Metrics are the key to demonstrating the value of navigation along the cancer care continuum. Navigation metrics can demonstrate the benefit of the program to the institution and demonstrate the value of the navigator.
Metrics for evaluating navigation programs need to include measures that assess reductions in barriers to care and improvements in the delivery of timely, effective, and equitable cancer services, said Cheryl Bellomo, MSN, RN, OCN, CN-BN, at the East Coast Regional Meeting of the Academy of Oncology Nurse & Patient Navigators.
“You are obtaining metrics every day,” she said. “You walk into your office and you start meeting with your patients. You are gathering those data, but what you are maybe not doing is just hitting the button to measuring it.”
In oncology, navigation arose to improve cancer screening, early detection, and timely follow-up among low-income and disadvantaged populations.
The success of navigation was measured based on its success at improving screening and detection and reducing follow-up delays among these vulnerable populations. “Over time, navigation programs have expanded their vision and now aim, among other goals, to improve the delivery of care for cancer patients who may encounter a variety of barriers that preclude their receipt of optimal treatment,” said Ms Bellomo, Oncology Nurse Navigator, Intermountain Southwest Cancer Center, Cedar City Hospital, Cedar City, UT.
Navigators receive an abundance of anecdotal information from patients, caregivers, and physicians regarding the value of navigation services.
A literature review of 10 primary studies that evaluated the interventions of the navigator found that navigation improves patient satisfaction, decreases barriers to care, promotes timely access to care, enhances continuity of care, improves symptom management, provides emotional support, and empowers patients.
Utilizing metrics is central to demonstrating the value of navigation in the navigators’ institutions. Metrics are defined as a standard for measuring or evaluating something, using figures or statistics.
As defined by the Centers for Medicare & Medicaid Services, metrics “measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality healthcare and/or that relate to one or more quality goals for healthcare.”
“We can utilize metrics to evaluate the success of our navigator role,” Ms Bellomo said, "to show how we improve the care of our patients by monitoring and measuring outcomes that patient nurse navigation impact.”
Metrics for evaluating navigation programs need to include measures that assess reductions in barriers to care and improvements in the delivery of timely, effective, and equitable cancer services.
Meaningful Measurement
“Many of the metrics that you may see in navigation or oncology lack specificity to navigation,” Ms Bellomo said. “All of our metrics should always be meaningful. Do not measure just for the sake of measuring. You need to measure what you’re going to utilize.”
As an example, although measuring the number of patient interventions and patient satisfaction scores is potentially useful, it doesn’t speak to the unique value that the navigator adds.
As healthcare providers, navigators are responsible for frequently evaluating their care programs by using objective outcome metrics. Navigation programs need to create quality outcomes that support a return on investment.
Navigation programs and the metrics utilized need to reflect the program’s overall goals and priorities. The metrics should evaluate patient experiences, clinical outcomes, and return on investment across the continuum of care.
Satisfaction survey questions to demonstrate value need to be navigator-specific. When measuring clinical outcomes, Ms Bellomo recommends the following:
- Select measures that demonstrate improved outcomes through evidence-based care/quality benchmark measures, whether national or internal
- Keep the data you measure simple, because the more complex the data, the greater the opportunity for confounding variables
- Measure the use of 1 treatment for a specific stage of cancer rather than looking at general outcomes for all patients with that type of cancer
“When looking at business performance, we’re often talking about outmigration. Measure more than just the number of patients that are leaving your institution,” she said. “Include a question as to why. Why are they leaving? Is it because they’re requesting a second opinion? Perhaps their insurance is not covered by your institution? Or is there a lack of navigation?” The responses that differ from the presence of a navigation program will help support navigation’s value.
Ms Bellomo also advises against tracking referral patterns from all physicians or tracking the number of specific procedures performed regardless of stage of cancer or patient preference. “Measure your referrals to multidisciplinary services as a whole, whether it be genetics, genomics, rehab, or radiology,” she said.
Three Categories of Metrics
Metrics to measure can be viewed in 3 buckets: patient experience, clinical outcomes, and business performance/return on investment.
Patient Experience Metrics
A patient experience survey can assess the percentage of patients extremely satisfied with the patient experience related to navigation services. Physicians can also be surveyed about their experience with navigation services and outcomes.
The patient discharge experience can be measured by counting the number of patients who received a discharge assessment and educational packet upon discharge, and from a surgical oncology perspective, by the number of patients who received a surgical oncology educational packet regarding discharge instructions. The same metric applies to the chemotherapy/radiation therapy patient experience.
“You can even look at factors of proactiveness,” Ms Bellomo said. “In planning that discharge, even prior to the patient being admitted, did you arrange for home care services, infusion services? That’s part of your role.”
Clinical Outcomes Metrics
The percentage of treatment plans that followed the National Comprehensive Cancer Network guidelines and recommendations, as discussed by your institution’s tumor conference board, is an important clinical metric.
Patient pathway and compliance with treatment plans takes on greater importance with the influx of oral chemotherapy agents.
Counting the number of patients who received psychosocial distress screening (compliance with Commission on Cancer Standard 3.2) and interventions is another clinical outcome metric.
The number and type of interventions provided to patients being screened for cancer can provide a measure of the success of overcoming barriers to such screening.
A navigator can monitor the time from diagnosis until first consultation and treatment plan. “By getting patients to treatment, getting to the consultation a little quicker, by having many of those questions answered for those patients and starting that discussion about the treatment plan, we were also able to cut down the time that the physician needed to spend on that consultation,” she said. By reducing consultation time, Intermountain Southwest Cancer Center was able to schedule an additional patient on a given day, saving additional money.
The goal of reducing barriers to clinical trial participation can start with a measure of the number of patients educated about clinical trials who had documented barriers and interventions. Navigators can document the number of patients referred to a clinical trials nurse.
The number of patients who received a quality-of-life survey at pivotal points throughout the continuum of care and the interventions provided should also be assessed.
Business Performance/Return-on-Investment Metrics
An institutional goal is to decrease the rate of outmigration and increase the rate of patient retention. Measure the percentage of patients who are diagnosed and treated, Ms Bellomo advised, and remember to document reasons for outmigration.
Document referrals to revenue-generating services to the institution as a whole, including radiology, rehabilitation, palliative care, and tumor-site–specific prehabilitation/rehabilitation programs.
Reducing the number of patients who have to be readmitted through the emergency department (ED) is another key business metric. Count the number of patients readmitted through the ED within 30 days and document the navigation services conducted in symptom management.
Similarly, being proactive in arranging discharge planning (ie, home infusion services, home care) can help reduce length of stay and discharge delays for inpatient medical and surgical oncology units. Measure average length of stay and document navigation services in the coordination of care.
Measure the rate of immediate referrals of self-pay patients by the navigator for financial assistance. “This is key,” she said. “Financial concerns are devastating to our patients.”
Medication coverage is also a huge concern for patients because of the financial burden. In this regard, the number of patients eligible for and assisted with pharmaceutical assistance programs (ie, copay cards and/or free drug programs) should be measured.
