To optimize patient care—and work smarter, not harder—navigators are in need of acuity tools to assist them in effectively allocating resources and managing their caseloads, according to members of the National Navigation Acuity Team, a collaborative initiative between the Academy of Oncology Nurse & Patient Navigators (AONN+) and Astellas, US, LLC.
To address that need, the National Navigation Acuity Team set out to develop, standardize, and validate an evidence-based oncology acuity tool for patient navigation that would help to ensure the optimal allotment of navigation services and resources.
At the AONN+ 12th Annual Navigation & Survivorship Conference in November 2021, Danelle Johnston, MSN, RN, HON-ONN-CG, OCN, senior vice president at Mission Delivery Cancer Support Community, and Tricia Strusowski, MS, RN, an independent oncology contractor, both members of the Acuity Initiative, took a deep dive into the hard work and research involved in developing such a tool and involved the audience of navigators in an interactive discussion to collect even more feedback on its design.
“Early in our work on metrics, we recognized a need to define and measure acuity,” said Ms Johnston. “So we pulled this idea of acuity out of the metrics work and made it its own initiative.”
In addition to enhancing the effectiveness of the work of oncology navigators, the acuity tool may have the potential to decrease the overall cost of care, according to the team.
Criteria for Tool Development
The overall goal of the acuity project was creating a tool that could provide safe, effective, and efficient care. Ideally, the tool should be easily implemented across settings and roles (ie, inpatient or outpatient unit; clinical or patient navigator, etc), and the design of the tool should be simple, easy to use, and easily embedded into existing practices.
“If it was cumbersome, it wasn’t going to be leveraged, and we knew it wouldn’t be of value,” said Ms Johnston.
Additionally, the team wanted to support sustainability for various navigation programs, while also supporting the national guidelines and AONN+ navigation metrics.
What Is Oncology Navigation Acuity?
Acuity refers to the intensity of the navigator’s engagement with their patient in working to mitigate barriers and address patient distress, so equating acuity with intensity might help to put the concept of acuity into perspective.
“Barriers and distress really come together to help determine a patient’s level of acuity,” said Ms Johnston.
More precisely, oncology navigation acuity is defined as a measure of patient distress and medical and psychosocial barriers. Acuity determines the intensity of navigator interventions that are necessary across the care continuum, and it is influenced by the complexity of a patient’s illness, along with social determinants of health.
“Navigation is about mitigating barriers to care, helping to support timely access to care, and addressing psychosocial distress,” she said. “Those are the fundamental principles of how we measure and define acuity.”
Developing the Acuity Tool
After identifying 123 different patient barriers through the process of a literature review, the acuity team divided each of those barriers into 1 of 5 different domains defined by the National Comprehensive Cancer Network (NCCN): practical, familial, physical, emotional, or spiritual/religious problems. Focus groups comprising navigators then evaluated the intensity of these barriers in their own practices.
The focus groups were asked to “weigh” each barrier by identifying their intensity: 1–very low, 2–low, 3–moderate, 4–high, and 5–very high.
Participants in the focus groups were instructed to ask themselves, “Does it require a significant amount of navigation time and resources to address the barrier?” According to Ms Strusowski, this question can help navigators in any setting—from solo navigators to large navigation teams—to identify the additional resources that they might need for their navigation programs.
Results from the focus groups, combined with a principal component analysis (an analytical method that streamlines the collection of data through reducing redundant feedback, further clarification, etc) conducted by a biostatistician from Astellas, allowed the team to narrow down the barrier set from 123 to 33 barriers, and to design a draft acuity tool.
Of the 33 barriers ultimately identified, 8 related to practical problems, 5 to family problems, 8 to physical problems, 7 to emotional problems, and 5 to spiritual problems.
“The work that was done in these focus groups was an absolutely essential piece to this project,” she added.
The team then conducted a scoping review, the objective of which was to investigate and analyze articles related to components of the oncology navigation acuity tool (ie, age, race, ethnicity, cancer stage), per NCCN guidelines or other national standards. Findings from the scoping review were then used to develop evidence-based oncology case studies, which were designed as part of the feasibility testing of the tool.
“In the scoping review, we looked at evidence-based literature, which was important, but we also used the knowledge and expertise of our navigation task force,” Ms Johnston explained. “These are navigators working, in real-world practice with patients, who shared their clinical insights and experience to help inform the case studies.”
Acuity Tool User Testing
Before actually testing the initial acuity tool, the team needed to understand the population of those who would be assessing the tool, so the participating navigators completed a self-assessment to identify their own level of proficiency and clinical competence as navigators, using a scale ranging from “novice” to “expert.”
“We have clinical and nonclinical navigators; we have navigators who work across the full cancer continuum, and others who focus on the time between abnormal finding and diagnosis,” she said. “We believe all of that plays a part in how a navigator would assess acuity.”
Acuity tool user testing finally took place with more than 75 nurse and patient navigators. Participants received a background and overview of the Acuity Initiative, completed a questionnaire about their background (location, type of navigator, practice setting, etc), and were then randomly assigned case studies, which they scored using the acuity tool.
“Each case study had 2 to 3 sections and followed the normal continuum of care,” Ms Strusowski explained. “At the end, we wanted to ask the navigators if the acuity scores were appropriate based on their experience, what was missing from the tool, as well as what they planned to do with this information.”
The feedback provided (about their own experience as well as the acuity tool) was utilized to revise the case studies for further user testing.
“The more feedback, the better,” said Ms Strusowski. “We want a strong, realistic tool.”
She noted that self-identified level of proficiency was considered when reviewing the results of the acuity tool user testing, and special attention was paid to the individual navigator questionnaires.
“We wanted to have a diverse group; we wanted to know their location, navigation type, and practice setting,” she added. “It’s so important that this tool is able to be used in every setting, by every navigator.”
Low-, Medium-, and High-Acuity Definitions
Based on the data and feedback collected, the team arrived at the following definitions for low, medium, and high acuity:
- High acuity: The patient requires an intensive level of care coordination and support. The acuity score is 8 or higher with multiple complex barriers that require intensive care coordination and intervention. The patient is experiencing a high level of distress concerning the barriers identified.
- Medium acuity: The patient requires a moderate level of care coordination and support. The acuity score can range from 4 to 7, with barriers that require a moderate amount of care coordination and support. The patient is experiencing a moderate level of distress concerning the barriers identified.
- Low acuity: The patient requires a low level of care coordination and support. The acuity score is 3 or below and requires minimal to no intervention. The patient is experiencing a low level of distress.
The next phase of the initiative will involve a pilot study, which will test the tool with real patients in real navigation programs. The final phase—implementation—will be complete with education modules and webinars, a toolkit, and study publication.
“And after that, we’re going to have a big party to celebrate,” said Ms Strusowski. “Remember, this is your tool, so your feedback has been so very important to us.”