People within the Johns Hopkins community have long known that Lillie Shockney is an amazing nurse. Now she’s got the moniker to prove it. Shockney, administrative director of the Johns [ Read More ]
February 2012 VOL 3, NO 1
Patient Navigation: Blending Imaging and Oncology in Breast Cancer
Jeannine Arias, RN, MBA, MSN, CBCN, CBPN-IC
Background: Patient navigation in cancer care refers to the individualized care provided to cancer patients, families, and caregivers to ease multiple barriers and facilitate timely access to qualified medical and psychosocial care. The relatively new patient navigation concept has become a healthcare buzzword as organizations strive to increase program efficiencies and system retention rates.
Objectives: The purpose of this study is to evaluate the optimization of our regionalized imaging/oncology patient navigation service program. Specifically, the evaluation process examines imaging/oncology volumes, retention rates, and integration rates of our service lines after 2 years of patient navigation implementation.
Methods: We performed our review and evaluation through the following initiatives. Identify key stakeholders, patient groups, and current resources. Define the scope of the patient navigation involvement, job description, necessary educational preparation, and expectations. Identify the current patient navigation process. Identify gaps, obstacles, and barriers to patients and families. Determine program scope, cost, and implementation strategy. Perform a needs assessment. Develop a plan to address and bridge weaknesses in current process. Implement strategies. Develop program outcome measures based on identified gaps and national quality of care standards. Evaluate for future goals.
Results: Immediate onset of patient navigation services, timely treatment, and follow-up remain pivotal in patient satisfaction, outcome measures, retained volumes, quality improvements, and cost-effectiveness. Our recall rate, positive predictive value, false predictive value, and cancer detection rate are well controlled and mirror or better the benchmark data. Our imaging volumes and surgical/oncology volumes have increased. Two of our 3 centers have earned the national accreditation programs for breast centers. The patient navigation employees have been nationally certified in patient navigation from the National Consortium of Breast Centers in breast imaging as well as cancer care.
Conclusion: Performing a systematic evaluation is vital in the identification of the program’s strengths and weaknesses. Regionally, our combined efforts have strengthened our cohesiveness and raised the bar with a friendly competitive spirit.
Patient navigation in cancer care refers to the individualized care provided to breast cancer patients, families, and caregivers to ease multiple barriers and facilitate timely access to qualified medical and psychosocial care.1 The relatively new patient navigation concept has become a healthcare buzzword as organizations strive to increase program efficiencies and system retention rates.2 Professionals linked to hospitals and community outreach efforts seek to improve the patient’s breast care experience with innovative strategies to attract and retain patients. The regional patient navigation focus has been to carve out personalized care service and exceed patient expectations.3
The term patient navigation is now used interchangeably for many layers of patient services. Patient navigator, however, has 2 well-accepted definitions: (1) an individual who may periodically assist with the coordination of care; (2) an individual who is educated to provide continuous support to patients along the entire illness trajectory.2 Our regional breast centers are considered high-volume, low-acuity tumor sites. Main taining consistently stable volumes has justified the presence of a full-time navigator.3 The inception of our navigation program came as the result of outmigration of breast biopsy patients and began with radiology technologist navigators intervening at the diagnostic evaluation process in breast imaging. For the purpose of this study, our region identifies with the second definition, and the duties of the patient navigator include patient needs assessment, patient education, therapeutic support, and coordination of care along the illness trajectory.2 A vast amount of literature supports the profession of nursing to assume the role of the patient navigator. Fifty-five percent of navigators currently working for cancer centers are registered nurses.4 The job class decision is due to the multifaceted responsibilities involved in patient navigation – a nurse practitioner or an advanced practice nurse with an oncology pedigree is best suited for the role.2 Working closely with imaging, we have a balance of nurse navigators, radiology technologist navigators, and volunteer navigators to properly round out our team.
The goal for this study and for the strategic growth of our breast care service line is to take a closer look and to identify our current process and potentially redefine the feasibility and scope of our service line at all levels. Our organization is aware of the breast cancer program accreditation standards, the need for careful oversight of clinical development, and the importance of central data management and development. The intention is certainly to have the special breast imaging services that will meet our patients’ needs. The facility is working on offering the patient an appointment as quickly as possible with 1 call. The vision is to streamline care and reach for patient empowerment, education, and informed decisions. To accomplish this vision, a plan has been created to incorporate a cohesive collaborative team approach. The center has designated 1 phone number for the patient to call. The line is specifically for the breast center patients and internally triaged accordingly. The patient is seen within 7 days. Initially, she meets with a breast physician and an advanced practice nurse. An initial treatment plan is established, providing educational information and resources and individualized support. This is the beginning of the patient navigation relationship. This navigational partner connection solidifies the patient’s care with discussed touch points between multiple modalities.4
The purpose of this study was to evaluate our regional imaging/oncology patient navigation service program. Specifically, the evaluation process examined imaging/oncology volumes, retention rates, and integration rates of our service lines after 2 years of phased-in patient navigation implementation.
