- G1. Bringing Navigation Communities Together
- G2. Development of a Dedicated Oncology Nurse Navigator Clinical Specialist
- G3. Fast Track to Oncology From an Emergency Department’s Incidental Finding Using Navigation to Address Social Determinants of Health
- G4. Impact of an Oncology Nurse Navigation Demonstration Program on Patient Conversion and Retention Rates
- G5. Improving Systematic Allocation of Navigation Resources: Exploring Time Intensity
- G6. Navigating the Navigators: Standardizing Oncology Nurse Navigation–Leader Orientation
- G7. Using Machine Learning to Accelerate Identification of Pancreatic Incidentalomas
- G8. Utilization of the 2022 ONS Oncology Navigation Standards of Professional Practice as a Foundational Precept to Explore a Revised Navigation Model Across a Large Academic Health System
G1 Bringing Navigation Communities Together
Elizabeth Wigozki, MSN, RN, OCN, CNL; Jennifer O’Brien, BSN, RN, OCN
Dana-Farber Cancer Institute, Boston, MA
Background: There are over a dozen cancer facilities in the Boston area with a variety of nurse navigators, patient navigators, and community healthcare workers collaborating to improve patient outcomes. The Boston Area Oncology Navigators was created to bring the Boston-area navigation community together under the AONN+ local navigation network.
Objective: To build and foster community in the Boston Area Oncology Navigators network by incorporating “Day-in-the-Life” presentations of members.
Methods: The Boston Area Oncology Navigators local chapter consists of oncology nurse navigators (ONNs) and patient navigators in the Boston area, with 87% of membership being ONNs. The mission of the local chapter is to unite, facilitate, and foster learning and collaboration among members. With the goal of facilitating and promoting a shared-governance model for the chapter meetings, an open forum for members was provided to discuss what they were hoping to gain and to learn at future meetings. Shared governance has been shown to be imperative for employee engagement, empowerment, and staff and job satisfaction. The goal was to lead the chapter with these guiding principles for the members. Although the majority of members were from the same cancer institute, there was a desire to share navigation experiences. An overall theme was to create a community of navigators with the ability to learn from each member’s individual experiences.
Results: At the chapter meeting in March 2023, the Day-in-the-Life portion of the meeting was initiated. Two nurses from different hospitals shared their typical day. They discussed their daily tasks, the patient population served, and what navigation looks like at their respective institutions. They also shared their favorite parts of the role, as well as the challenges they face. After the positive feedback following the March presentations, dedicated time was allocated for 2 members to present at each future meeting. This remains a standing agenda item for all future chapter meetings, with both ONNs and patient navigators presenting. The Day-in-the-Life series is a direct outcome of the shared-governance input from the members, with the goal of continuing to provide content that matters to the members to ensure that their voices are heard.
Conclusion: The incorporation of the Day-in-the-Life presentations of members’ experience in navigation has fostered community-building. The approach of shared governance for our chapter meetings has continued to help inform chapter-meeting content. Throughout the country, the role of the ONN and patient navigator is critical in care coordination and to meeting the needs of the patient within multidisciplinary teams. Even though all navigators strive for improved patient outcomes, the work they do to achieve this goal varies. Highlighting roles, responsibilities, accomplishments, and challenges among members helps to underscore the value they hold in the Boston navigator community.
Sources
Aversano J, Boehmer LM, Spira A. Improving cancer care delivery: learnings for oncology nurses and patient navigation from a national quality survey. J Adv Pract Oncol. 2022;13(5):484-493. Accessed June 14, 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9328452/
Olender L, Capitulo K, Nelson J. The impact of interprofessional shared governance and a caring professional practice model on staff’s self-report of caring, workplace engagement, and workplace empowerment over time. J Nurs Adm. 2020;50(1):52-58. Accessed June 14, 2023. https://journals.lww.com/jonajournal/Fulltext/2020/01000/The_Impact_of_Interprofessional_Shared_Governance.12.aspx?context=FeaturedArticles&collectionId=5-
Return to TopG2 Development of a Dedicated Oncology Nurse Navigator Clinical Specialist
Elizabeth Wigozki, MSN, RN, OCN, CNL; Kaitlen Reyes, DNP, FNP, RN; Laura Ma, MS, BSN, RN, OCN
Dana-Farber Cancer Institute, Boston, MA
Background: The role of nurse clinical specialist (CS) provides foundational support that positively impacts oncology nursing care. Historically, this role has been applied to the inpatient setting and ambulatory infusion nursing, but has not been directly applied to oncology nurse navigator (ONN) practice.
