients’ CV health is well-managed. Future studies could identify other CV/MACE risk factors in PCa patients on ADT.
Funding: Tolmar Pharmaceuticals, Inc.
- Zhao J, Zhu S, Sun L, et al. Androgen deprivation therapy for prostate cancer is associated with cardiovascular morbidity and mortality: a meta-analysis of population-based observational studies. PLoS One. 2014;9:e107516.
- Brady B, Pruett J, Winer I, et al. PCN194 Prevalence of major adverse cardiac events (MACE) in patients with prostate cancer (PC) receiving androgen deprivation therapy (ADT) in the United States. Value in Health. 2020;23(suppl 2):S457.
- American Heart Association. 2021 Heart Disease & Stroke Statistical Update Fact Sheet. Older Americans & Cardiovascular Diseases. https://professional.heart.org/-/media/PHD-Files-2/Science-News/2/2021-Heart-and-Stroke-Stat-Update/2021_Stat_Update_factsheet_Older_and_CVD.pdf. Published 2021. Accessed January 10, 2022.
- Lee DH, Ha KH, Kim HC, Kim DJ. Association of body mass index with risk of major adverse cardiovascular events and mortality in people with diabetes. J Obes Metab Syndr. 2018;27:61-70.
- Voogdt-Pruis HR, Beusmans GH, Gorgels AP, et al. Effectiveness of nurse-delivered cardiovascular risk management in primary care: a randomised trial. Br J Gen Pract. 2010;60:40-46.
- Kavita, Thakur JS, Vijayvergiya R, Ghai S. Task shifting of cardiovascular risk assessment and communication by nurses for primary and secondary prevention of cardiovascular diseases in a tertiary health care setting of Northern India. BMC Health Serv Res. 2020;20:10.
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B5 Navigating Cancer Patients to Improved Outcomes During COVID-19
Candace Bashaw, MSN, OCN; Kris Blackley, MSN, OCN; Laura Kabrich; Britany Ragon, MD; Ashley Sumrall, MD; Ify Osunkwo, MD; Declan Walsh, MD; Beth York; Kelly Leonard; Tamara Moyo, MD; Levine Cancer Institute Patient Navigation Team
Levine Cancer Institute, Charlotte, NC
Background: Early COVID-19 data coming out of both China and Europe indicated additional risks and concerns for oncology patients, specifically a higher rate of complications and mortality due to COVID,1 suggesting they may need more intensive intervention. The Centers for Medicare & Medicaid Services Healthy at Home (HaH) initiative was created as an early intervention process intended to help keep COVID-positive cancer patients out of the hospital and prevent the overwhelming hospitalizations that could have led to the collapse of the healthcare system. Atrium Health’s Levine Cancer Institute (LCI) initiated this HaH plan in March 2020, locally termed the Virtual Hospital (VH).
Objectives: (1) To utilize oncology nurse navigators for more intensive monitoring to decrease hospitalizations in cancer patients who test positive for COVID, and (2) to utilize oncology nurse navigators for more intensive monitoring to decrease deaths for cancer patients who tested positive for COVID.
Methods: The LCI VH liaison team partnered with the Department of Supportive Oncology and Information and Analytic Services to develop a navigation protocol that incorporated an LCI-specific COVID-positive daily patient report and the VH documentation tool, which graded each patient by the severity of, or number of, symptoms they were experiencing. For the navigators, the frequency of patient assessment and instructions for when and how to escalate high-acuity cases were included in the protocol and based on the calculated scores. By following this protocol, it allowed for intensive assessment and monitoring and proactive interventions to address symptoms or complications, prevent hospitalizations, and improve survival. As navigators followed the patient, they assisted with scheduling follow-up COVID tests so the patients could return to the clinic as soon as possible and prevent extended delays in treatment. Often, testing sites had no availability for COVID testing, and navigators worked hard to find timely appointments for the patient. Navigators also helped overcome other potential barriers that were a direct result of an active COVID infection, such as transportation issues, food insecurity, and lack of required medications.
Results: A total of 974 patients were reviewed with approximately half being navigated (n = 488; 50%) and the other half not navigated (n = 486; 50%). Data showed that only 35 navigated patients versus 89 non-navigated patients were hospitalized as a result of COVID-19 complications (P <.01). Subsequently, there were only 25 deaths in the navigated patient population compared with 49 deaths in the non-navigated patient population (P = .004).
