June 2014 VOL 5, NO 3

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Nurse Navigation

Using a Nurse Navigation Pathway in the Timely Care of Oncology Patients

Deborah Christensen, BSN, RN, OCN, HNB-BC 

Patients and their families facing the diagnosis of cancer can feel lost, uncertain, overwhelmed, and fearful of the healthcare system. The goal at the Intermountain Southwest Cancer Center is to provide patients and their families with a hand to hold throughout their cancer journey and to improve the delivery of oncology care. This goal has been realized by using a nurse navigation pathway that defines steps for early involvement of an oncology nurse navigator (ONN).

The role of the ONN is pivotal in assessing and providing interventions that address the patient’s immediate concerns and barriers to care, addressing the knowledge deficit of diagnosis/treatment/prognosis, hastening staging workup, and enhancing the initial consultation with the oncology physicians. The preparation enhances the initial consultation between the patient and the oncologist by allowing them to focus on the treatment plan, make informed decisions, and receive treatment services in an equitable and timely manner to improve outcomes.

Early oncology nurse navigation and physician collaboration demonstrate significant improvements in the timeliness of care. Notably, with patients who are seen by an ONN prior (3-day minimum) to their initial medical oncology consult, the time interval between referral to medical oncology and the initiation of treatment was reduced by 10 days. An unexpected finding was that the time spent between patients and their medical oncologist in the initial consult was reduced by 24 minutes compared with patients who had not met with the ONN prior to the consult.

Establishing pathways of oncology care that involve the intervention of early oncology nurse navigation can greatly enhance care delivery. Institutions that establish oncology nurse navigation interventions at the earliest opportunity may also see similar or additional benefits.


One word changes lives: cancer. The uncertainty surrounding a cancer diagnosis can be paralyzing, and not only to the individual receiving the diagnosis; questions and concerns also ripple through immediate and extended families. Through the assistance and emotional support of an oncology nurse navigator (ONN), uncertainty and anxiety can be alleviated. The ONN coordinates care and resources for patients with cancer throughout their oncology experience from diagnosis into survivorship.

The role of the ONN is pivotal in providing patients with information and resources to empower them to make informed decisions regarding their care, identify and remove barriers to care, and assist patients in receiving treatment services in an equitable and timely manner. Through early ONN interventions, such as basic oncology education on diagnosis and treatment, coupled with explanation and scheduling of staging studies and molecular assays, patient anxiety can be diminished, and the experience of the medical oncology consult can be enhanced.1,2 Importantly, improved patient outcomes, including time to diagnosis and treatment, mobilization of financial and psychosocial support, and continuity of care, have all been associated with the involvement of an ONN at the earliest opportunity.1,3

Background
Intermountain Healthcare

With 22 hospitals and more than 185 clinics, Intermountain Healthcare is a major healthcare provider throughout Utah and parts of Idaho.4 Intermountain is ranked among the nation’s finest integrated systems and is a leader in defining methods to reduce costs while providing clinical, operational, and service excellence.5 Intermountain’s answer to meeting healthcare reform is shared accountability, which is defined as “...an overarching strategy or approach, based on quality improvement, to deliver the highest quality patient care, optimize the health of those we serve, and manage costs.”6 Key components of this strategy include patient education, shared decision-making between providers and patients, and insurance plan benefits that reward consumers for making optimal choices based on healthcare savings.5

Intermountain Southwest Region
The mission of the Intermountain Southwest Cancer Center (ICC) is aligned with Intermountain’s quest for excellence and shared accountability. Specifically, ICC provides a supportive environment for patients with cancer through the collaboration and coordination of a skilled ONN. At ICC, our goal is to provide patients and their families with a hand to hold throughout their cancer journey and to improve delivery of oncology care. Modeling the patient education focus of shared accountability, new patients referred to ICC receive optimal navigation interventions, education, and resources.

The ICC has 2 facilities: Dixie Regional Medical Center (DRMC) in St. George, Utah, and Valley View Medical Center (VVMC) in Cedar City, Utah. Unique to the ICC is the hospital employment of 5 medical oncologists and 2 radiation oncologists. To date, there are no oncology surgeons employed by either facility. Oncologists from DRMC travel to VVMC to provide oncology care. Statistically, average monthly new oncology patient referrals to the cancer centers are 33 and 18 at DRMC and VVMC, respectively. An ONN meets with oncology patients and families early in the illness trajectory either postoperatively or on referral from the medical or radiation oncologist.

