November 2011 VOL 2, NO 6

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AONN 2011 Second Annual Meeting Coverage, Patient Navigation

Patient Navigation Across the Continuum

Linda Fleisher, PhD, MPH 

A collaborative approach to patient navigation that involves both clinical and community navigators can ensure that the final navigation program reflects the needs of your particular institution, according to Linda Fleisher, PhD, MPH, assistant vice president of Health Communications and Health Disparities at Fox Chase Cancer Center, Philadelphia.

Navigation is both a noun and a verb, she said. “Ask yourself, ‘Whose role is it?’ But also ask yourself, ‘What are we trying to accomplish?’”

At Fox Chase, Fleisher and her colleague, Bonnie J. Miller, RN, BSN, OCN, FAAMA, administrative director of the Women’s Cancer Center, have taken a collaborative approach to patient navigation by bringing together the community side and clinical side in a comprehensive fashion.

“Many of us at Fox Chase want to have a more comprehensive, systematic approach to patient navigation,” Fleisher said. “One size does not fit all. There are a lot of best practices and standards for navigation programs, but the program at your institution needs to be designed to fit your needs.”

STEERING COMMITTEE

In her quest to get navigation programs off the ground, Miller said she has learned many lessons over the past few years. A key accomplishment was developing a navigation steering committee, which she chairs.

“I really believe that navigation is not just in the clinical setting. And that’s where I feel like Linda and I bridge that gap,” said Miller, who is also a cancer survivor. “She’s doing a lot of work in the community setting, and I’m doing it in the clinical setting. And there’s a pass-off back and forth.”

The navigation steering committee has 3 goals: consistency in the messaging about navigation, communication, and collaboration.

Miller said their navigation program is very disease specific. They began with a breast cancer program and have added head and neck, gynecology, and thoracic. They are launching a gastrointestinal program and an expanded gynecology program, and they have placed a navigator in the infusion room.

“Each and every one of the navigators is part of the steering committee,” she said. “We are not making decisions, and we are not building a strategic plan unless the navigators are a part of the process.”

QUALITATIVE MEASURING

“My responsibility as the administrator is to make sure that I’m collecting data, measuring, and sustaining the program,” Miller said. “My role is to make sure that I’m pushing out the information to physician champions, senior leadership, and the board so that navigation becomes a part of their verbiage and they understand what we’re doing. I can’t tell you enough that it’s very, very important to data capture.”

Equally important is finding a database that makes sense for your institution. Included in the database are the patients, their demographics, contact information, insurance, and next of kin.

“We’ve been able to take the time and effort in our database and our data entry from about 40% to 50% now down to about 15% to 20%,” Miller said.

It’s also important to have effective internal and external marketing, including physician champions, presentations to the management team, a Web site, and commercial and print materials.

“By adding patient navigation, our retention rate on an average, across the disease sites, is somewhere around 66% to 68%,” Miller said.

She added that the next steps in their program include the following:

  • Expand navigators’ role in research

  • Develop and conduct systematic patient satisfaction and impact evaluation

  • Expand navigators’ role in service line design

  • Continue education about the role and scope of navigation

“I would suggest that you communicate with your administration and that you build something that is going to help sustain your program,” Miller said. “I really believe that navigation is ever-changing, ever-evolving, and always patient-focused.”

COMMUNITY OUTREACH PROGRAMS

Community outreach at Fox Chase starts with a program called the Office of Health Communications and Health Disparities, which includes community cancer education in multiple languages and community screening. And its Resource Education Center, for both navigators and patients, work hand-in-hand.

“Community navigators are different from the clinical navigators,” Fleisher said. “These are seasoned health educators who have extensive community work and cancer background. Their role is really to ensure follow-up care. They are helping with appointments, transportation, and referrals to support services.”

Fox Chase’s Mobile Mammography Navigation is a pilot program that focuses on the underserved population. Women who participate and have an abnormal finding are contacted by a navigator, who then assesses and addresses barriers to follow-up care. The navigator then provides support to return to Fox Chase or another appropriate facility for follow-up.

“We looked at 29 women who were uninsured. Many of them needed additional tests,” Fleisher said. “One of those women was diagnosed with breast cancer, and we’ve been able to get her insurance. She’s being treated at Fox Chase. To me, this is the success. I do not want to be screening in the community and not have ways to get people to receive quality care.”

A separate service called Project REACH is a pilot for the community-based prostate risk assessment program and is geared toward high-risk men. Community partners provide a screening location for the mobile van, which provides full services, including digital rectal examination, PSA screening, and education.

“So far, we’ve screened 12 men,” Fleisher said. “Like the mammography program, the navigators are present at the screenings, they address barriers, follow all men with an abnormal result, and work with financial services.”

She said that plans for community navigation include identifying more opportunities for funding and seeking IRB approval to conduct quality improvement and outcomes analyses.

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