The current study was conducted in 3 suburban Midwest hospitals that are part of the same notfor- profit privately owned healthcare system headquartered in the United States. As part of our review and evaluation, we identified our key stakeholders, patient groups, and current resources. These groups include all members of breast care leadership, oncology leadership, and current referral relationships.
A convenient sample of breast biopsy patients within our region was included in our study. The sample consisted of all patients who had Breast Imaging Reporting and Data System (BIRADS) scores of 4, 5, or 6 (suspicious abnormality, highly suggestive of malignancy, and known biopsyproven malignancy, respectively5) who were moving forward and consenting to a breast biopsy.6 Each patient included in the study had been a breast biopsy patient at 1 of the 3 hospitals within a 2-year time frame, specifically from January 2009 through December 2010. The sample size was 1278, ensuring a sufficient sample was referred to the patient navigators.3 The scope of the patient navigator involvement had a defined starting point, the breast biopsy recommendation, and an ending point encompassing the patient’s extended treatments, resources, and other referrals needed post breast biopsy. The patient navigator continued with her patient throughout the treatment phase, reinforcing the surveillance and survivorship programs. Community referrals and resources were encouraged by the navigator to fortify a consistent ongoing support structure for the patient. Survivorship touch points will keep the navigator and the patient in contact throughout her life.
Defining the ending point for navigation can be unclear. Though 85% of women diagnosed will be long-term survivors and the mortality rate has been inching down over the past few years, this disease still took the lives of 41,000 women and men in the United States in 2010.6 There were no exclusion criteria: all patients being recommended for a breast biopsy and completing breast biopsy procedures in our region were included. No population was excluded, and patient referrals to navigation were exclusively provided by our physicians. The job description, necessary educational preparation, and expectations for the role of patient navigator had been defined prior to the study. These stated expectations and job descriptions remained consistent throughout the study.
The post discussion and accumulation of data analysis for further educational endeavors had been requested and approved by the institutional review board for our regional efforts. Content and face validity had been established for all instruments by having them reviewed by our stakeholder physicians, nurses, and other appropriate staff. Furthermore, the cancer registry department confirmed the validity and reliability of our collected data with their data. Their team worked collaboratively with our study.
Outcomes of patient navigation programs reported in the literature include an increase in timely screening services, promotion of timely treatment after a suspicious finding, improved adherence to treatment regimens, and increased patient satisfaction with care.7 Our evaluations show that immediate onset of patient navigation services, timely treatment, and follow-up remain pivotal in patient satisfaction, outcome measures, retained volumes, quality improvements, and cost-effectiveness. Our recall rate, positive predictive value, false predictive value, and cancer detection rate are well controlled and mirror or better the benchmark data. Figure 1 illustrates the patient navigation process implemented in our region.
Imaging volumes have increased 10% as a region and 30% in 1 hospital. Figure 2 reveals the hospital with the largest volume uptake due to our patient navigation program.
Regionally, our surgical/oncology volumes have increased 25% and 40% in 1 of our hospitals. We have room for improvement on our surgical turnaround time, re-excision rates, and surgical retention rates. The integration of our service lines grew exponentially with the natural addition of patient/community outreach programs. Figure 3 shows the growth in surgical volumes.
This integration has increased credibility and physician confidence throughout the area. The clinicians met the challenge of learning and creating a blended role,8 and 2 of our 3 centers have earned national accreditation for breast care centers. The third center was actively working to apply in 2011. The patient navigation employees have all been nationally certified in patient navigation from the National Consortium of Breast Centers in both breast imaging and cancer care.
Retention rates following breast biopsy within the top 2 hospitals of our region have greatly improved since beginning our navigation program. Figure 4 illustrates the difference in the retention rates before and after starting the navigation role in our region. In addition, the number of days between the patient’s screening mammogram and diagnostic mammogram has been dramatically reduced from an average of 16.82 days to 9.82 days. Figure 5 reflects the improvement in turnaround time from screening mammograms to diagnostic mammograms. It became apparent, as expected, that the majority (99%) of our patients were women. In addition, the majority (62%) were over 50 years of age, and 81% were experiencing their first breast biopsy.
Each of the 3 facilities has its individual administrations, demographic markets, and individual payer mix.6 The hospitals are in the same region yet experience a wide variety of patient challenges. Barriers to care vary by geographic location based on characteristics of the population, such as socioeconomic status, ethnic diversity, health system organization, services, resources, and patientspecific factors.7
The region shares the same quality benchmarks, cancer registry information, and outcome measurements. Our radiologist group is contracted by the region and shared by all 3 hospitals, providing consistent readings and the highest quality of care. Our radiologists pride themselves on assigning a breast radiologist lead at each facility.