Conclusion: Early intervention from navigators showed benefit in reducing hospitalizations and mortality in high-risk cancer patients. This is attributed to intensive monitoring, proactive interventions, and escalation of higher-acuity patients to the appropriate provider. A specific COVID process utilizing an assessment tool and escalation of patient concerns was developed, which would be easily scalable and replicable to other high-risk patient populations.
- Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020;21:335-337.
- Braun KL, Kagawa-Singer M, Holden AEC, et al. Cancer patient navigator tasks across the cancer care continuum. J Health Care Poor Underserved. 2012;23:398-413.
- Wells KJ, Valverde P, Ustjanauskas AE, et al. What are patient navigators doing, for whom, and where? A national survey evaluating the types of services provided by patient navigators. Patient Educ Couns. 2018;101:285-294.
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B6 Navigating ER Patients with an Incidental Finding Suggestive of/for Cancer
Megan Roy, MSN, RN, OCN; Margaret Rummel, RN, MHA, OCN, NE-BC; Eleanor Miller, MSN, RN, ONC; Katie Fanslau, DNP, RN; Patricia Gambino, MSN, RN; Keith Hemmert, MD
Abramson Cancer Center, Penn Medicine, Philadelphia, PA
Background: The oncology nurse navigators (ONNs) at Penn Medicine’s Abramson Cancer Center (ACC) observed that patients seen in the emergency room (ER) and found to have a suspicion of cancer were being told to call a medical oncologist. Many ACC oncologists are highly specialized, and because the patient did not have a confirmed cancer diagnosis, they were told they could not schedule an appointment. Due to the complexity of the health system, patients did not know how to access the ACC and were lost to follow-up, which often delayed diagnosis and time to treatment. These barriers also led to a poor patient experience and a financial loss for the health system. The ONNs identified this as an opportunity to change the process to improve patient care.
Objectives: To improve collaboration with the ER and ONNs to smooth the transition of care from the ER to the correct outpatient specialist. To overcome system barriers in access to care during the cancer workup and improve time to treatment.
Methods: The initiative formally began in June 2021 when the ONNs connected with ER leadership to collaborate on a quality improvement project to streamline the process from ER visit to oncology workup and diagnosis. The Plan-Do-Study-Act methodology was utilized. Direct referral to oncology nurse navigation from the ER facilitates timely navigation assessment and coordination of care. A “Consult to Nurse Navigation” order was built into the electronic medical record (EMR) for ER providers to directly refer patients to the navigation team. The ONNs contacted the patient within 1 business day to assess their needs. The ONNs scheduled the patient with the appropriate oncology specialist, followed the patient through the diagnostic phase of care, and assisted with decreasing barriers to care. Data collection is ongoing to determine the impact of the interventions.
Results: The EMR consult to ONNs went live in April 2022 and now includes 3 urban hospital ERs in the health system with diverse populations that often have limited access to healthcare. Barriers to treatment include transportation, lodging, psychosocial distress, financial toxicity, health literacy, and many others. To date, 90% were appropriate referrals and triaged to cancer specialists for diagnostic workup and treatment; 90% had insurance accepted by the health system. Patients with unacceptable insurance plans were referred to ER social work and financial advocates. Seventy percent were diagnosed with cancer and began treatment in a timely manner.
Conclusion: Additional data collection is ongoing, which will further enhance the initiative. This initiative has improved multidisciplinary collaboration between the ER and the ACC. ONNs are vital in identifying and removing barriers to care. The ONN team’s clinical knowledge, assessment skills, and expertise of the health system have closed a gap in care while increasing patient satisfaction, patient retention, and downstream revenue. The ONN’s leadership has directly enhanced the diagnostic process and timeliness to care for patients newly affected by cancer.
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B7 Navigating the Patient Navigator: The Impact of Nonstandardized Workflows Among Patient Navigators Supporting Women with Breast Cancer
Alaina L. Carr, PhD1; Naomi Vinod, MS2; Maen J. Farha, MD3; Kristi D. Graves, PhD1
1Department of Oncology, Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC; 2Department of Psychology, Howard University, Washington, DC; 3Department of Surgery, MedStar Union Memorial and Good Samaritan Hospitals, Baltimore, MD
Background: Patient navigators (PNs) are integral members of cancer care programs and improve quality of care by performing outreach, communication, education, and coordination for patients diagnosed with cancer.1,2 PNs reduce barriers to patient care across the continuum of cancer care from screening and detection, diagnosis, treatment, and survivorship to end of life.1 The types of information, resources, and support that PNs provide to patients vary based on their phase within the care continuum and patient characteristics.2 We conducted a needs assessment among PNs supporting women with breast cancer (BC) to identify avenues to optimize PN workflows.
