National AONN+ Initiative in Collaboration with Astellas: Unlocking Navigation Acuity

October 2019 Vol 10, No 10
Danelle Johnston, MSN, RN, HON-ONN-CG, OCN
Chief Nursing Officer & Senior Director of Strategic Planning and Initiatives, The Lynx Group/AONN+
Tricia Strusowski, RN, MS
Manager, Chartis Oncology Solutions, Decatur, GA
Nicole Messier, RN, BSN, ONN-CG, OCN
Nurse Navigator,
University of Vermont Medical Center
Lianna Willhite, RN, BSN, ONN-CG, CBCN
Hendricks Regional Health, Danville, IN

Executive Summary

A gap exists in the availability of a standardized and validated evidence-based acuity tool in patient navigation to aid in the optimal allotment of navigation services and resources. The Academy of Oncology Nurse & Patient Navigators (AONN+) announced a collaboration with Astellas US, LLC, in response to this identified gap in navigation at the AONN+ 9th Annual Navigation & Survivorship Conference in 2018. The aim of the project is to develop, standardize, validate, and implement an evidence-based navigation-specific acuity tool that will characterize the intensity of the navigation workload, aid in the allocation of navigation resources, and measure the effectiveness of navigation on patient outcomes.

A team of national leaders with knowledge and experience in navigation and acuity was assembled and included 2 leaders from Astellas with expertise in patient experience, quality, and outcomes, as well as statistical analysis. The AONN+ Acuity Team performed a thorough literature review of articles published in the past 10 years related to acuity in oncology to establish an evidence base for the development of a navigation-specific acuity tool; 1711 articles were screened, 199 full-text publications reviewed, and 105 relevant articles identified. Findings from the review and analysis of relevant articles, using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) model, identified the relevant articles with key factors and barrier categories that should be included in a navigation acuity tool that could be utilized in all models and settings of navigation. The acuity project team then met in March 2019 for an “Unlocking Navigation Acuity” Retreat for further in-depth discussion about defining acuity in navigation and the weighting of specific barriers within each barrier category.

Four focus groups comprising navigators and administrators were held at the AONN+ 2019 Midyear Conference in May to gain insight regarding the design and function of the acuity tool. Identified barrier categories to be utilized in the acuity tool were introduced, and participants provided feedback about the weighting of the distinctive barriers within each category. A biostatistician was enlisted to further assist in the weighting of the barriers discussed within the focus groups. Four additional focus groups following the same format will be held at the AONN+ Annual Navigation & Survivorship Conference in November 2019 to ensure that the insight gained is relevant, reliable, and valid.

Once developed, the evidence-based navigation acuity tool may aid navigators in the identification of levels of patient acuity based on the barriers to care, weights of the barriers, and level of distress of their patients.

Introduction

Tools that help to characterize patient acuity have been used in healthcare for decades and have proved successful as a means of improving patient care, determining staffing needs, and controlling costs. In fact, a wide array of acuity tools used for a variety of different purposes exist, but there has been little nursing research into the relevancy, validity, and reliability of these tools. One of the problems inherent to the study of acuity is that the term is often used without specifying an exact meaning or referencing which attribute of acuity is being examined.1 In other words, an acuity attribute must be defined by how it is intended to be used or what it attempts to quantify. Brennan and Daly identified 4 acuity attributes: nonpatient-related, patient-related, provider-related, and system-related. The authors further defined each attribute with specific characteristics. For example, one of the ways that patient-related acuity can be characterized is by Severity, or the seriousness of the illness or the amount of psychological distress.1 Another similar attribute is Nursing Intensity, which refers to the amount of work a patient requires and that can be measured by “nursing hours per patient day.”1 In their concept analysis, Brennan and Daly only describe acuity and acuity tools that relate to nursing care of patients on an inpatient unit.

Over the past decade, there has been enormous change within the oncology setting, which has led to the need for navigation services. Navigators have become an integral part of the multidisciplinary team with a focus on guiding the patient through the cancer care continuum while identifying and addressing barriers to care. These services are carried out by professionals of different backgrounds and education levels. Commonly, navigators may be nurses, social workers, or other nonclinically trained individuals. They may be employed or volunteer and may work in various settings, including academic centers, private practice, and specialty centers, with either an inpatient or outpatient focus.