Objective: To create a CS position dedicated to ONN practice to meet the ongoing educational and competency needs of this dynamic nursing role.
Methods: ONN leadership met with the vice president of nursing at Dana-Farber Cancer Institute (DFCI) to advocate for the development of a dedicated ONN CS. The ONN nurse manager and director roles and responsibilities were analyzed to delineate tasks and projects that could be amplified by a dedicated ONN CS. Some of the responsibilities identified as CS-appropriate were providing orientation to new ONNs; ongoing education to ONNs on new anticancer therapies; coordination of care; documentation; and telephone triage. A business case was presented to executive leadership that highlighted several areas that required immediate CS leadership. Some of these immediate needs included ONN competencies, updates and conceptualization of policies that directly impact ONN work, and providing ongoing professional development for ONNs and navigation resources.
Results: The position for a dedicated ONN CS was approved. ONN leadership engaged the ONN community in discussion about the vision of the role. Job-description development was modeled after existing CS positions. Requirements included a master’s degree in nursing; a minimum of 3 to 5 years’ experience in oncology nursing; leadership and education experience; and clinical expertise in oncology nurse navigation. The ONN CS would be a member of the ONN leadership team. Their focus would be to proactively identify learning opportunities for ONNs and to collaborate with both ONNs and leadership to develop, implement, and evaluate ONN practice at DFCI. The ONN CS would additionally be an expert clinician and mentor to ONNs.
Conclusion: The ONN leadership team was successful in gaining approval for a dedicated ONN CS. Through advocacy and a comprehensive business case, executive leadership was able to understand the need to support ONNs with a dedicated clinical expert in navigation. Navigation is growing and the need to continually scope the role to support ONNs and patients is essential. Onboarding of the new CS has consisted of working with ONN leadership and existing CS within DFCI. The ONN CS position has immediately enabled the ONN nurse directors and manager to focus on ONN program development and the individual needs of the ONN direct reports.
Source
Oncology Nursing Society. 2008. ONS Oncology Clinical Nurse Specialist Competencies. https://www.ons.org/sites/default/files/2017-05/oncology_clinical_nurse_specialist_competencies.pdf
Return to TopG3 Fast Track to Oncology From an Emergency Department’s Incidental Finding Using Navigation to Address Social Determinants of Health
Jeanne Silva, MSN, RN-BC, CMSRN, CN-BN1; Portia Lagmay-Fuentes, APN1; Avni Patel, MSN, RN1; Amanda Gaughran, BSN, RN1; Odalys Ferguson, MPH2
1RWJBarnabas Health System and Rutgers Cancer Institute of New Jersey; 2Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
Background: Abnormal findings unrelated to the indications for testing are occasionally identified in studies performed on patients presenting to the emergency department (ED). The literature denotes these findings as incidental, and such findings may represent an important discovery requiring an oncologist’s further investigation. Patients leaving the ED after identification of incidental findings are often lost to follow-up due to confusing next steps and practical barriers.
Objectives: To (1) operationalize a standard-care transition from the ED to the ambulatory setting; (2) reduce the time to the ambulatory visit; and (3) identify barriers and social determinants of health (SDOH) that would impede or delay a successful oncology visit with close-the-loop communication.
Methods: A plan-do-study-act method was deployed, and in March 2023, a stakeholder working group was convened to address the ED findings. The group identified specific barriers, including the system’s lack of standardization for referrals to oncology; the ED’s absence of internal referral resources; the patient’s lack of knowledge related to the severity of the incidental finding; and the next steps. Patient barriers included language, lack of insurance, transportation, distrust, and fear of pursuing further diagnostic follow-up. A literature review for evidence-based industry standards provided few examples of comprehensive, systematic processes for managing incidental findings. A standardized workflow was developed and disseminated to the respective stakeholders, illustrating the utilization of the oncology access center (OAC) as the hub, with the ambulatory navigation team as the spokes to connect with the patient in the care setting.
