An Interview with Lisa Allison, MS, RN, OCN, University of Colorado Health, and Jeanne Melton, RN, OCN, ONN-CG, Karmanos Cancer Institute
The Academy of Oncology Nurse & Patient Navigators published the highly anticipated Standardized Navigation Metrics last year in the quest to demonstrate the value of navigation programs. Care coordination is one of the areas, or domains, where measurements are applied. The metrics in the domain of care coordination include treatment compliance, barriers to care, interventions, clinical trial education, clinical trial referrals, patient education, time from diagnosis to first oncology consult, and time from diagnosis to initial treatment.
The publishers of the Journal of Oncology Navigation & Survivorship (JONS) were interested in exploring the topic of care coordination further. Specifically, how those elements of care coordination listed above are approached and implemented by navigators in their institutions.
We were fortunate to speak with Lisa Allison, MS, RN, OCN, University of Colorado Health, and Jeanne Melton, RN, OCN, ONN-CG, Karmanos Cancer Institute, about their experiences as navigators, the critical touch points they have with patients, and how coordinating care is executed at their institutions.
JONS Good morning, ladies. And thank you for taking time out of your schedules to talk about your experiences as oncology nurse navigators, and specifically about coordinating patient care. To begin, please introduce yourselves and tell us a little about your work as an oncology nurse navigator.
Ms Allison My name is Lisa Allison, and I have been working as an oncology nurse navigator at UCHealth since 2009. We have a pretty extensive program that includes 2 dedicated thoracic nurse navigators, breast oncology navigation, and GI navigation.
Ms Melton I am Jeanne Melton. I’m an oncology nurse navigator at Karmanos Cancer Institute at McLaren Northern Michigan navigating patients with lung cancer and head and neck cancer.
Specifically, I lead a multidisciplinary lung tumor board that includes our pulmonologists, cardiothoracic surgeons, medical oncology, radiation oncology, radiology, pathology, and support staff. I follow patients who have an abnormal scan, specifically patients with a suspicious nodule.
In addition to my work in lung and head and neck, my center also has a navigator dedicated to our patients with breast cancer.
JONS Can you describe the critical touch points for navigators to meet with patients?
Ms Melton We begin the navigation process as early as possible. For me, that’s with an abnormal scan; for our breast navigator, it’s with initial biopsy. I make contact with patients once they’ve had an abnormal scan and conduct a barrier assessment. I follow them through contact with primary care, pulmonary physicians, surgery if that’s the course, radiation oncology, and medical oncology and stay with them until there is a treatment plan. When that treatment plan is initiated, our care coordinators triage those patients.
Ms Allison We have pretty distinctive, required touch points. Our goal is to meet with patients within 12 hours of receiving a diagnosis. A patient will be given tools, information, and a description of our involvement in their care. They receive an initial introduction to the team and are informed of all the services that are available to them. At this time, we also conduct our initial barrier assessment and provide the foundation for those navigation services and ancillary service referrals they may require throughout the continuum of their care. This barrier assessment is reassessed at several points throughout the continuum.
JONS Beyond the time of diagnosis, what are some of the other critical touch points?
Ms Allison After time of diagnosis, we want to connect with our patients at the initiation of therapy, completion of therapy, and any time the treatment plan changes. There are many examples of those critical times—it could be at a recurrence, initiation of second-line therapy, progression, or creating a survivorship care plan. It is useful for navigators to conduct barrier assessments at any of these times along the continuum.
JONS Can you elaborate on your role in the patient care process from diagnosis through survivorship and end-of-life care? Are you responsible for all patient care, or are there care coordinators in your institutions?
Ms Melton We have nurse care coordinators who educate and triage patients with chemotherapy side effects or questions regarding therapy. I follow patients from the initial appointment with the surgeon, medical oncologist, or radiation oncologist until the final treatment begins.
Ms Allison At our institution, we work in parallel with other staff; for example, the education nurses or the clinic nurses. We coordinate our multidisciplinary tumor boards and facilitate communication throughout the continuum. Our navigators really are the primary touch point for patients if they’re not sure who to call.
JONS We’d be very interested to hear about your typical day.
