Category IV: Original Research on Navigation Programs

August 2014 Vol 5, No 4

Development and Utilization of an Acuity Scale for Oncology Patient Navigation

Raizalie Roman, RN, BSN, OCN, CMSRN; Laura Beaupre, RN, OCN, CBPN-IC

Lehigh Valley Health Network

Background: The oncology navigation team at Lehigh Valley Health Network (LVHN) is responsible for removing barriers, coordinating care, and assisting patients with complex medical, social, and emotional needs during cancer treatment. In 2013, the navigator team was charged with broadening their scope to navigate patients according to complexity, not just by diagnosis. The acuity tool and needs assessment help determine which patients do not need navigation, which can be referred to other internal cancer support resources, which are appropriate for navigation, and the level of navigation needed.

Objective: To determine which patients are appropriate for active navigation, utilizing the acuity tool. Methods: A literature search proved unsuccessful in finding other acuity tools suitable for our purpose of navigating oncology patients; therefore, the team benchmarked with other oncology programs to share information regarding patient acuity tools.

A survey was sent to LVHN oncology medical staff, including providers and nurses, asking them to prioritize their needs from the navigation team. Navigators met with 3 outpatient care teams (Palliative Care, Hospice, and Medical Home) to review case studies, complexity of care, and scope of services, and to eliminate duplication of services. Navigators met monthly to discuss time requirements for individual patient needs to determine the degree of navigation needed. The navigators created a needs assessment to identify barriers to care and to determine appropriate referrals. The navigation acuity scale is based on the time and amount of coordination needed to navigate patients before, during, and after treatment. The patient is assigned a score from 0 to 4 (low to high) and is incorporated into the electronic medical record (MOSAIQ), which allows all staff to identify the navigator and level of navigation care required. The acuity tool was implemented in March 2014.

Results: The poster will show the tools developed by the navigation team, including the needs assessment and acuity scale. A graph outlining the patient acuity levels for the patient caseload during the most recent quarter will be displayed, demonstrating for the period from March 2014 through May 2014 that 4% of patients assigned an acuity score had an acuity of 0, 21% of 1, 24% of 2, 27% of 3, and 23% of 4. The data show that the acuity of the navigated patients is evenly distributed.

Conclusions: By utilizing the needs assessment and acuity scale, the navigators are able to determine if patients are appropriate for navigation, have stable needs, or require active navigation. The intensity of navigation is also indicated. In the future, we hope to include the acuity measurements to help determine workload.


Understanding the Needs for Cancer Care Patient Navigation at an Academic Medical Center

Melissa Grossman, MPH1; Jessica Keim Malpass, PhD, RN2; Lindsay Hauser, MS1; Christi Sheffield1; Pamela DeGuzman, PhD, MBA, RN2

1University of Virginia Cancer Center; 2University of Virginia School of Nursing

Background: Improving quality of life and minimizing suffering are priorities for clinicians across the cancer continuum from diagnosis, through treatment, and continuing into survivorship and end-of-life care. Patient navigation is a healthcare service delivery model that is patient-centered and created to reduce barriers to care through the use of patient navigators. These professionals support patients through the continuum of care as it pertains to their specific diagnosis. The purpose of this analysis was to explore the experiences of cancer care providers and staff in delivering complex cancer care in a tertiary academic medical center with a rural catchment area.

Methods: Cancer center key informants (nurses, physicians, support staff) and community partners (medical providers in the community who refer to the cancer center) underwent in-depth interviews regarding an overall needs assessment for the cancer center. Interviews were transcribed verbatim and coded based on hermeneutic interpretation. Results were interpreted using content analysis.

Results: There were 5 themes that emerged: (1) care of patients who are both rural and low income is highly complex; (2) patients’ care is centered around medical needs; (3) providers use “work-arounds” to address patients’ complex needs; (4) consolidation of care to minimize patients’ trips; and (5) employees want a stronger link to survivorship care.

Conclusion: Providers and staff who deliver cancer care to rural and low-income patients make tremendous efforts to address the complex needs of their patients. However, to provide continuity of care for this complex population, development of a patient navigation process is necessary. A well-planned patient navigation program will help to coordinate care and support rural cancer patients and their families to overcome barriers in the healthcare system.


Disease Burden Among Cancer Patients Suffering from Anemia and Their Caregivers: A Multinational Study in the United States, Italy, and France

November McGarvey, MPH1; Patricia Corey-Lisle, PhD, RN2; Elizabeth Donahue, BS3; Marie-Pierre Desrosiers, MSc4; G. Chet Bohac, PharmD, MD, MSc Epi2; Sharon Hunter, MS2; Stephanie Hubbard, BA3

1UCLA Fielding School of Public Health; 2Amgen Inc; 3United BioSource Corporation; 4United BioSource Corporation, Canada

Background and Aims: Chemotherapy-induced anemia (CIA), prevalent in cancer patients, may contribute to patient fatigue, declining functional capacity, and health-related quality of life (HRQoL), potentially increasing the need for caregiver assistance and caregiver burden. The study aims to explore the burden of disease among patients with CIA and their caregivers.