Objectives: To identify what information, resources, and tools may be useful to help PNs in their work to support women diagnosed with BC. Our long-term goal is to develop a mobile health (mHealth) tool to assist PNs in their role.
Methods: Eleven PNs were recruited from community- based settings, oncology clinics set in community hospitals, and oncology clinics set in academic medical centers. PNs completed a demographics survey and participated in individual structured interviews to identify PN needs. Study staff (ALC and NV) analyzed qualitative data using thematic analysis to identify salient themes. Descriptive statistics were used to analyze demographic survey data.
Results: Participants identified as female (100%), non-Hispanic (72.7%), White (45.4%), African American (36.4%), and multiracial (18.2%), and fewer than one-third were bilingual in English and Spanish (27.3%). PNs reported a mean age of 46.2 years (SD = 11.4), and most navigated greater than 20 patients per month. More than one-third (36.4%) worked in a hospital within a large healthcare system, 27.3% in an academic hospital, 27.3% in a community-based support services organization, and 9% in a community-based clinic. Participants characterized themselves as communication liaisons and oncology care providers for their patients. PNs overwhelmingly described frustration with barriers in their work that hindered optimal care for female BC patients. The following subthemes emerged related to PN work barriers: (1) lack of patient insurance coverage; (2) limited patient resources and knowledge, especially for underserved patients; (3) patient language barriers; and (4) heterogeneous care team communication channels. All participants reported a consequence of nonstandardized workflows as taking on tasks outside their job description, such as assisting patients with completing online applications, scheduling, and following up with referrals to ensure appointments were kept. More than half of the participants expressed the culmination of these added work demands led to emotional strain and burnout in their roles.
Conclusions: Barriers within PN workflows hinder optimal BC patient care and create increased workload, leaving PNs to feel overloaded and burdened from their role. Results from the current study point to future areas of investigation, such as the use of mHealth tools to increase PN operational efficiencies, centralize information about resources, and facilitate communications, collaborations, and knowledge transfer between PNs, patients, and providers.
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B8 Partnering to Improve Access to Cancer Care for Diverse, Underserved Patients
Carla Strom, MLA1; Emily Copus, MSW, OPN-CG1; Alexis Daniels, MS, OPN-CG1; Ashley Gonzalez1; Jane Smart, RN, BSN, MBA2; Ronny Bell, PhD1
1Office of Cancer Health Equity, Wake Forest Baptist Comprehensive Cancer Center at Atrium Health Wake Forest Baptist; 2American Cancer Society
Background: To address the inequities underserved populations often face during their cancer experience, the Wake Forest Baptist Comprehensive Cancer Center developed a novel nonclinical navigation program for African American (AA), Hispanic, and rural cancer patients. Population health navigators (PHNs) provide culturally and linguistically competent navigation services to cancer patients, families, and caregivers to help them overcome healthcare system and social barriers, facilitating timely access to quality medical and supportive care through cancer treatment. In partnership with the American Cancer Society (ACS) through their patient transportation and lodging grants, funding increased from previous years to expand direct support to underserved patient populations by PHNs by serving as a hub for transportation (cab rides, gas cards) and lodging assistance for clinics across the hospital system.
Objective: To evaluate an underserved patient navigation program’s collaboration with the ACS to better address patients’ structural and logistical barriers to cancer care.
Methods: PHNs partnered with members of the multidisciplinary care team, including nurse navigators, ambulatory nurses, advanced practice providers, and pediatric oncologists, at 4 satellite clinics across the system to provide expanded direct support for lodging and transportation to patients in treatment. Direct support included gas cards, cab rides, and discounted lodging through a local nonprofit hospital hospitality house. General guidelines were provided for allocating resources based on clinic ethnography. We then retrospectively compared data captured by PHNs in EPIC/Healthy Planet prior to collaboration (1/1/2021-5/31/2021) with data tracked by PHNs for grant reporting purposes from 1/1/2022 to 5/31/2022 to evaluate partnership outcomes. Data are reported in the aggregate.