Results: The OAC nurse navigator (NN) contacts the patient within 24 hours to assess SDOH. Practical concerns such as financial, language, and transportation obstacles are transitioned to the equity patient navigators (EPNs) for resources to avoid care delays. The key performance indicators are the number of referrals and facilities, timeliness of oncology visits, completed visits, and practical barriers addressed. In this study, 27 patients were transitioned from the ED to oncology in the first 60 days. Fifteen percent of the patients (n=4) were African American, and 22% (n=6) were Hispanic. Sixty-six percent (n=18) spoke English, 18% (n=5) spoke Spanish, and 11% (n=3) spoke another language. Thirty-seven percent of patients (n=10) were uninsured or underinsured. The EPNs’ skill in expediting charity-care applications reduced the time to care, with most patients (54%) seeing the oncologist within 3 days. In 48% of the ED cases, NNs intervened to accelerate timeliness and avoid return visits.
Conclusion: In March 2023, our system implemented the new workflow at all ED locations with collaborative efforts between the EDs, NNs, and the EPNs, to expedite ambulatory services to vulnerable populations. Using standardized protocols after an incidental finding effectively decreases return visits and improves timeliness, close-the-loop communication, and completed ambulatory visits. NNs effectively address barriers and can transition practical aspects of care, such as transportation and charity-care applications, to EPNs to improve timeliness to care and increase access to financial and supportive services.
Funding: This project was supported, in part, by a grant from the Merck Foundation.
Return to TopG4 Impact of an Oncology Nurse Navigation Demonstration Program on Patient Conversion and Retention Rates
Judy Moore, MSN, RN, OCN, NEA-BC; Sylvia Brown, MS, RN, OCN, CNL, ONN-CG; Cecilia F. Aguerre, PhD, MA; Prince Ampomah, FACHE, MBA, MHA, CHFP; Alexandra Blake, MHA; Sue Ferguson, DNP, MBA, RN, CPHQ, NEA-BC; Elizabeth Garcia, MPA, RN, NEA-BC, CPXP; Sarah J. Harrigan, MSN, MA, RN, OCN; Trina C. Henry, MHA, FACHE; Jena Hodges, MMHC, BSN; Altrivice Revis, MBA; Martha Salas, MBA, MSW; Crystal Swalwell, MS, RN, OCN; Sue Wilson, DBA, RN-BC; Michael Frumovitz, MD, MPH
The University of Texas MD Anderson Cancer Center, Houston, TX
Background: Oncology nurse navigators play a crucial role in the cancer patient’s care. They provide resources, education, and support to identify and mitigate barriers to care, facilitate shared decision-making, and optimize care transitions throughout the treatment journey.
Objective: To describe the impact of an oncology nurse navigator pilot program on conversion and retention rates for new patients at a National Cancer Institute–designated cancer center in Texas.
Methods: A prospective, observational cohort study was conducted. Electronic medical health records and institutional retention data were used to measure the primary outcomes. Conversion rate was defined as the percentage of patient referrals who completed a new patient appointment. Retention rate was defined as the percentage of completed new patient appointments and treatment received at our institution within 4 months of their first patient appointment. Conversion and retention rates were compared between patients who participated in the oncology nurse navigation pilot program and all patients overall during the same time period.
Results: From October 2022 through April 2023, 7 oncology nurse navigators participated in the pilot program. A total of 355 patients received nurse navigation during intake and treatment from breast, gastrointestinal, head and neck, and thoracic cancer service lines. A total of 1735 patient encounters were conducted. The conversion rate for navigated patients was 77%, compared to 54% for patients overall. The retention rate for navigated patients was 59%, compared to 48% for patients overall.
Conclusion: In this study, the oncology nurse navigation pilot program positively impacted patient conversion and retention rates. In addition to providing support to cancer patients and an enhanced patient experience, our results indicate oncology nurse navigation likely positively impacts hospital financial margins through retention of additional patients for cancer therapies.
