Integrated Care Collaborative: Navigating Patients Through the Colorectal Cancer Continuum

Background: The healthcare system in Canada is complex, and patients with a colorectal cancer diagnosis are oftentimes left to navigate this system with limited resources and knowledge. Although the acute care community academic hospital in Toronto, Ontario, Canada, had strong clinical expertise in colorectal cancer, healthcare providers worked in silos, resulting in fragmented care.

Objectives: The Colorectal Cancer Integrated Care Collaborative (CRC ICC) program, including the implementation of the nurse navigator role, was developed in August 2016. This was intended to eliminate gaps in care, improve accessibility, and enhance communication by addressing patients and families’ care coordination, information and psychosocial needs. The goal of the CRC ICC is to provide high-quality integrated colorectal cancer care and enhance the patient experience.

Methods: The CRC ICC is a method of value-based healthcare that involves collaboration among the interprofessional team of physicians, nurses, allied health professionals, administrators, and community stakeholders in the implementation of best practice guidelines and the standardization of clinical processes. The CRC ICC expands beyond the provincial Cancer Care Ontario’s Diagnostic Assessment Program or the diagnostic phase of the colorectal cancer journey. In the CRC ICC, the nurse navigator additionally supports patients and families through the treatment, recovery, and survivorship trajectories. With a focus to advance patient- and family-centered care, the nurse navigator provides assessment, education, and psychosocial support at predefined transition points during the cancer journey via telephone, e-mail, and in-person encounters. The nurse navigator anticipates patients’ needs and manages complex clinical issues using the nursing process and identifies appropriate resources. Furthermore, a marketing and communication strategy was developed to profile the CRC ICC to increase patient referrals. This consisted of a new website, social media plan, promotional brochures for primary care providers, and patient educational materials, including a video and guides.

Results: In the past 3 years, the acute care community hospital has consistently achieved Ontario’s best cancer surgery wait times (time from decision to treat to treatment). The CRC ICC program has seen increases in surgical volumes and decreases in the average length of hospital stay, which reflect the improved care transitions and communication between the interprofessional team and patients. The implementation of the CRC ICC has streamlined a single point of access for patients with colorectal cancer where all their clinical appointments and consultations are coordinated in a timely manner. Patients are navigated according to standardized evidence-based clinical pathway maps, and the nurse navigator has become a resource to provide relevant and appropriate information and education to support patients and families through the cancer journey. The nurse navigator has provided support to 90% of the patients who reliably report feeling less anxious and more prepared. The website and social media metrics have also seen increases in public views and impressions.

Conclusions: The nurse navigator role operationalizes the goal of the CRC ICC to improve access, value, and outcomes for patients with colorectal cancer. Through collaborative partnerships and leveraging of information technology, the CRC ICC improves efficiency and decreases costs while enhancing the patient experience during a challenging time.