Recipients of Early Navigation
Oncology Patients and Families

Being diagnosed with cancer is a life-changing event. Patients and families are plunged into uncertainty. Beginning at diagnosis, further diagnostic testing, surgery, and subsequent treatments must be accomplished. It has been shown that oncology patients benefit from early navigation and care coordination.1,2 Realized benefits include: reduced anxiety, timely care, a reduction in overusage of hospital services, and, importantly, one point of contact to assist with each patient’s individual needs.1,2,7

Ideally, an ONN meets with patients and families as close to diagnosis as possible. During a time when many medical decisions must be made, providing education and supportive care is vital. Informed decision-making and shared accountability does not happen without this key component. Early patient education on diagnosis, treatment options, and symptom management empowers patients with the information needed to make informed de­cisions regarding their care, alleviating anxiety and uncertainty surrounding their diagnosis. It also prepares patients for their initial consultation with the oncology physician and allows them to focus on the treatment plan, make informed decisions, and receive treatment services in an equitable and timely manner to improve outcomes.

Oncologists and Healthcare Providers
Each ONN at ICC routinely communicates with physicians and other healthcare providers to assist in the care of patients. Formal communication by members of the navigation team occurs weekly. One-on-one communication between oncologists and the ONN happens on a daily basis.

Accordingly, both healthcare providers and patients benefit through the personalized communication the ONN provides. General oncology education provided by the ONN can answer many of the initial questions that patients and families have and allows the oncologist to focus on treatment planning. Staging studies and other preliminary tests may be scheduled prior to the initial consult if there is time.

Methods
Clinic Transitions/Gap Analysis

Throughout 2011, the ICC experienced major transitions in medical oncologists. Changes in staffing and a subsequent influx of referrals led to perceived gaps in care by patients and providers alike. As would be expected, a gap analysis demonstrated that timeliness from referral to an appointment with the medical oncologist had increased from 7 days to 14 days. Temporary oncologists were brought in to help address the situation as permanent oncologists were recruited and interviewed. It was a difficult time for patients and staff and required diligence on the part of the ONN staff to assist patients during this transition.

The navigation team revised the care coordination pathway and developed the navigation pathway depicted in Table 1. Group consensus foresaw the navigation pathway as a fitting answer to timely interventions with patients and families. Newly diagnosed patients with breast cancer referred to ICC were selected as the first group to pilot the use of the navigation pathway.

Breast Patient Pilot Program
Starting in November 2011, the navigation pathway was followed for newly diagnosed patients with breast cancer referred to ICC. Schedulers contacted referred patients with breast cancer and scheduled both the medical oncology consult and an appointment with the ONN. It was explained to the patient that the ONN appointment, termed new patient education (NPE), was to assist them in preparing for their physician visit, identify and address barriers to care, and ultimately, provide education intended to reduce anxiety and uncertainty. Family members were also encouraged to attend.


Table 1

Basic oncology education was provided and patients were assessed for their understanding of treatment options and feelings about these treatments. Any tests ordered by the physician were also explained and scheduled. Molecular testing and education were initiated for eligible patients so that the results would be available at the initial medical oncology consult.

Patients with breast cancer were also given the new patient paperwork to complete at home and a brief tour of the cancer center. Referral to a financial counselor and/or licensed clinical social worker (LCSW) was also provided when needed. Patients were referred to the LCSW if they met 2 of the following criteria: advanced-stage cancer, age 50 years or younger, history of depression or anxiety disorder, weak social support, or if there were children under age 18 years in the home. The conditions were based on items from the National Comprehensive Cancer Network (NCCN) Distress Thermometer and an abbreviated version of the Brief Systems Inventory (BSI-18). Both of these tools have been validated for use in the inpatient and outpatient oncology setting.2,8,9

During November 2011 through May 2012, a total of 29 patients with breast cancer were navigated using the navigation pathway. All of the patients and their caregivers were given the opportunity to ask questions and receive information on staging and treatments for their cancer type. Molecular studies were requested for 7 patients, 12 patients needed additional lab tests, and 7 patients were set up with a financial counselor (Figure 1). Previsit paperwork was given to 28 of the patients, and 20 patients took advantage of a short tour of the infusion area and an explanation of where to present for their appointment. The ONN also used this visit to identify barriers to care such as transportation, lodging, emotional concerns, and financial hardship. Survivorship and support groups were also introduced and encouraged.