Methods: This cross-sectional study was conducted from March 2012 to July 2013 in 8 oncology centers in the United States (3), Italy (3), and France (2) among consecutively presenting adult breast, colorectal, lung, and gynecological cancer patients with anemia (hemoglobin [Hb] <12.0 g/dL) currently receiving myelosuppressive chemotherapy and their caregivers. Patients and their caregivers completed surveys with questions on sociodemographics, time spent caregiving, burden, productivity, fatigue, and HRQoL. Descriptive statistical analysis was conducted.

Results: A total of 182 patients and their caregivers were enrolled (United States: n = 55; Italy: n = 101; France: n = 26). Patients across all countries (74.7% female; 50.5% ?65 years; mean Hb = 10.4 g/dL) reported a Functional Assessment of Cancer Therapy-Fatigue (FACT-F) mean score of 30.1 and a Short Form 12-Item Health Survey (SF-12) physical component mean score (PCS) of 38.1 and mental component mean score (MCS) of 45.0. Italian patients reported the highest mean FACT-F score (33.15), followed by French (30.71) and US patients (24.61) (score range, 0-52; higher score = less fatigue). Patient SF-12 PCSs were highest in France (41.6), followed by Italy (38.3) and the United States (36.2), whereas MCSs were highest in the United States (47.3), followed by Italy (44.1) and France (43.8) (score range, 0-100; higher score = better health). Across all countries, caregivers (50% female; 65.4% <65 years) reported a daily mean of 4.4 hours providing assistance with instrumental activities of daily living (IADLs) and 7.9 hours with activities of daily living (ADLs). US caregivers reported the greatest daily mean hours in assistance (ADL: 9.80; IADL: 6.83), followed by Italy (ADL: 7.81; IADL: 3.55) and France (ADL: 4.14; IADL: 2.92). Caregivers reported a Zarit Burden mean score of 10.02 across all countries with highest mean scores in the United States (10.8), followed by Italy (9.8) and France (9.1) (score range, 0-48; high burden cut-off at ?10; higher score = greater burden). Caregivers also reported weekly work impairment (WI) (among employed, mean WI = 31%) and activity impairment (AI) (mean AI = 23.43%). The greatest WI occurred in Italy (36.6%), followed by the United States (30.1%) and France (2.9%), and the United States had the highest AI (28.0%), followed by Italy (24.2%) and France (11.2%). Conclusions: Data support that patients with CIA and their caregivers in the United States, Italy, and France are experiencing disease burden. Research of this kind aids healthcare providers, patients, and caregivers in making more informed decisions related to patient and caregiver needs.


90-Day Pilot Program: A Nurse Navigator’s Assessment of Psychosocial Distress in Gynecologic Cancer Patients

Antoinette Solnik, RN, BSN

Johns Hopkins Medicine, Sibley Memorial Hospital Center for Gynecologic Oncology and Advanced Pelvic Surgery

Background: In 2012, the Commission on Cancer (CoC) developed Standard 3.2, which calls for screening patients with cancer for psychological distress and is now being phased into practices nationwide by 2015. This standard requires accredited hospitals to define a process by which practitioners monitor on-site distress screening and make referrals to services as needed for patients with cancer. To prepare to meet the new CoC standard, a newly appointed nurse navigator began implementing a 90-day pilot to assess sources and levels of stress in women facing gynecologic cancers. Because issues related to depression, insurance, financial matters, social and family relationships, and spirituality are often seen as a cause of psychosocial distress in patients facing a cancer diagnosis, screening these newly diagnosed patients with cancer helped the nurse navigator identify issues that had the potential to negatively impact their treatment and outcome.

Objectives: The purpose of this 90-day pilot was to fine-tune a process to address gynecologic patients who reported significant distress early in the treatment trajectory in order to treat them proactively and hopefully avoid future psychosocial problems. The other important objective was to better determine the capacity with current staffing to respond and follow up with patients who met or exceeded a threshold for significant distress. The information obtained in the screening was reviewed and triaged by the nurse navigator, who then either acted upon the expressed concern or referred the patient to the social worker.