Results: In 2021, 70 (rural n = 32, AA n = 21, Hispanic n = 17) patients were assisted with transportation funds only, increasing to 237 patients (rural n = 121, AA n = 83, Hispanic n = 33) assisted with transportation and lodging funds in 2022, a 238% increase. Transportation support increased 167% serving 187 patients with 219 gas cards (average $25 each) and 61 cab rides (average $45 each), nearly double the same period in 2021. In addition, by providing free lodging for the first time in 2022, we facilitated 28 stays for 23 patients (average 11 nights per stay) totaling $15,000 in assistance. Within our priority underserved patient populations:
- Transportation assistance for rural patients increased 256% (n = 111) overall; 34% for gas cards alone (n = 116)
- Transportation assistance for AA patients increased 335% (n = 61), primarily from a 141% increase in cab rides provided (n = 29)
- Unexpectedly, Hispanic patients utilized lodging funds more than anticipated and had a greater average number of days per stay (15 days)
Conclusion: Partnership and collaboration with national resources is vital to expanding access to care for traditionally underserved patient populations. By working with our regional ACS manager, the data clearly indicate an increased ability to provide rural, AA, and Hispanic patients with transportation and lodging to reduce the structural and logistical barriers to timely and quality cancer care. Identifying differences in the type of support among the underserved patient populations can assist with programmatic development and tailoring future interventions. Future plans include analyzing the impact of transportation and lodging funds on treatment adherence in underserved patients.
- Dixit N, Rugo H, Burke NJ. Navigating a path to equity in cancer care: the role of patient navigation. American Society of Clinical Oncology Educational Book. 2021;41:3-10.
- Rodday AM, Parsons SK, Snyder F, et al. Impact of patient navigation in eliminating economic disparities in cancer care. Cancer. 2015;121:4025-4034.
- Brawley OW. The American Cancer Society and the American Health Care System. Oncologist. 2011;16:920-925.
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B9 The Impact of Navigation: Demonstrating Sustainability and Continued Improved Access, Timeliness, and Care Coordination in an Interdisciplinary Breast Program
Sharon Inzetta, RN, MS, CBCN, CN-BN, ONN-CG
Summa Health, Akron, OH
Background: The Institute of Medicine (IOM) quality cancer care report (2013) stated that “cancer care is often not as patient-centered, accessible, coordinated, or evidence-based as it could be.” One of the goals in the IOM report is to improve process measures, including timeliness, access, and coordination of care. The IOM recommendations address barriers to care with a focus on patient navigation as a key pillar in providing care across the continuum.
Historically, cancer care has been identified as fragmented, with barriers for access, timeliness, and coordinated care being problematic. Delays and barriers in breast care delivery may impact patient satisfaction and outcomes surrounding a breast cancer diagnosis. The onset of the COVID pandemic in March 2020 affected all aspects of healthcare globally, including access for screening mammography.
The imaging nurse navigator role was added in October 2014 and challenged to develop a navigational model of care that would impact access, timeliness, and retention across the breast care continuum. Patients were dissatisfied with care delivery, and outmigration was measured at 5% in 2014.
The imaging nurse navigator would be responsible for improving access and timeliness for breast care, which in 2014 measured 26 days from an abnormal diagnostic finding to a breast biopsy.
Objectives: (1) Develop and expand the role of the nurse navigator; (2) improve timeliness for breast care delivery through navigational intervention; and (3) improving access of breast care delivery will impact outmigration, return on investment (ROI), and improve overall patient satisfaction.
Methods: Data collection has continued annually from 2014 to 2020 for over 6500 patients followed by the nurse navigator.
Results: Results have shown continued annual increases in both consults and biopsy volumes, improved timeliness for care and same-day consults, decreased outmigration, and improved patient and provider satisfaction.
In 2020, the timeliness for breast care would be challenged by the COVID-19 pandemic. The nurse navigator continued to provide navigational support for breast care throughout the initial shutdown in March 2020 and continuing through the remainder of the year. Days from abnormal imaging and recommendation showed the highest improvement since program launch, declining to 6 days from a baseline of 25.9 days in 2014.
Navigation had a positive impact on patient accrual and retention, with the lowest decrease in outmigration to 0.5% from a baseline of 5%. The nurse navigator was successful in coordinating a plan of care from outside referring providers, empowering patients for informed decision resulting in increased retention and significant ROI.
Continued collaboration throughout the COVID pandemic to impact same-day breast specialty consults/biopsies initiated by the nurse navigator was sustained at 45% or 425 of 932 cases in 2020 from a baseline of 5%.
Conclusion: Despite the challenges faced globally by COVID-19 we were able to continue to demonstrate the impact the role of the nurse navigator has had on patient accrual, ROI, and overall financial successes of the breast program.
As a result of our program’s success and growth, we have added additional navigators—an imaging nurse navigator, a nurse navigator in high-risk, and a patient navigator.
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