June 2015 VOL 6 NO 3

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Nurse Navigation

Metrics for Successful Nurse Navigation

Alice Goodman 

The role of the nurse navigator in helping patients through the trajectory of their journey from diagnosis to treatment to survivorship has evolved, and in many settings, the nurse navigator has become a key component of a multidisciplinary approach to cancer care.

Studies show improved outcomes in settings where nurse navigation is a part of care. Angelina Esparza, RN, BA, BSN, MPH, Director of Health Equity, American Cancer Society, discussed metrics for measuring quality care and the sustainability of nurse navigation at the 2015 Oncology Nursing Society (ONS) annual meeting.

“Metrics can help us understand the role of nurse navigator and American Cancer Society lay navigator and how that plays out prospectively in the patient’s life,” Ms Esparza said. The effort to develop metrics was initiated at the 2010 National Patient Leadership Summit. This summit convened to develop a consensus and to propose a set of metrics and methodologies to effectively measure the impact of navigation on individuals and systems across the cancer continuum. These metrics were published in a supplement of Cancer.

“ONS funded and participated in developing the metrics,” Ms Esparza explained, “so our roundtable discussions truly reflected the various thought processes we went through. The navigators brought a practical sense of what would work, and sometimes we had to adjust our recommendations accordingly.” The metrics address:

• Eliminating health disparities

• The prevention and early detection of cancer

• The diagnosis and treatment of cancer

• Survivorship and end-of-life care

• Palliative care

• Navigation, family, and caregiver partners

• Patient-related outcomes

• Cost-effectiveness.

Once the metrics were developed, a feasibility study was conducted at the Sanford Cancer Center in Sioux Falls, SD, a large healthcare system that encompasses 43 hospitals. The feasibility study is currently assessing the possibility of success fully implementing nurse navigators, and Ms Esparza shared information from that process. The next step after the study is completed is to disseminate the metrics.

Four tasks were proposed, including (1) characterizing in detail the specific nature of the activities of the navigators as they remedy barriers to the receipt of cancer care, (2) determining whether the presence of a navigator minimizes the percentage of patients with significant delays in receipt of necessary care, (3) providing a baseline assessment of the care coordination activities provided through the patient navigation program, and (4) measuring patient satisfaction with care and their perceptions of the value of a navigator.

“We had clear objectives about what we wanted to measure, but as we started to partner with staff we saw that some of this was not feasible. So, we had to scale back on some of the measures. We were worried about patient burden. Our ideas about timing were not feasible and posed burdens on the patients,” Ms Esparza explained.

The selected measures and instruments used included barrier log, timeliness review utilizing the data abstraction tool, psychosocial and health (eg, the 7-Item Anxiety Scale, the 9-Item Patient Health Questionnaire, and the Functional Assessment), and a patient satisfaction survey.

“We hoped to learn how to effectively measure care coordination and navigation impact on timeliness of care [diagnosis through treatment process], stage of diagnosis and presentation, patient education, continuity of care, and patient-related outcomes [psychosocial measures],” she continued. The patient-reported barriers to care were evenly divided among no barriers, fear and anxiety, and deficit in patient knowledge. A smaller percentage reported access to care, transportation, and financial barriers.

“But even among those reporting no barriers, if you read the log, the navigator’s notes revealed some barriers that were not reported,” Ms Esparza said. “The idea of patient education is really important. It helps allay some of the anxiety and fear.”

She emphasized the important contribution of the lay navigator provided by the American Cancer Society. Ms Esparza noticed that access to care was a big problem for patients who lived in rural areas. Having the lay navigator’s perspective was enlightening, and supports the importance of multidisciplinary teams and collaboration.

“In many cases, it takes 3 navigators to get 1 patient through the cancer journey, addressing access to care, transportation, and financial barriers,” she said.

Some of the lessons learned from the feasibility study include the importance of partnership with staff at all levels, the fact that the selection of measurement tools does not always reflect the reality of the particular environment, and that it takes time to formalize and refine the metrics process. Having a multidisciplinary team approach provides the biggest gain for patients and families. Systematic evaluation yields potential for quality improvement, and collaboration with nonprofit organizations and patient advocacy organizations can be fruitful. 

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