December 2014, VOL 5, NO 6

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Patient Navigation

Relationship-Based Care: Creating a Patient Navigation Program Through a Professional Practice Model

Patient navigation has become essential for the care of the oncology patient in a complex healthcare environment; however, the term “navigation” has been used loosely to describe several functions of the role of a patient liaison, social worker, or registered nurse. A navigation program was created recently for patients who were newly diagnosed with breast cancer. This pilot program utilizes (1) relationship-based care, an established nursing professional practice model that employs primary nursing as a care delivery method; (2) the communication functions of the electronic medical record (EMR); and (3) a multidisciplinary team. Using the EMR, essential patient information was entered preoperatively by an ambulatory primary nurse into the care coordination note (CCN). The use of the CCN, which could be viewed by multiple disciplines throughout the continuum of care, provided a means of gathering information related to each patient’s specific healthcare needs associated with the diagnosis of breast cancer, both in the hospital and at home. It also created a link of communication between the ambulatory and inpatient settings, a barrier that has been difficult to overcome for many organizations. Removing the barriers of communication experienced by care providers in ambulatory and inpatient settings facilitates continuity of care and restores patient confidence in the care they are receiving during an extremely challenging experience.

Key words: navigation, relationship-based care, primary nursing

Relationship-Based Care: Creating Patient Navigation Through a Professional Practice Model

In recent years, the terms “patient navigator” and “patient navigation” have become common buzzwords throughout the oncology nursing community; the terms, however, have been used loosely. There are several definitions of what this role means for the patient as well as the qualifications needed to hold this position within an organization. Although many patient navigation specialists are registered nurses, there are also social workers who take on this role and those with other, varied backgrounds.1

Patient navigation is especially important for oncology patients who are thrust into an unknown and complex healthcare world with little or no warning. It provides the tools needed to help transition the patient from initial diagnosis through treatment and into survivorship.1 For navigation to be successful, effective communication with multiple disciplines throughout the treatment journey is essential.1 A lack of effective communication leads to fragmented care and a sense of poor care coordination.2

Using a nursing professional practice model (PPM) with primary nursing as the framework, a pilot project was implemented to provide a communication solution across the continuum of care. Utilizing primary nursing to navigate patients who were undergoing breast cancer surgery and employing tools through an existing electronic medical record (EMR) system, a multidisciplinary team of stakeholders created a communication process for nurses as well as other disciplines to share information throughout the continuum of care. The team included ambulatory and inpatient nurses, managers, informatics personnel, social workers, nurse practitioners, patient care resource managers, and clinical nurse specialists.

Professional Practice Model

According to Johnson and Ezekielian, PPM is defined as “a schematic description of a theory, phenomenon, or system that depicts how nurses practice, collaborate, communicate, and develop professionally to provide the highest quality of care for those served by the organization.”3 Hoffart and Woods also described the PPM as a method of giving control directly to the registered nurse regarding the nursing care that is delivered.4

Having a PPM gives nurses a sense of ownership and autonomy regarding their care delivery. They are able to make independent decisions regarding patient care, have the authority to develop a patient’s care plan, and place orders accordingly.5 An example of PPM—and the specific model used for the project discussed in this article—is relationship­-based care (RBC), which was introduced to the nursing profession in 2004 and includes 3 main relationships: care of patient and family, care of self, and care of colleague.6

The relationship with patients and their families is considered to be the most important within the model. In the context of the RBC model, the patient and family are encouraged to take a very active role in developing a plan of care. This helps build the relationship with all members of the healthcare team and fosters an environment of trust and accountability within the healthcare environment.6

The second relationship within the model is the relationship with self. The model conveys that a nurse cannot safely, effectively, and competently care for a patient if he or she has not first taken care of himself or herself.6All members of the patient’s care team should encourage team members and involve themselves in good self-care practices. Taking the time to care for self helps to reduce the risk of burnout while increasing the ability to provide the quality of care required and expected by patients and their families.6

The final relationship within the model is the nurse’s relationship with his or her peers and other essential members of the healthcare team. Collaboration is crucial within complex healthcare environments. One must take great care to establish healthy relationships with other disciplines that may have a direct effect on the patient. Having healthy working relationships increases effective communication while positively impacting care coordination and patient outcomes.6

Recent research has revealed a connection between having a PPM in place and improved patient outcomes. One year after the RBC professional practice model was implemented at a small hospital in rural Texas, a study demonstrated favorable patient satisfaction outcomes as well as readmission rates after 24 hours.7 Although the sample size was small, the results suggest that the increase in consistency of care had an impact on overall patient experience and satisfaction scores.7

Primary Nursing
Primary nursing is the care delivery model used in correlation with PPM, or RBC specifically, as described in this article. This form of care delivery was introduced in 1968 at the University of Minnesota and has continued to evolve over the past 40 years.8 The emphasis of this care delivery model, much like the previously mentioned PPM, is on the relationship between the nurse and the patient. Having a patient-centered relationship provides the patient with a sense of continuity across all treatment environments.6