Although a formal survey was not done with this pilot group, patients and families expressed feeling more prepared for their visits. They also expressed that wait times to initial contact with the ONN were reduced and timely care was initiated. Notably, the pathway did not establish a process for the ONN to meet with patients prior to being referred to medical oncology. Therefore, patients with breast cancer who were navigated prior to the medical oncology referral were not included in the data set.

Navigation Pathway Extended
By November 2012, the shortage of medical oncologists at ICC was resolved. The cancer center now employed 4 full-time medical oncologists. Consequently, the time lapse from referral to medical oncologist returned to a baseline of 7 business days. Irrespective of these resolutions, the use of the navigation pathway was extended to new patients with all solid tumor types at the initiation of referral to ICC.

Patients, families, and the navigation team expressed their perception of improved care delivery and support through the use of the navigation pathway. This alone influenced the decision to extend the use of the pathway. A database was set up to capture the metrics associated with the use of the pathway when navigating solid tumor oncology patients within the ICC.


Figure 1


Figure 2

Results
Data analysis demonstrated that when patients were navigated via the navigation pathway and attended the NPE, overall care delivery was expedited (Figures 2 and 3).

The time span between oncology referral to the start of treatment was reduced by 7 days in advanced-stage patients with cancer (stages III-IV) and 10 days in patients with stages I-IV solid tumor types compared with patients who were not navigated using the steps of the navigation pathway.

Scheduling patients for the NPE at the earliest possible appointment reduced the time between oncology referral and face-to-face navigation contact by 7 days and 11 days, respectively. Medical oncologists perceived a time reduction in the amount of time needed to complete a new patient consult if the patient had met with the ONN prior to the initial consult.

Billing charges and new consult time values were collected for analysis on 149 patients that were seen by 1 of 4 medical oncologists between September 2012 and June 2013 (Figure 3). Variation in the consult times between oncologists was expected due to each oncologist’s years of experience in oncology and communication styles. Despite these variations, a combined group analysis demonstrated that, on average, the time needed to complete a new patient consult was reduced by 24 minutes when patients attended the NPE prior to the initial consult. This reduction in time may be a result of patients having immediate barriers to care addressed and resolution initiated prior to meeting with the oncologist, which may have led to improved patient and physician preparation, enhanced shared decision-making, and the ability to expedite treatment. As a result, the oncologists at ICC have requested that qualifying patients meet with the ONN a minimum of 3 days prior to the medical oncology consult.

Interventions deemed critical to the success of timely treatment and seamless transitions for the patient were also tracked. The ONN referenced the NCCN guidelines and facilitated a total of 33 staging studies on the appropriate patients. The studies were ordered by the medical oncologist or the referring physician and completed prior to the initial medical oncology consult. Financial hardships were identified in 15 patients and financial counselors or the ONN assisted these patients with the forms and instruction necessary to begin the financial assistance process. Addressing the financial concerns of patients and families at the earliest opportunity enabled patients to make decisions concerning their care with less financial barriers influencing their choices.

In addition, molecular tests were facilitated for 7 patients and 36 referrals were made for other members of the multidisciplinary team, including lymphedema management, nutritionist, LCSW, and physical therapy. All 60 patients received basic oncology education that answered questions such as: What is cancer? How is it treated? What can I expect regarding testing and appointments? Moreover, the ONN addressed cancer treatment goals, tips on how to communicate with physicians, and specific patient needs and concerns.

In addition to a hand to hold, the goal of the ONN is to empower the patient with a voice in his or her healthcare decisions. One of Intermountain Healthcare’s board goals for 2011 was for 25% of patients to have advance directives completed and scanned into their electronic medical records (EMRs); this initiative was extended through 2013 with the new goal being 75% completion.10 Addressing the call for advance directives was also part of the NPE. To illustrate, less than 10% of the 60 patients included in this data set had advance directives in their EMRs, but as a result of having the conversation with patients regarding their desires for immediate treatment throughout their lifetime, 52 of the 60 patients were given advance directive packets.


Figure 3


Table 2

Cost-Benefit Analysis
Prior to the navigation pathway, new patient consults were scheduled for 80 minutes. As shown in a cost-benefit analysis (Table 2), new patient consults were scheduled for 60 minutes if the patient was scheduled for the NPE with the ONN. Theoretically, a medical oncologist could see an additional patient each day due to the time reduction associated with the navigation visit. More important, however, is the early establishment of the ONN/patient relationship because when the ONN is involved early in the patient’s care, a patient reports greater satisfaction and less anxiety overall.2,3

The cost-benefit analysis was also used to demonstrate the cost-savings to the clinic that may be realized when patients have received education through the NPE meeting. Coupled with the metrics in Figure 2, these data were used to promote the need for an additional ONN, which, subsequently, was successful. Consequently, the program was extended again to include hematologic patients with cancer. Data on patients who have been navigated by using the navigation pathway continue to be collected. These are examples of how data can justify the expansion of ONN positions as well as define the role of the ONN nationwide.