Return to TopG5 Improving Systematic Allocation of Navigation Resources: Exploring Time Intensity
Carla Strom, MLA; Emily Copus, MSW; Alana Willis, MS; Katherine E. Weaver, PhD, MPH
Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
Background: Patient navigation can be resource intensive when working on the often-complex needs of underserved patients with cancer. Our nonclinical population health navigator (PHN) program was developed to address the inequities underserved populations often face during cancer. With limited resources, programs need to optimize navigation services based on patient population needs.
Objectives: To (1) understand the potential association between time spent on navigator-patient interactions and navigation characteristics, such as the population of focus, type of interaction, and acuity score; and (2) improve systematic allocation of resources and better adjust caseloads among navigators for more equitable distribution.
Methods: PHNs for adolescent and young adult (AYA), African American (AA), Hispanic, and rural patients document each patient interaction, including the type of interaction and time spent, as well as patient characteristics and potential barriers. An acuity scale is also utilized to pre-identify navigation needs and stratify care based on patient characteristics and barriers. Data captured by the 5 PHNs in EPIC/Healthy Planet were abstracted retrospectively from July 1, 2022, to March 31, 2023, for analysis. Data are reported in the aggregate.
Results: In this cohort of 438 patients (AYA, n=85; AA, n=110; Hispanic, n=108; rural, n=135) spanning 1583 patient interactions, 79.6% lasted 30 minutes if the patient was female versus male (55% vs 45%, respectively) or self-identified as Hispanic (52%). The acuity level (no, low, medium, high) is based on the acuity score, and the majority of patients were low (49%) or medium (43%). Patients with a high level of acuity were more likely to have interactions >30 minutes. Patients navigated by the AA PHN were more likely to have interactions >30 minutes (40%), and those navigated by the rural PHN were more likely to have interactions <30 minutes (95%).
Conclusion: Understanding the effort and time needed to identify populations at risk, establish priorities, and address barriers is critical to maximizing patient navigation and, ultimately, to increasing cancer health equity. If certain patient populations have more barriers and higher acuity scores, and are therefore more intensive to navigate, management of navigation resources can contribute to ameliorating disparities and improving outcomes. Further evaluation of the correlation between time intensity, patient barriers, and acuity scores for the refinement of caseload management and the development of systems- level interventions is warranted.
Sources
Baldwin D, Jones M. Developing an acuity tool to optimize nurse navigation caseloads. Oncol Issues. 2018;33(2):17-25. https://www.accc-cancer.org/docs/documents/oncology-issues/articles/2018/ma18/ma18-developing-an-acuity-tool-to-optimize-nurse-navigation-caseloads.pdf?sfvrsn=b0706cfb_7
Carroll JK, Winters PC, Purnell JQ, Devine K, Fiscella K. Do navigators’ estimates of navigation intensity predict navigation time for cancer care? J Cancer Educ. 2011;26(4):761-766.
Strom C. Population health navigators: an innovative approach for supporting underserved patients. Oncol Issues. 2023;38(1):33-40. https://www.jons-online.com/issues/2021/november-2021-vol-12-no-11/4123-population-health-navigation-an-innovative-approach-for-addressing-health-disparities
Return to TopG6 Navigating the Navigators: Standardizing Oncology Nurse Navigation–Leader Orientation
Laura Ma, MS, BSN, RN, OCN; Kaitlen A. Reyes, DNP, FNP, RN; Elizabeth Wigozki, MSN, RN, OCN, CNL
Dana-Farber Cancer Institute, Boston, MA
Background: There are diverse models of leadership across the field of oncology nurse navigation. As the role of the oncology nurse navigator (ONN) continues to evolve, so does the role and competency need of the oncology nurse navigation leader. There are nationally published competencies for ONNs, but there are none yet for oncology nurse navigation leadership.
Objective: At the Dana-Farber Cancer Institute (DFCI), oncology nurse navigation practice had successfully grown 97% over 3 years. The objective was to create a dedicated oncology nurse navigation–leadership orientation to train and support new oncology nurse navigation leaders and sustain momentum and innovation of the oncology nurse navigation program.