In the RBC model, the primary nurse is assigned at the initial point of contact, whether that is an office visit or a hospital admission. The primary nurse then assumes responsibility for the design of the patient’s nursing plan of care and works closely with other disciplines to make sure the patient’s goals are achieved. When the primary nurse is unavailable, an associate nurse is assigned to the patient’s care with the expectation that he or she will continue to carry out the previously designed plan of care agreed on by the primary nurse and the patient.9

Patient Navigation
The first studies on patient navigation date back to 1990 and were originally designed to reduce barriers for low-income patients receiving treatment for breast cancer. The purpose of the patient navigator was to make sure the patients remained in contact with providers throughout the follow-up period.2 Studies dating from 2007 to 2010 showed that patient navigation programs varied depending on the medical setting and the needs of the population served.10 These findings are consistent with recent studies that continue to suggest a high level of variability in patient navigation programs and navigator roles and responsibilities.11

Although early patient navigation studies focused on the low-income patient with breast cancer, more current studies have included the newly diagnosed patient with breast cancer across all socioeconomic demographics. A randomized controlled trial published in 2014 focused on adults who had been recently diagnosed with breast, lung, or colorectal cancer. One group was given standard care, whereas the other group was given access to a nurse navigator for 4 months.11 The study participants identified 3 major challenges, including poor care coordination, lack of relevant information regarding their treatment process, and insufficient attention given to their emotional issues. Participants receiving standard care indicated that a navigator or advocate would have been helpful in the period immediately after diagnosis.11

The participants in the experimental group were contacted by a nurse navigator (NN) within 2 weeks of their diagnosis. The NN served as a patient advocate and source of support, assisted the patients throughout their treatment process, and worked with them to create goals and action plans related to their care.11

The results of the study showed that patients who experienced interventions provided by the NN reported significantly less issues relating to care coordination, improved levels of health information as it related to their treatment, and increased satisfaction in how their psychosocial needs were addressed.11 It was also shown that the effects of this intervention persisted even after the contact with the NN was eliminated.11 Because this study was conducted within an environment where all care was provided in 1 building, many issues with care coordination were effectively eliminated. A replication of this study in a more fragmented care setting may show even more promising results.11

The Pilot: Creating a Communication Plan

The first step in this pilot process was to identify the problem, which was determined to be the lack of communication between ambulatory and inpatient staff regarding a patient’s plan of care in the different environments. The ambulatory staff setting was a freestanding comprehensive breast center affiliated with a large, academic medical center with a freestanding cancer hospital where the inpatient staff was located. Lack of communication among these teams caused care of the patient after surgery to become fragmented, which was not in alignment with PPM and the care delivery model of primary nursing. Evidence of this process could be seen when reviewing verbatim patient comments captured in the organization’s patient satisfaction surveys.

After pinpointing the issue, all key players related to the problem were identified, and each was formally invited to be an active participant in the change process. The key players included a multidisciplinary team of inpatient and ambulatory nurses, managers, clinical nurse specialists, nurse practitioners, physicians, nursing informatics staff, social workers, and patient care resource managers.

The group was brought together for an informal meeting to discuss the issue at hand. It was quite difficult to coordinate a meeting that accommodated everyone’s schedules. This created a sense of frustration that turned to empathy for what our patients must have been experiencing while trying to navigate care provided in multiple settings. Therefore, all meetings were conducted via the Internet. Attendance was high, and participants could attend from a location that was convenient for them.

The next step was to concentrate on the lack of communication between clinical settings and how this could potentially be improved. Utilizing the EMR system available in the ambulatory and inpatient settings became the focus of the team’s efforts. The key was to identify a means by which ambulatory and inpatient care providers could communicate patient information before and after the planned surgical procedure.

The EMR contained an appropriate communication tool; however, ambulatory and inpatient care providers had different viewing capabilities, and research revealed the tool was not being utilized in either setting. The nursing informatics specialist assisted with this part of the project and navigated the group through the EMR. The communication tool was easy to locate, user-friendly, viewable by any care provider in either setting, and was aptly named the care coordination note (CCN).

The group decided that the initial CCN should be completed by the primary nurse. For the purposes of this project, it was determined that the nurse in the ambulatory setting would be the primary nurse, whereas the inpatient nurse would take on the role of the associate nurse, as defined in the primary nurse model. This decision was made based on information provided by frontline nursing staff from the ambulatory clinic and inpatient hospital unit, as well as the patient’s length of stay after the surgical procedure (≤24 hours). According to the inpatient nurses and their manager, the short time frame of the patient stay was making it difficult for the nurses to develop a meaningful relationship with the patient and to implement the primary nursing model of care delivery.

The nursing staff, social workers, nurse practitioners, and patient care resource managers collaborated and devised a system of communication that would provide useful patient information to others who may be involved in the care. Two sets of questions, termed in the EMR system as smart phrases, were created within the CCN. The first set of questions was to be answered by the patient during the preoperative appointment with his or her primary nurse in the ambulatory clinic. The second set of questions would be answered before the patient’s discharge postoperatively by the associate nurse in the hospital. The questions were entered as smart phrases into the EMR using the CCN function. The nurses simply entered the smart phrase, and all questions were automatically populated into the note.