Navigation services are rarely reimbursable, so there has been debate about whether such services are fiscally prudent. There has been a call for a measurable way to validate the benefit of navigation services. Oncology administrators and leaders want to be able to measure the return on investment for navigation programs. A major step to addressing this concern was made with the introduction of standardized navigation metrics from AONN+ in 2017. These 35 evidence-based navigation metrics allow all models of navigation programs to measure their success and sustainability.2

Although standardized metrics help us measure the outcomes of navigation, a gap exists for best practices to optimize the utilization of navigation resources. The diversity of practice settings and types of navigators along with the need for a tool to be used across the cancer care continuum present unique challenges. A number of practices and professionals have sought to develop navigation acuity tools as a means to assist with allocation of resources, caseload management, and workflow. A review by the task force of these existing tools reveals that a navigation acuity tool, although similar in structure to nursing acuity tools, requires unique structure and measurements. There are reports that some institutions have abandoned their “homegrown” tools because they did not, in fact, measure patient acuity. Most tools were designed specifically for a particular practice or purpose. None of the existing tools have been validated, and most cannot easily be replicated in other facilities.

In 2018, AONN+ identified a gap regarding the lack of an available navigation-specific acuity tool and recognized the opportunity to develop a validated evidence-based tool to measure the intensity of navigation services. The tool will be designed for use across the cancer care continuum with the intent to be used in all care settings and navigation roles to build sustainable navigation programs. In November 2018, at the AONN+ 9th Annual Navigation & Survivorship Conference, a collaboration was announced between Astellas US, LLC, and AONN+. The goal of the collaboration is to develop, standardize, and validate an evidence-based oncology acuity tool. When finalized, the acuity tool is expected to help oncology navigators characterize the intensity of the patient navigation workload, aid in the allocation of resources, and measure the effectiveness of navigation on patient outcomes. The acuity tool may support and enhance the effectiveness of oncology navigators through patient-centric evidence-based methods that may have the potential to decrease the overall cost of care.

A team of national key knowledge leaders in navigation with experience in exploring acuity within the navigation setting were identified and brought together. The team includes 2 leaders from Astellas who have expertise in the patient experience, quality and outcomes, and statistical analysis, which has enhanced value to the team.

The project team has examined the known navigation acuity scales found in the literature to provide the basic framework for the development of a standardized acuity measurement incorporating navigation core competencies, national oncology standards, and the AONN+ navigation metrics. Research articles related to patient acuity in an oncology setting published in the past 10 years were analyzed to provide an evidence base for the development of a navigation-specific patient acuity tool to determine the level of support cancer patients may need from their oncology team. A total of 1711 articles were screened, 199 full-text publications were reviewed, and 105 relevant articles were identified. For the full review of literature, please reference “Key Considerations for an Evidence- Based Oncology Patient Navigation–Specific Acuity Tool: A Scoping Review,” published in the Journal of Oncology Navigation & Survivorship in July 2019.

Focus groups with navigators and administrators are being held to collect navigators’ perceptions of the design and function the acuity tool will play in their work environment. Barrier categories will be introduced that will be utilized in the navigation acuity tool, with discussion about the weighting of specific barriers within each category.

With the vast amount of literature that was reviewed, the national acuity team decided how to dissect the evidence-based literature so it would support the creation of a validated evidence-based navigation acuity tool. The acuity team divided into pairs, and each examined and evaluated the literature with the following question-related categories:

  • What are the definitions of acuity, acuity tool, acuity system, barriers to care, and distress?
  • How can barriers be categorized?
  • Is there a relationship between barriers and acuity?
  • Is there a relationship between distress and acuity?
  • What acuity tools already exist?
  • How can a patient acuity score relate to productivity, return on investment, staffing/caseload, effectiveness, and time management?
  • Review of the AONN+ Metric/Acuity Crosswalk

Each team presented their assigned categories with the goal to summarize the highlights and share the level of evidence. The entire team further discussed the key factors that would need to be in the navigation acuity tool and brainstormed next steps.

The acuity team discussed what is essential to be included in an oncology navigation acuity tool that could be utilized by all models of navigation in all settings. There was a realization that some barriers may need to be weighted more heavily to demonstrate the higher complexity related to barriers and distress that could exist for the patient and their family. A biostatistician was enlisted to aid with the weighting of the specific barriers that were discussed during the AONN+ navigation acuity focus groups. The goal for the evidence-based, validated navigation acuity tool is to identify the levels of patient acuity based on their barriers, weighting of those barriers, and level of distress.

