September 2011 VOL 2, NO 5

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Tracking Processes

Boston Medical Center Cancer Care Patient Navigation Program: Tracking Processes Across the Continuum of Care

Sheldon Reeves, PN 

Background: Our patient navigation (PN) program is based at Boston Medical Center (BMC), a private, not-for-profit academic medical center and the primary teaching affiliate for Boston University School of Medicine. PN programs exist in multiple departments at BMC, including medical oncology, urology, otolaryngology, breast health, and primary care. The Cancer Care Patient Navigation Program, housed in the chemotherapy clinic, was developed in 2005. The BMC PN program tracks patients throughout the continuum of care, from a suspicious finding at a community health center, up until completion of treatment and survivorship.

Methods: BMC is affiliated with 15 community health centers throughout the city of Boston. Through this relationship, BMC has created a 2-way communication system between the diverse patient populations and the PN program. By hosting monthly community health center PN train-ings, the BMC navigators have created multiple standardized procedures to ensure optimal patient care. On a cancer diagnosis, the patient is entered into the PN program and is followed through his/her possible surgeries, treatment plan, follow-up appointments, and survivorship. With the advancement of this program, BMC navigators have standardized and tracked their practice and development through myriad systems. These systems include algorithms, Excel spreadsheets, designated navigator medical documentation in electronic medical records, written standard operating procedures, and the computation of monthly provider clinic no-show rates. To keep all of these procedures consistent, BMC navigators attend weekly meetings with the BMC research nurse navigator to discuss patient progress. To track patients throughout their time at BMC, multiple tracking tools are used to follow progress, but also to provide feedback to the PN program for improvement. Examples of these tracking tools include receiving monthly clinical statistical updates, recording attendance at support groups, providing feedback surveys to patients, large enrollment of patients in clinical trials, and attending weekly multidisciplinary tumor board conferences to identify new patients. Navigators keep daily calendars of all patients who are currently enrolled in the program that include clinical appointments, radiology scans, and treatment information.

Results and Conclusions: Patients and caregivers are considered survivors upon diagnosis; therefore, every BMC cancer patient is welcomed into the survivorship program. Whether it is support groups, annual luncheon celebrations, or traveling with patients to a complimentary spa day, patients provide support and encouragement to other patients, caregivers, and family members. Oncology patients can be tracked across the continuum of care through the plethora of tools used by the cancer care PNs that begin at the health center and continue on through survivorship

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