The associate nurses from the inpatient unit also followed up with patients by contacting them via a postdischarge phone call. These calls were made to the patient, a designated caregiver, or a family member within 24 to 48 hours after discharge from the hospital. The information gathered from the phone call was entered into the CCN as a telephone encounter and could be viewed by the primary nurse before or during the first postoperative ambulatory visit. This allowed the patient and/or family needs to be identified, reported, and addressed by the appropriate providers throughout the continuum of care. The process utilizing the CCN across both care settings can be viewed in the Box (see page 26).


In this project, the driving force was the PPM shared by the ambulatory and inpatient nursing staff. Expanding the role of the primary nurse to an ambulatory care site for this specific patient population allowed better navigation and communication across the continuum of care, keeping in mind that how and what we communicate impacts patient care. The CCN created a visible time line of the patient’s progress through the continuum of care. Patient responses to questions provided valuable information from the ambulatory nursing staff and nurse practitioners to inpatient nurses, social workers, and patient care resource managers who assist in the discharge planning process.

The project was implemented in a relatively short time frame with appropriate available resources and could be easily replicated in other healthcare organizations. Mandatory EMR systems allow easier and more efficient communication options for healthcare systems. With more acute symptom management taking place in ambulatory settings, fragmented care will continue to be an issue because of a disconnect between care settings. Developing a patient navigation process that improves care coordination throughout the continuum will likely vary depending on the patient population, demographics, and healthcare setting. However, implementing a navigation process may prove to be invaluable for patients and worth the organization resources and time invested.

Author Disclosure Statement: Both authors have nothing to disclose.

Corresponding Author: Amy Rettig, MSN, MALM, RN, ACNS-BC, PMHNP-BC, CBCN, The Ohio State University Wexner Medical Center, James Cancer Hospital and Solove Research Institute, 58 Olentangy Street, Columbus, OH 43202. E-mail:

1. Oncology Nursing Society. ONS positions: Oncology Nursing Society, the Association of Oncology Social Work, and the National Association of Social Workers Joint Position on the Role of Oncology Nursing and Oncology Social Work in Patient Navigation. Navigation. Accessed December 4, 2014.
2. Hendren S, Fiscella K. Patient navigation improves the care experience for patients with newly diagnosed cancer. J Clin Oncol. 2014;32:3-4.
3. Johnson L, Ezekielian J. Use of a professional practice model to illuminate the importance of relationships.Creat Nurs. 2014;20:127-136.
4. Hoffart N, Woods CQ. Elements of a nursing professional practice model. J Prof Nurs. 1996;12:354-364. 
5. Arford PH, Zone-Smith L. Organizational commitment to professional practice models. J Nurs Adm. 2005;35:467-472.
6. Koloroutis M. Introduction. In: Koloroutis M, ed. Relationship-Based Care: A Model for Transforming Practice. Minneapolis, MN: Creative Health Care Management, Inc; 2011:1-22.
7. Cropley S. The relationship-based care model: evaluation of the impact on patient satisfaction, length of stay, and readmission rates. J Nurs Adm. 2012; 42:333-339.
8. Manthey M. The 40th anniversary of primary nursing: setting the record straight. Creat Nurs. 2009;15:36-38.
9. Tiedeman ME, Lookinland S. Traditional models of care delivery: what have we learned? J Nurs Adm. 2004;34:291-297.
10. Paskett ED, Harrop JP, Wells KJ. Patient navigation: an update on the state of the science. CA Cancer J Clin. 2011;61:237-249.
11. Wagner EH, Ludman EJ, Bowles A, et al. Nurse navigators in early cancer care: a randomized, controlled trial.J Clin Oncol. 2014;32:12-18.

Patient Flow Through Ambulatory and Inpatient Care Environments Utilizing the Care Coordination Note

Initial diagnosis: primary nurse assigned as patient is roomed

  • Establish primary nurse relationship
  • Introduce the nursing plan of care
  • Gather information from patient and place into the electronic medical record (EMR)
    Patient is seen by nurse practitioner
  • Preoperative teaching completed
  • Primary nurse communicates to other members of the patient care team (ie, associate nurses, patient care resource managers, social workers) through documentation in the care coordination note (CCN) in the EMR

Associate nurse admits patient from postanesthesia care unit

  • Checks CCN
  • Discusses plan of care with patient
  • Reinforce education on discharge
  • Advise patient to expect a follow-up phone call 24-48 hours after discharge
  • CCN updated in EMR by associate nurse with any issues encountered during hospital stay (ie, pain, nausea and vomiting, anxiety, problems with anesthesia)

Follow-up Phone Call
Phone call to be made by associate nurse or other designee

  • Will utilize call-back tool in EMR
  • This will be reviewed in ambulatory setting by primary nurse

Postoperative Visit
Primary nurse reviews CCN

  • Discusses patient concerns
  • Reinforces postoperative education
  • Reinforces need for physical restriction
  • Makes note regarding any specific educational needs
  • Updates CCN in the EMR, if necessary

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