Methods: New oncology nurse navigation leaders need to orient to both technological systems and organizational systems. An understanding of how navigation fits within the larger institutional ecosystem is critical. A checklist of multidisciplinary leaders and stakeholders was generated for new leaders to meet one-on-one, as well as cross-functional meetings to attend. ONNs are clinical, but the day-to-day work makes it essential that strong relationships exist with both operational and clinical colleagues. In this rapidly emerging field, a thorough understanding of navigation’s past, present, and its vision for the future is essential for new oncology nurse navigation leaders to learn. In addition, these leaders learn that ONNs also play leadership roles on the multidisciplinary care team and how best to support them. Oncology nurse navigation leaders are there to listen, educate, translate institutional direction, advocate for, and professionally develop their staff.
Results: Within a 5-year time period, DFCI oncology nurse navigation leadership has grown from 2 nurse directors to the current staff of 3 nurse directors, a nurse manager, and a dedicated ONN clinical specialist. Six out of 7 oncology nurse navigation leaders were previously ONNs at DFCI, which has fostered continued professional development and leadership of staff. Oncology nurse navigation–leadership orientation has successfully onboarded new leaders in their role and maintained alignment of practice and vision. This leader orientation has set the foundation and building blocks, as continued growth is expected as navigation grows at DFCI.
Conclusion: As the ONN role continues to grow and evolve, so does the role of the oncology nurse navigation leaders. Developing an oncology nurse navigation–leadership orientation is beneficial to support new leaders in their dynamic role and to continue building relationships across the institute. The oncology nurse navigation–leadership role differs from a traditional nurse-leader position due to the cross-functional nature of oncology nurse navigation practice, and the frequent overlap of workflows with other disciplines. Some of the core competencies of an oncology nurse navigation leader include cross-functional collaboration, innovation, and critical thinking/problem-solving. Future areas for research could include investigation of best practices of oncology nurse navigation leadership so that they can further and foster navigation programs.
Source
Baileys K, McMullen L, Lubejko B, et al. Nurse navigator core competencies: an update to reflect the evolution of the role. Clin J Oncol Nurs. 2018;22(3):272-281. doi: 10.1188/18.CJON.272-281
Return to TopG7 Using Machine Learning to Accelerate Identification of Pancreatic Incidentalomas
Mitch Naylor, MS; Christi French, PhD; Zack Burch, MS; Brook Blackmore, MBA, MSN, RN
Azra AI, Franklin, TN
Background: Pancreatic cancer is among the deadliest forms of cancer, with a 5-year relative survival rate of 12.5%. Pancreatic cancer presents symptoms later than many other cancer types, leading to delayed identification and poorer outcomes. Additionally, certain pancreatic lesions, such as intraductal papillary mucinous neoplasms (IPMNs), carry a malignancy risk of up to 73%. Since pancreatic cancer is difficult to diagnose early, prompt diagnosis and workup of premalignant conditions leads to better patient outcomes. Furthermore, incidentally identified disease may fall through the cracks, leaving the patient to self-manage their diagnosis and treatment. The timely identification and navigation of pancreatic incidentalomas are crucial to ensuring that the patient receives the appropriate follow-up, which may include surgery, cancer treatment, or surveillance.
Objective: Azra AI has developed a navigation workflow built on machine learning (ML) to accelerate the identification of incidental pancreatic findings, including malignancy, as well as premalignant lesions such as IPMNs. This study will explore the prevalence of these suspicious findings and assess the performance of this ML-assisted workflow.
Methods: Azra AI uses natural language processing (NLP), an ML technique, which learns patterns from unstructured text found in clinical documents. Azra AI has developed NLP models that identify the presence of findings in radiology reports in real time. In this study, we use data from 4 health systems in the United States to identify the prevalence of these conditions and evaluate model performance. The model was trained with over 250,000 records. Roughly 88% were not relevant to pancreatic findings and were filtered prior to labeling. Subject-matter experts, including physicians and gastrointestinal nurses, manually labeled 29,462 pancreatic-related radiology reports according to whether the documents contained certain pancreatic cysts, lesions, masses, or suspicion of malignancy. Of the labeled set, roughly 3.4% were found to have these conditions, only 0.4% of the total radiology report set.