Methods: Newly diagnosed patients were identified during their first scheduled appointment. The nurse navigator provided eligible patients with a letter explaining the pilot’s objective and instructions for completing a distress screening form, “The Distress Thermometer,” prior to seeing the physician. The National Comprehensive Cancer Network (NCCN) Distress Thermometer was chosen because of its proven reliability, ease of use, and review of both practical and psychosocial issues. Two additional questions were added at the end of the distress screening tool to determine if the patient is already getting help for these problems and/or if she wanted Sibley staff to follow-up to provide additional support. If a patient indicated a 6 or greater (of a potential high of 10) on the thermometer, the nurse navigator called her within 1 week to more clearly determine which staff could appropriately address each area of concern. The nurse navigator then made referrals to the oncology social worker, a physical or lymphedema therapist, the palliative care nurse practitioner, oncology dietitian, or the hospital chaplain. For issues pertaining to medical care, the nurse navigator would address them directly.

Results: One hundred women were surveyed during the 90-day pilot. Approximately 25 (25%) of these women indicated a distress score of 0 (no distress), with many of these indicating they were already working with a therapist. More than 50 (50%) of the women surveyed indicated a distress score of 4 or greater, prompting follow-up by the nurse navigator and social worker with about 50% of these patients being referred to a specialist (eg, dietitian, physical therapist, etc) for their targeted need. Physical and emotional problems ranked highest among patient problems above child care, house, insurance/financial, transportation, work/school, and family problems. Primary physical problems included fatigue, pain, and sleep. Top emotional problems included fear, nervousness, and worry.

Conclusions: Distress screening is extremely useful to the nurse navigator and has become crucial in identifying patient needs at a challenging time of early diagnosis and pretreatment. Appropriate screening and triage can likely result in treatment of those patients who are most in need of care and may not have accessed it otherwise. The modified NCCN Distress Tool offers an efficient way to identify which newly diagnosed patients may require and be receptive to additional support from the oncology team. Next steps include evaluating whether current staffing has the capacity to respond to patients with a screen of 4 or more. Staff will also compare the gynecologic patients’ needs to a parallel pilot being conducted at Sibley with newly diagnosed patients with breast cancer. The data obtained will allow staff to better meet individual patient needs, as well as to develop supportive programming and education that may serve the broader population of cancer patients. Other pilot projects may include screening individual patients at various transition points in their cancer care.


The Evolution of Navigation in Virginia; If You Build it, They Will Come: Leveraging Data and Best Practices to Create a Sustainable Statewide Network

Katie Benson, BS1; Donna Moore Wilson, BSN, RN, CBCN2; Christi Sheffield, BS3

1Onyx Pharmaceuticals; 2Bon Secours Richmond Health System; 3University of Virginia Cancer Center

Background: In the past decade, patient navigation has become a core component in defining and providing quality patient-centered oncology care. In 2007, recognizing that a new position was emerging in the oncology nursing field, a Virginia-based Genentech Territory Manager created a forum, Virginia Coalition of Oncology Nurse Navigators (VCONN), to bring oncology nurses from various health systems together to share how their roles were evolving to incorporate patient navigation. As time progressed, statewide stakeholders, health systems, administrators, industry partners, and cancer advocacy groups noticed the patient navigation model expanded beyond nursing into other areas of the cancer control spectrum to include other professionals such as social workers as well as community lay navigators.

Methods: In 2012, these stakeholders, in collaboration with VCONN, conducted a statewide multistep analysis to identify existing navigation services, explore gaps and barriers, and define essential elements for professional development. This multidisciplinary team used existing data sources from national organizations and other state networks to conduct focus groups and numerous internal surveys to address the needs of patient navigation in their state. As a leading partner and funder, the University of Virginia Cancer Center hosted a series of interactive conferences to explore opportunities, best practices, and lessons learned from other states such as Georgia and North Carolina.

Results: The needs assessment identified 5 priorities: (1) a desire for a multidisciplinary network of navigators; (2) a need for continuing education and professional development opportunities; (3) systems that aid in data collection, metrics, and return on investment; (4) promoting navigation within organizations and statewide; (5) increased need in survivorship resources; and 1 nonpriority: establishing credentials/educational standards. This in-depth analysis provided focus and a clear opportunity for multidisciplinary collaboration. Within 1 year, this group established the Virginia Cancer Patient Navigator Network (VaCPNN), defined their mission and vision, elected a steering committee, and grew from 30 to 142 members. Based on survey data and programmatic evaluations, VaCPNN has hosted 5 seminars with leading experts, provided continuing education credits, and is developing an interactive website for members.

Conclusion: Leveraging national data and experiences from other states, VaCPNN has created a statewide platform to empower patient navigators across the continuum of cancer care to become advocates and educate their own organizations on the evolution of navigation and, ultimately, act as leaders in this emerging career to define their role and value to the patient and the organization.

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Last modified: April 9, 2021

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