Based on the findings of this study, the individual hospitals have been able to look more closely at individual operations. The study demonstrates there are some clear operational differences indicated by the biopsy retention rates, surgical retention rates, and the turnaround times. With this objective observation, we can heighten our insight and work more effectively, individually and as a group. This study has piqued discussion, strengthened our work relationships, and supported sharing information across many departments.
Analysis of these data commands the quest for more studies. Identifying gaps as a result of this study elevates credibility and validity for patient navigation. Although there is some agreement in the need for our patient navigation services to expand, this is only the beginning. We continue to strive for less fragmented care and more personal connection, ideally with 1 navigator. Demonstrating our value to leadership is critically important, especially in difficult economic times.3 Our next steps are to address our weaknesses, expand our services, bridge our gaps, and reevaluate.
There is a need to assess the specific navigation requirements for breast patients utilizing valid and reliable instrumentation. This information can then create and provide an educational framework structure for the community outreach programs on an ongoing basis. To extend our regional success, reduce redundancy, develop an acuity system, and increase seamless communication, navigational software is highly recommended. Furthermore, the regional recommendation has been to realign the navigational leadership structure, revamp the navigation job descriptions, redefine clear levels of navigation, create a volunteer patient navigational support team, and provide a strong reporting leadership infrastructure within each hospital. Our multidisciplinary case conferences have become interdisciplinary conferences combining the 2 larger hospitals in close proximity. This recommendation encourages a team approach and improves meeting management for everyone. Our recommendations for the future include providing high-risk assessment and genetic counseling in all of our regional hospitals, and maintaining continuing education programs and seminars internally and externally to strengthen our program.
In an effort to sustain our success and build credibility, the region strives to develop partnerships with neighboring organizations, engage physicians in the navigation processes, and refine our current patient navigation model. Our strategy is to develop our programs and increase foot traffic in our hospitals. We plan to fortify our downstream revenue, retain our current volumes, and cultivate new growth.
This study was generated by a convenient regional sample for 2 years. A longer-term controlled study with a larger population would be useful. The study instruments have been developed by staff within the region and are available to administration, physicians, and staff. The increased accessibility and availability can be greater if offered to others via the Internet.
Performing a systematic evaluation is vital in the identification of our matrix continuum of patient navigation’s interdisciplinary care. The cookie cutter is ineffective. Tailored individuality is woven into the success of the patient’s navigation tapestry. Despite the added cost of the patient navigator’s salary, the program is financially sound and self-supporting. Dynamic patient navigation must continue to evolve and redefine itself to remain relevant.
Our approach is based on a wellness model, not a cancer center model. Our patient focus is our leadership strength, and our journey begins with the patient’s first visit, her screening mammogram. Due to our navigation program success, the region is considering broadening patient navigation service models to all oncology service lines. Breast cancer can be described as a microcosm of the oncology services provided in our region and a springboard template for our innovative business strategy. We look to build our tangible and intangible assets: downstream revenue, market share, reputation, and patient satisfaction.
Essentially, the patient navigation program improves volumes and patient/physician satisfaction and identifies opportunities for potential program development. Patient navigation continues to evolve as an influential component of breast cancer care.
The author gratefully acknowledges the interdisciplinary team at Adventist Midwest Health who provided care, resources, and services to assist the goals and objectives of this study. This article would not have been possible without the assistance of Jason C. Goliath, MD; Clarissa Moholick, MHSA, CCRP, CTR; and Linda Wild, RN, CBPN-IC.
Jeannine Arias, RN, MBA, MSN, CBCN, CBPNIC, is employed by Adventist Bolingbrook Hospital.
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Hoelz TM, Sladek ML, Michaelson PL. Blending nursing roles in oncology and imaging: an innovative strategy. Oncol Nurs Forum. 2007;34:27-31.
Shockney LD. Becoming a Breast Cancer Nurse Navigator. Sudbury, MA: Jones and Bartlett Publishers; 2011.
Stephan P. BIRADS – Breast Imaging Reporting and Data System. http://breastcancer.about.com/od/diagnosis/a/birads_2. htm. Updated July 2, 2011. Accessed August 15, 2011.
Shockney LD. Navigating Breast Cancer: A Guide to the Newly Diagnosed. 2nd ed. Sudbury, MA: Jones and Bartlett Publishers; 2011.
Shockney LD, Tsangaris TN. The Johns Hopkins Breast Cancer Handbook for Healthcare Professionals. Sudbury, MA: Jones and Bartlett Publishers; 2007.
Campbell C, Craig J, Eggert J, et al. Implementing and measuring the impact of patient navigation at a comprehensive community cancer center. Oncol Nurs Forum. 2010;37:61-68.