Ms Allison I think trying to describe a typical day highlights the variability and uniqueness of the role in comparison to what is typically thought of as an oncology nurse role. Every day is different. There’s a lot of follow-up work. There’s a lot of follow-through with hospital and facility processes for referrals and authorizations. As much as you try to approach your day in an organized way, you can count on getting that one phone call that presents a crisis and has to be dealt with right away.
Ms Melton I do attempt to keep a schedule, starting each morning by reviewing hospital lists and pathology reports. I coordinate patient appointments and accompany patients to their first meetings with medical oncology, radiation oncology, or thoracic surgery. I also coordinate the lung multidisciplinary tumor board.
My office is in a hallway between medical oncology and the infusion center, so a lot of patients stop by. Many times, just in those informal conversations, you can determine a barrier, something that’s going on with that patient that needs to be addressed.
JONS How much of your day is spent coordinating care as opposed to your clinical obligations?
Ms Melton I would say one-third of my time at the very least. But it certainly varies. Yesterday, I put in about 3 hours coordinating care for 2 patients. That entailed getting orders from pulmonary arranged through central scheduling, interventional radiology, and calls with the providers. Coordinating care is very time-consuming.
Ms Allison Yes, I would say at least 30%, sometimes as much as 50%. For a young navigation program that is still developing its communication processes, it’s going to take longer. I remember coming to a young program, and I probably spent close to 70% of my time coordinating care. Navigators are uniquely positioned within an organization to identify the gaps in the organizational process. An effective program will reduce the time required to coordinate care.
JONS How do you identify barriers to care, and what interventions can you introduce to remove them?
Ms Allison We use the distress screening tool as the foundation for our assessment. This tool helps us assess the emotional, physical, psychosocial, financial, and logistical needs of our patients. Once we complete our assessment and identify those barriers, we have a range of interventions and support services to offer our patients. For example, if there’s a psychosocial barrier, we have social workers who can help. Depending on the barrier, we may refer our patients to nutrition, oncology rehab, financial counseling, and so on.
Ms Melton I use a flow sheet to identify barriers, and we have a team of people ready to help address them. We have a social worker who can help patients with barriers such as transportation needs. We have a financial counselor. We have a dietitian. All of them work within our medical oncology clinic.
JONS Can you talk about your role in providing education to patients?
Ms Melton Education is ongoing, and it starts at the very beginning; at times that’s even before a diagnosis when there’s just an abnormal scan. Education can be as simple as informing patients about the process and what they can expect. Beyond the process, we want to educate patients on their treatment plan, the purpose of each test and scan, and how that information impacts treatment decisions. It’s also important to provide legitimate websites where they and their families can obtain reliable information.
I provide chemotherapy education, including possible events that may change the original plan. I help patients along their treatment path understand each step while helping them deal with the anxiety and the frustrations that so often accompany treatment.
Ms Allison It’s very similar at our institution. The navigators lead chemotherapy education and are involved in ongoing education, but we can also defer to educators at our institution, as this is their specific role. A lot of the educating we’re involved in is really assessing for understanding. Once they’ve completed an education, do they understand what they’ve been taught?
JONS Are there cultural considerations in your settings that affect your job as a navigator?
Ms Melton We live in northern Michigan, and we have a large Native American population. We’ve had to learn to identify and overcome barriers specific to these particular patients.
Ms Allison It’s a struggle. We have a very diverse population regionally—socioeconomically, educationally, and culturally—so our navigators have to be agile and flexible. We have several resources for non-English speakers in both video and written format. We have to access those services quickly for patients who need them. Becoming familiar with resources available in the community is sometimes the hardest thing for new navigators to learn.
JONS Do either of you have advice for navigators who are just starting out?
Ms Allison From my perspective, one of the things that I’ve seen over and over is that people don’t know what navigation actually means until they’re navigating. I always advise my new navigators to use their resources. Is there somebody else who is positioned within the organization to do what I am trying to figure out? Delegating appropriately can maximize efficiency, thus increasing the caseload of patients a navigator can carry.
Ms Melton Get to know people and their roles within the organization. Those relationships are key to executing your responsibilities and to impacting care. It’s through those relationships and your understanding of people’s roles that you will be able to make a difference. From the schedulers to the pulmonary staff and their office staff, having those relationships help me to efficiently coordinate my patients’ care.
My other advice is to always keep the patients’ needs in focus. They are the ones we are here to serve.
JONS Thank you both for your time today.