Limitations and Future Direction
The initial results of the benefits of using the navigation pathway to establish early ONN contact for education and addressing barriers to care appears promising. However, several limitations of the study have been identified. The sample size was not optimal and the study was limited to 1 institution. Furthermore, patient demographic information was not collected and analyzed. Therefore, it is not known if the study population is a true representation of the ICC oncology patients benefiting from early navigation. Stratifying results by using patient demographics, including age, diagnosis, socioeconomic status, and culture, may have identified consequential variances in statistical results. To improve further study results, patient demographics, including, age, gender, and diagnosis, are now being collected in a dedicated database designed specifically to capture ONN interventions and outcomes.

The results of patients’ perceptions of distress pre- and postnavigation would have been useful in verifying study results. To that end, a patient satisfaction survey and results from using the NCCN Distress Thermometer will be used in the coming year to help qualify patient’s perception of distress and the benefits of the NPE and early intervention and support by the ONN.

Conclusion
With a diagnosis of cancer, patients and their families need assistance, resources, emotional support, and a hand to hold during a time filled with uncertainty, fear, and anxiety. The interventions of an ONN in identifying and addressing barriers, providing education and resources, and giving emotional support can assist in alleviating patients’ fear and anxiety, as well as helping to empower them to make informed decisions regarding their care. Statistical outcomes have demonstrated that at ICC, early ONN interventions led to reductions in time from referral to medical oncology and the initiation of treatment. In addition, patients that were educated on the basics of oncology treatments, staging studies, molecular profiling, and patient-­specific resources were better prepared for their initial medical oncology consult and were able to focus on treatment plans, resulting in less time needed to thoroughly complete the initial consult.

Further research into pathway and process design is needed within each institution to continue to gather best practice evidence and to extend the ONN role and benefits of early oncology nurse navigation in the care of oncology patients.

Author Disclosure Statement: Ms Christensen reports receiving honorarium from Millennium Pharmaceutical and Celgene Pharmaceutical. Ms Bellomo has nothing to disclose.

Corresponding Author: Deborah Christensen, RN, BSN, HNB-BC, Intermountain Southwest Cancer Center, 1155 W. Bloomington Drive South, St. George, UT 84790. E-mail: deborah.christensen@imail.org.

References
1. Case M. Oncology nurse navigator: ensuring safe passage. Clin J Oncol Nurs. 2011;15(1):33-40.
2. Swanson J, Koch L. The role of the oncology nurse navigator in distress management of adult inpatients with cancer. Oncol Nurs Forum. 2010;37(1): 69-76.
3. Campbell C, Craig J, Eggert J, Bailey-Dorton C. Implementing and measuring the impact of patient navigation at a comprehensive community cancer center. Oncol Nurs Forum. 2010;37(1):61-68.
4. Intermountain Healthcare. Awards and recognition website. http://inter mountainhealthcare.org/about/overview/awards/Pages/home.aspx. Updated 2013. Accessed October 28, 2013.
5. Intermountain Healthcare. Shared accountability strategy website. http://intermountainhealthcare.org/about/overview/trustees/fortrustees/shared accountability/Pages/strategy.aspx. Updated 2013. Accessed October. 28, 2013.
6. American Nurses Association. The value of nursing care coordination (white paper). American Nurses Association; 2012:1-24. www.nursingworld.org/carecoordinationwhitepaper. Accessed August 18, 2013.
7. Fulcher C, Gosselin-Acomb TK. Distress assessment: practice change through guideline implementation. Clin J Oncol Nurs. 2007;11(6):817-821.
8. Jacobson P, Donovan K, Trask P, et al. Screening for psychological distress in ambulatory cancer patients. Cancer. 2005;103(7):1492-1502.
9. Merport A, Bober S, Grose A, Recklitis C. Can the distress thermometer (DT) identify significant psychological distress in long term cancer survivors? Support Care Cancer. 2012;20(1):195-198.
10. Intermountain Healthcare. Cancer services at Intermountain facilities website. http://intermountainhealthcare.org/services/cancer/centers/Pages/ home.aspx#Intermountain. Updated 2013. Accessed October 23, 2013.

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