Problem Definition

As stated above, today’s healthcare is driven by the delivery of value, quality, and outcomes. For cancer programs to receive full reimbursement from payers, they must not only demonstrate that patients receive high-value, high-quality care, but they must also show improved patient outcomes. This, in and of itself, is a challenging endeavor. Adding to the challenge are healthcare workforce shortages, diminishing financial resources, and an aging patient population. It has been shown in the literature that navigation services are an essential component of quality oncology services that can address many of the challenges to provide patient-centered, value-based healthcare.3,4 The Commission on Cancer (CoC), the National Accreditation Program for Breast Centers, and the Oncology Care Model are some of the governing bodies that have mandated that navigation processes must be in place to achieve accreditation or reimbursement.5-7 The expectation of these agencies is that effective navigation services will impact clinical outcomes, patient experience, and return on investment. Yet, significant programmatic challenges exist for organizations trying to adequately staff navigation programs and provide services to all cancer patients throughout the continuum of care. As navigation programs are developed, administrators struggle to answer questions such as: Which patients need to be navigated, and for how long? How do we know if the navigation process has been effective? What is a manageable workload? How can we measure patient outcomes related to navigation? Is navigation cost-effective?

To answer such questions requires a thorough examination of patient acuity attributes specific to navigation. When patients are classified according to a reliable system, some generalizations can be made about their needs. For example, intuitively, we can understand that a very ill patient requires more time, resources, and services than a healthy person. The issue of how to allocate resources becomes very muddy when the spectrum of health-related needs is multifaceted and diverse. It is also complicated by the complexity of the current healthcare system, the many barriers to care that exist, and the unique desires of patients. The issue is further compounded by the fact that navigation programs are not uniform in size, structure, or function. Only when the needs of the patient can be accurately quantified can a practical method for allocating resources, measuring effectiveness, and determining outcomes be defined. As such, a navigation-specific tool that will reliably assign acuity to any given patient is of paramount need.

High-Level Solution

It is possible to define attributes of acuity that are specific to navigation when specific navigation activities are agreed upon. In a navigator role delineation study conducted in 2016, many attributes of navigation were defined.8 In that study, Lubejko and colleagues cited “identifying and assisting patients with individual barriers to care” and “collaborating with physicians and other health care providers to identify and reduce barriers” as being 2 of the top 10 tasks reported by navigators. Reviewing the recommendations from professional nursing organizations and other governing bodies also sheds light on important navigation activities. Recently, the Oncology Nursing Society updated their Oncology Nurse Navigator Core Competencies.9 Under the heading of Coordination of Care, a number of navigation activities are listed, including the following:

  1. Assesses patient needs upon initial encounter and periodically throughout navigation, matching unmet needs with appropriate services and referrals.
  2. Uses appropriate screening/assessment tools such as the [NCCN] Distress Thermometer.
  3. Identifies potential and realized barriers to care and facilitates referrals to mitigate barriers.

AONN+ recognized that the profession of patient navigation is rapidly expanding and evolving. Therefore, AONN+ identified an opportunity to define oncology navigation areas of functional knowledge domains to create standardization in role definition and execution. The 8 functional knowledge domains are as follows: Community Outreach/Prevention, Coordination of Care/Care Transitions, Patient Advocacy/Patient Empowerment, Psychosocial Support Services/Assessment, Survivorship/End of Life, Professional Roles and Responsibilities, Operations Management/Organizational Development/Healthcare Economics, and Research/Quality/Performance Improvement.2

The attributes specific to navigation acuity include (but are not limited to):

  1. Identification of barriers to care in each stage of the cancer continuum.
  2. Interventions to remove barriers to care.
  3. Distress screening: “The primary objective/reason for screening for psychosocial distress along the cancer continuum is to address patients’ perception of quality of life.”
  4. “Utilization of the distress assessment tool can effectively guide and assist the nurse navigator in providing high-quality, holistic, and patient-centered care.”