Results: The model used in this study achieved precision of 83.9%, recall of 90.1%, and F1 score of 87.1% on the held-out test data set. In summary, the model has a false-positive rate of approximately 16%, while capturing over 90% of the documents containing suspicious pancreatic findings. The model successfully captures these suspicious findings regardless of location within the report, whether they contain specific follow-up recommendations or their inclusion is in the overall impressions. The navigation workflow driven by this model is able to filter over 99.5% of radiology report volume, while surfacing the most likely cases to a navigation team for review and follow-up.
Conclusion: The identification of incidental pancreatic findings is a true “needle-in-a-haystack” opportunity. ML-assisted navigation of pancreatic incidentalomas can drastically reduce manual case-finding effort, increasing time available to spend on patient follow-up. This study proves there is an opportunity to improve patient outcomes with pancreatic incidentalomas, while promoting health equity.
Sources
Hackert T, Fritz S, Klauss M, et al. Main-duct intraductal papillary mucinous neoplasm: high cancer risk in duct diameter of 5 to 9 mm. Ann Surg. 2015; 262(5):875-881. doi: 10.1097/SLA.0000000000001462
National Cancer Institute. Cancer stat facts: pancreatic cancer. 2023. Accessed May 31, 2023. https://seer.cancer.gov/statfacts/html/pancreas.html
Rawla P, Sunkara T, Gaduputi V. Epidemiology of pancreatic cancer: global trends, etiology and risk factors. World J Oncol. 2019;10(1):10-27. doi: 10.147 40/wjon1166
Return to TopG8 Utilization of the 2022 ONS Oncology Navigation Standards of Professional Practice as a Foundational Precept to Explore a Revised Navigation Model Across a Large Academic Health System
Jackie Miller, MSN, RN, OCN
Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
Background: Role delineation provides a critical framework for team-based oncology support services. The Sidney Kimmel Cancer Center (SKCC)-Jefferson Health is part of an 18-hospital, academic health system spanning 2 states and the largest in the Philadelphia region. It comprises 4 Advanced Cancer Care Hubs (ACHs) with a main National Cancer Institute–designated center in Philadelphia. Within this expansive enterprise, 4 oncology navigation teams functioned independently. To streamline workflows and maximize efficiencies, we adopted the 2022 Oncology Nursing Society (ONS) Oncology Navigation Standards of Professional Practice (ONSPP).
Objective: To conduct a process evaluation of our mixed-navigation model using the ONSPP as a framework.
Methods: The enterprise director of navigation (EDN) presented the ONSPP to the enterprise team. In-person, 3-hour, “deep-dive” sessions were held at each ACH to explore application of these standards—based on direct feedback from the navigation teams—and to elevate our current navigation model. All navigation teams participated in these sessions. Posters were created, printed, and distributed to each site. Categories included clinical and nonclinical tasks. Each team brainstormed daily tasks and categorized them during the session. A summary was provided by the EDN and plan-do-study-act models were created for each hub to track changes. Next steps include meeting with stakeholders, reviewing current processes, and determining changes needed. Tasks were transcribed and coded as clinical, nonclinical, and non-navigation by the EDN. Spreadsheets were shared with ACH leadership.
Results: Four enterprise-wide areas of priority were identified: (1) establish a standardized process for medical record retrieval; (2) formalize standards for tumor board management; (3) create aligned metrics; and (4) explore alternative staffing models.
Conclusion: Role delineation is a crucial component to understanding and implementing consistent navigation services. This structured approach provided time and a safe space for navigators to “think critically” about their daily work and identify opportunities for change using the ONSPP as a framework. These deep-dive exercises resulted in a constructive mapping of core actions to fully develop a navigation model across a large health system.
Disclosure: This poster was presented at the 48th Oncology Nursing Society Congress; April 26-30, 2023; San Antonio, TX.
Source
Ciccarelli H, Csik VP, Rogers A, Scheid K, Vadseth C. Delineating roles in a hybrid nurse and patient navigation model can reduce care variation. J Oncol Navigation Survivorship. 2020;11(1). Accessed May 13, 2023. https://www.jons-online.com/issues/2017/april-2017-vol-9-no-4?view=article&artid=2761:delineating-roles-in-a-hybrid-nurse-and-patient-navigation-model-can-reduce-care-variation
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