May 2016 VOL 7, NO 4

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Evidence into Practice

Continuum of Care and Care Transitions

Cheryl Bellomo, RN, MSN, OCN, CN-BN, and Pamela Goetz, BA 

The scope of navigation has evolved from the Freeman model of community outreach and prevention to spanning the entire continuum of care for oncology patients. Navigators help individuals overcome barriers to care and navigate through the screening/diagnostic, treatment, survivorship, and end-of-life care continuum. These barriers impact outcomes for patients during times when they rely on us to ensure the best outcomes for their situations. Navigators need to have an awareness of the healthcare system, available community resources, and act as members of the multidisciplinary team in order to address an individual’s identified barriers and needs, as well as the coordination of care along the continuum. The role of the navigator along the continuum of care is bidimensional in nature with a patient-centered (empowerment with education and knowledge) and health system (multidisciplinary) orientation to deliver timely, seamless care. Within the multidisciplinary team, the navigator works as an advocate, care provider, educator, counselor, and facilitator to ensure that every patient receives comprehensive, timely, and quality healthcare services.

Competencies of the navigator in regard to continuum of care and care transitions include:

  • Understanding the Chronic Care Model
  • Identification/intervention of clinical and service barriers to care
  • Understanding the patient care process/cancer care continuum (prevention/screening, risk assessment, diagnosis, clinical trials, treatment, survivorship/end-of-life care) and providing referrals to appropriate disciplines and transitions across the continuum of care based on a comprehensive assessment
  • Providing patient/family-centered education (screening, diagnosis, treatment, side effects and management, survivorship/end of life)
  • Identifying models of navigation
  • Understanding and practicing cultural awareness
  • Understanding and practicing health literacy
  • Increasing communication among the healthcare team/multidisciplinary approach to care
  • Participating in Tumor Board/Cancer Conference
  • Understanding of National Comprehensive Cancer Network guidelines, Commission on Cancer, Institute of Medicine, and other national standards in relation to oncology care
  • Using evidence-based guidelines and tools in the assessment, intervention, and evaluation of patient care
  • Understanding of clinical trials (eligibility, enrollment criteria)
  • Understanding of and participation in performance/process improvement across the continuum of care
  • Understanding of available institution, community, and state/national resources. Collaborating with available community resources
  • Providing psychosocial support and empower the patient and family with treatment decisions
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