And, finally, the CoC also acknowledges the importance of assessing barriers to care (Standard 3.1 Patient Navigation) and distress (Standard 3.2 Psychosocial Distress Screening). To complete the process, the CoC requires written documentation of barrier resolution processes in each institution’s policies and procedures.5

Clearly, these experts in the field of navigation concur that assessing patients for barriers to care and for psychosocial distress are key functions specific to the navigator role. It stands to reason, therefore, that a definition of acuity attributes specific to navigation would include a consideration of the number of barriers that a patient is experiencing. Barriers to care are many and varied. They can be categorized in a variety of ways, such as physical barriers, psychosocial barriers, systemic barriers, financial barriers, educational barriers, etc. If the work of the navigator is to facilitate the resolution of these barriers, then a patient with more barriers or more challenging barriers would be assigned a higher acuity score. Similarly, distress is an important indicator of how a patient is coping with life challenges, a cancer diagnosis, and barriers to care. If a patient reports a high distress level, the navigator works to facilitate interventions to reduce that level through active listening, education, and referrals to support services. It would seem that “the intensity of navigator work is inversely related to both barriers and distress.”10 It would also seem that the resolution of barriers and distress would increase the quality of the patient’s oncology experience and increase their satisfaction with navigation services.

Examples of navigators using barriers to care and distress to define acuity can be found in actual practice. In their Patient Navigator Acuity Monograph, Sullivan-Moore and Cook11 created a Patient Navigator Acuity Scale that describes acuity as a function of both assessed barriers to care and the patient’s distress level. They associated higher acuity scores with higher intensity (hours of labor) and theoretically have the potential to decrease as patients move toward treatment.11 At the University of Arizona, navigators are using the same tool in a novel way to measure navigation-driven patient outcomes.10 Similarly, they postulate that decreasing acuity levels demonstrate effective navigation. Moving a patient from high acuity to low acuity may be considered a navigation-specific patient outcome measurement.

An important clinical question to ask: Is a decrease in the number of barriers and the level of patient-reported distress, as indicated by a lower acuity score, a direct result of navigation interventions? There are no published data to uphold that supposition, which is a clear indication that more work is needed to better understand the concept of acuity as a function of barriers and distress. There has been some unpublished preliminary work applied to the Patient Navigator Acuity Scale in a retrospective chart review conducted by Lianna Willhite, RN, BSN, ONN-CG, CBCN, from Hendricks Regional Health.12 In that review, she found a direct relationship between the number of identified barriers and a higher acuity score. She also discovered that a high number of barriers and higher acuity scores correlated to increased navigation time. Additional study is needed to further correlate productivity and cost savings related to navigation of the high-acuity patient.

Additionally, the University of Arizona and others are using acuity scores to drive navigation activity.10 In this model, a “Telephone Follow-up Protocol” is assigned to each acuity level, with patients of higher acuity receiving more follow-up calls than patients of lower acuity. Barriers and distress, as well as the success of previous interventions, are reassessed during each call. In an effort to offer navigation to all patients with a cancer diagnosis, the protocol was implemented to stratify navigator workload. Although informative, further investigation is needed to determine how acuity scores can drive navigation activity. A corollary study of barrier/distress resolution algorithms or pathways could also be explored.

Other cancer centers are also applying acuity in novel ways to optimize nurse navigation caseloads.13 The Mitchell Cancer Institute in Mobile, AL, has a unique process they call the “Rule of 400.”14 Mitchell uses an acuity scale from 0 to 4, with the midline score being 2. Based on anecdotal reports, navigator caseloads typically average around 200 patients. If you multiply a hypothetical caseload of 200 times an average acuity of 2, the resulting score of 400 might represent a desirable caseload. When navigators at Mitchell exceed a score of 400, their manager considers ways to rebalance their workload.14 Again, this process has not been tested in a scientific manner, but it represents the ingenuity of navigation leaders in an effort to “right-size” the workloads of their staff.

Currently, despite an acute need and the efforts of individual institutions, a standardized, validated, evidence-based acuity tool available for oncology navigation program administrators to implement does not exist. In recent years, there has been a great deal of interest among navigators in the development of an acuity tool. Since 2016, a top item identified by navigators at the AONN+ meetings as being essential to improving their practice has been the development of an acuity tool. At the AONN+ Midyear Conference on May 5, 2018, in Boston, the following questions were asked of the participants:

1. Would your navigation program utilize a validated, standardized, evidence-based acuity tool if the program had access to this tool?

  • Yes: 62
  • No: 6

2. Has your navigation program had discussions about the need for an acuity tool?

  • Yes: 41
  • No: 31

These responses clearly indicate that programs across the country are engaging in discussions about patient acuity to resolve those hard-to-answer questions about allocating resources and evaluating processes. Increasingly, as navigators are asked to do more with less, it is evident that there is a tremendous need to operationalize a navigation-specific acuity tool. As a professional organization, AONN+ wants to assist its members in their efforts by bringing together subject matter experts, concerned members of industry, and other oncology leaders as a task force to develop a navigation-specific acuity tool that can be used by all levels of organizations, by all types of navigators, and at all points in the cancer continuum.

Benefits

Navigators recognize that each patient is unique, and that some patients demonstrate a higher acuity due to the number of barriers coupled with their level of distress, background, and education. It was noted in several articles that worry will increase the level of distress for the patient, and that older and younger cancer patients have significantly different reasons for worry.15,16 The elderly cancer patients are more concerned with losing their mobility and ability to care for themselves, whereas the younger cancer patients will be extremely concerned and worry about their family.15,17 Recognizing the barriers and level of distress with an evidence-based navigation acuity tool could have vast benefits. The literature demonstrated that distressed patients are less likely to follow the treatment plan and are at a higher risk for readmission.14 Early identification of the patient’s level of distress and providing interventions to reduce the distress could provide a fruitful return on investment by keeping patients out of the emergency department, reducing readmission, and ensuring that the patient is compliant with the treatment plan. The quality of life for the patient and his or her family could also be enhanced across the continuum through early identification of the patient acuity and interventions, therefore increasing the patient experience and clinical outcomes. An acuity tool may also be a first step toward looking at the navigator’s caseload based on disease site, stage, and acuity of their patients. The navigation acuity tool could also be designed to support national guidelines and the AONN+ navigation metrics, which could then ensure the success and sustainability of oncology navigation programs. There is also the vision piece of acuity, a validated acuity tool with weighted barriers that would lead to next steps of reviewing caseloads, productivity, and eventually benchmarks for navigation staffing and assignments. A navigation acuity tool could also help identify the immediate needs of the patient for specific interventions. Lastly, an evidence-based, validated navigation acuity tool could be designed to be patient centered and support the concept from the Institute of Medicine regarding the most important request from the patient, “I want my healthcare clinician to listen to me.”18 Through listening to the patient and applying the AONN+ navigation acuity tool, the navigator could then meet, if not exceed, the patient’s needs and ensure that the navigator is addressing the barriers to help set up the patient for success.

Summary

The evolution of healthcare mandates the delivery of higher-quality, more coordinated oncology care at lower costs nationwide with the expectation of improvements in clinical outcomes, patient experience, and return on investment. Navigation services have been recognized as one of the essential components in achieving this higher-quality oncology care to meet this rising challenge. AONN+ and Astellas professionals have reacted to this demand and are now working together to develop and implement an evidence-based, navigation-specific acuity tool to help guide best practice in oncology care. Once completed, the acuity tool may be used to characterize patient complexity and workload intensity, aid in the allocation of navigation resources, and measure patient outcomes.

Literature review supports the success of patient acuity classification in determining staffing needs, improving patient care, and controlling healthcare costs. Yet, the quest to establish a valid and reliable evidence-based acuity tool for oncology patient navigation continues. Literature experts and focus groups both acknowledge the complexity of defining acuity and the patient attributes that impact acuity measures; however, fundamental determinants have been identified as key to tool development, such as patient needs and distress levels (illustrating severity), barriers impeding care (employing complexity), and navigation workload or time (calculating intensity). Research by field navigators reflects that higher acuity levels are associated with higher workload intensity and further suggests that decreasing acuity levels demonstrates effective navigation. The dilemma remaining is how to quantify these factors, can this be done successfully, and can it be proven to be valid and reliable.

Members of the acuity task force are in the midst of analyzing the currently available data to design a solution. Efforts are focused on effectively weighting barriers, based on complexity, to formulate this measure. Our group now seeks united direction and support from the navigation profession to ensure the tool developed has the best potential for universal functionality in all navigation settings, by all personnel involved, throughout the continuum of care; and to ultimately align with oncology standards of care, AONN+ navigation metrics, and governing accreditation requirements to achieve sustainability and success.

Plan to Action

The outcomes from the literature review and identified gaps will help the AONN+ Acuity Team to develop an oncology patient navigation–specific acuity tool. The work continues with correlating distress and barriers by conducting targeted focus groups of all patient navigator roles to obtain additional input regarding how to weight barriers to care. Once developed, the tool will be tested for reliability and validity. When finalized, the intent of the acuity tool will be to help oncology navigators optimize the productivity of navigator programs and would have the potential to support and enhance oncology navigators’ effectiveness through patient-centric evidence-based methods, potentially leading to a decrease in the overall cost of care.

Acknowledgments

AONN+ gratefully acknowledges Astellas US, LLC, for its collaboration on the Oncology Navigation Acuity Initiative. A special thank you to Astellas US, LLC, for the funding of this initiative, which makes it possible for AONN+ to lead a national research project and develop a navigation-specific acuity tool.

The authors would also like to acknowledge the Acuity Committee members for their expertise, dedication, and time on this very important project: Cheryl Bellomo, MSN, RN, OCN, HON-ONN-CG; Nicole Erb; Sharon Gentry, MSN, RN, AOCN, CBCN, HON-ONN-CG; Barbara Hale, MSW, LCSW; Rani Khetarpal; Rita Kristy, MS; Wendy Latash, PhD; Colleen Sullivan-Moore, RN, MS.

Disclosures

Rita Kristy, MS, and Wendy Latash, PhD, are employees of Astellas US, LLC.

References

  1. Brennan CW, Daly BJ. Patient acuity: a concept analysis. J Adv Nurs. 2009;65:1114-1126.
  2. Strusowski T, Sein E, Johnston D, et al. Standardized evidence-based oncology navigation metrics for all models: a powerful tool in assessing value and impact of navigation programs. Journal of Oncology Navigation & Survivorship. 2017;8(5):220-243.
  3. Shockney LD, ed. Team-Based Oncology Care: The Pivotal Role of Oncology Navigation. Cham, Switzerland: Springer International Publishing AG; 2018.
  4. Blaseg KD, Daugherty P, Gamblin KA, eds. Oncoloy Nurse Navigation: Delivering Patient-Centered Care Across the Continuum. Pittsburgh, PA: Oncology Nursing Society; 2014.
  5. American College of Surgeons. Commission on Cancer. Cancer Program Standards: Ensuring Patient-Centered Care. Chicago, IL: American College of Surgeons; 2016.
  6. American College of Surgeons. National Accreditation Program for Breast Centers Standards Manual. https://accreditation.facs.org/accreditationdocuments/NAPBC/Portal%20Resources/2018NAPBCStandardsManual.pdf. 2018.
  7. Centers for Medicare & Medicaid Services. Oncology Care Model Fact Sheet. www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-06-29.html. 2016.
  8. Lubejko BG, Bellfield S, Kahn E, et al. Oncology nurse navigation: results of the 2016 role delineation study. Clin J Oncol Nurs. 2017;21:43-50.
  9. McMullen L, Christensen D, Haylock P, et al. 2017 Oncology Nurse Navigator Core Competencies. www.ons.org/sites/default/files/2017-05/2017_Oncology_Nurse_Navigator_Competencies.pdf. 2017.
  10. High B, Baldwin D. Acuity: The 36th Metric? Slides 22-29. Presented at: 9th Annual Navigation & Survivorship Conference; November 15-18, 2018; Dallas, TX.
  11. Sullivan-Moore C, Cook C. Patient Navigator Acuity Tool. National Consortium of Breast Centers. http://files.ctctcdn.com/b59f4183201/350b2d96-b1a0-44e9-a585-76207345dbbb.pdf. 2015.
  12. Willhite L. Navigation acuity. Journal of Oncology Navigation & Survivorship. 2018;9(11):473-474. Abstract.
  13. Baldwin D, Jones M. Developing an acuity tool to optimize nurse navigation caseloads. Oncology Issues. 2018;33(2):17-25.
  14. High B, Baldwin D. Acuity: The 36th Metric? Slides 34-44. Presented at: 9th Annual Navigation & Survivorship Conference; November 15-18, 2018; Dallas, TX.
  15. Johnson RL, Larson C, Black LL, et al. Significance of nonphysical predictors of distress in cancer survivors. Clin J Oncol Nurs. 2016;20:E112-E117.
  16. Kim JH, Yoon S, Won WY, et al. Age-specific influences of emotional distress on performance status in cancer patients. Psych Oncology. 2013;22:2220-2226.
  17. Rocque GB, Taylor RA, Acemgil A, et al. Guiding lay navigation in geriatric patients with cancer using a distress assessment tool. J Natl Compr Canc Netw. 2016;14:407-414.
  18. Institute of Medicine. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press; 2013.
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Last modified: November 8, 2019

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