Leveraging Navigation to Improve Oncology Programs: Establishing the Role of the Navigator

January 2021 Vol 12, No 1
Tricia Strusowski, RN, MS
Independent Oncology Contractor
Cheryl Bellomo, MSN, RN, HON-ONN-CG, OCN
Oncology Nurse Navigator
Intermountain Cancer Center Cedar City Hospital
Cedar City, Utah
Nicole Messier, RN, BSN, ONN-CG, OCN
Nurse Navigator,
University of Vermont Medical Center
Linda Burhansstipanov, MSPH, DrPH
Native American Cancer Research Corporation, Native American Cancer Initiatives, Inc, Denver, CO

Many practices and institutions have implemented navigation programs to improve oncology care. Although professional oncology nursing organizations have established, well-defined roles and responsibilities for navigators,1,2 many practices and institutions have yet to adopt formal job descriptions for their navigators. A discussion and 2020 goal for the Navigation Metrics Committee was to further define the role of the oncology navigator based on the Oncology Nursing Society (ONS) core competencies and the Academy of Oncology Nurse & Patient Navigators (AONN+) knowledge domains. The core competencies and knowledge domains of the 2 national navigation organizations are comparable and provide a solid foundation for the oncology navigator, support staff, and their administrator. The next step was to overlay the 35 AONN+ evidence-based navigation metrics that also support value-based cancer care initiatives and oncology standards, such as Commission on Cancer (CoC), National Accreditation Program for Breast Centers (NAPBC), Oncology Care Model (OCM), Quality Oncology Practice Initiative (QOPI), Alternative Payment Models (APMs), and Merit-Based Incentive Payment System (MIPS). The navigation metrics support the categories of patient experience (PE), clinical outcome (CO), and return on investment (ROI). The appropriate navigation metrics were applied to each core competency and knowledge domain. Lastly, the 2020 CoC and 2018 NAPBC standards were cross-referenced with the core competencies, knowledge domains, and metrics. This robust information will lend itself to creating solid job descriptions and performance improvement outcomes based on national organizations and oncology standards for the oncology navigator.

Organizations with thoughtfully implemented navigation programs have reported improvements in PEs and COs, as well as a positive ROI for the navigation program itself, as discussed in the article Standardized Evidence-Based Oncology Navigation Metrics for All Models: A Powerful Tool in Assessing the Value and Impact of Navigation Programs.1

Here, we endeavor to guide oncology practices and institutions to use the current literature on roles and responsibility to create job descriptions for their navigators, implement the AONN+ metrics to measure the impact of their navigation programs, as well as to demonstrate how an effective navigation program ensures compliance with value-based cancer care initiatives and oncology standards such as CoC, NAPBC, OCM, QOPI, APMs, and MIPS.

We encourage all oncology programs to review the fundamental tenets of oncology navigation and use them to implement a navigation program with well-defined job descriptions.

ONS Competencies and AONN+ Domains

Click to View Crosswalk of ONS and AONN+ Core Competencies/Knowledge Domains, Metrics, and CoC/NAPBC Standards©

There continues to be some confusion in understanding boundaries, specifically what the role of the navigator actually is, and where the navigator role potentially ends and transitions to other members of the care team begin. Often oncology nurse navigators, patient/lay navigators, social workers, as well as other members of the multidisciplinary team all play a part in navigation of patients throughout the cancer continuum, with overlap of their specific roles as they collaborate and work to ensure the needs of the patient are met. However, this overlap of roles can lead to confusion among the larger team regarding who is doing what or who is responsible for what. In general, nurse navigators deal with the clinical aspects of patient care, diagnosis, and treatment; patient navigators, including social workers, often focus on practical problems, including transportation, childcare, housing, and psychosocial issues. Although each professional has distinct roles and responsibilities, there is often overlap in these responsibilities. For example, all would provide patient education. However, the focus of the education should be specific to the role of the educator. Clear communication and collaboration among all members of the care team is vital to avoid any confusion, reduce duplication of services, and help prevent the potential for patients to fall through the cracks and be lost to follow-up. In addition, clear role delineation and job descriptions are needed to ensure consistency across the navigation profession.

To address this need, both AONN+ and ONS have worked to identify and define navigator roles and associated job descriptions. ONS created Oncology Nurse Navigator Core Competencies,2 which “outline the fundamental and advanced knowledge, skills, and expertise needed to effectively (a) coordinate the care of patients with a past, current, or potential diagnosis of cancer; (b) assist patients with cancer, families, and caregivers to overcome healthcare system barriers; and (c) provide education and resources to facilitate informed decision making and timely access to quality health and psychosocial care throughout all phases of the cancer care continuum.”2 Specific roles and tasks of the oncology nurse navigator were placed into 4 competency categories: Coordination of Care, Communication, Education, and Professional Role.

Similarly, AONN+ created navigation knowledge domains that contain a comprehensive list of all areas and competencies navigators practice to provide quality patient care and financial stability for their organizations. The 8 domains are defined as: Community Outreach/Prevention, Coordination of Care/Care Transitions, Patient Advocacy/Patient Empowerment, Psychosocial Support Services/Assessment, Survivorship/End of Life, Professional Role and Responsibilities, Operations Management/Organizational Development/Health Economics, and Research/Quality/Performance Improvement.

When compared, the core competencies and knowledge domains of the 2 national organizations truly mirror each other and together provide a comprehensive and solid foundation for navigators and navigation programs that will support and ensure consistency in navigation throughout the cancer continuum. Some examples include:

  • ONS: Coordination of Care/AONN+: Community Outreach/Prevention, Care Coordination/Care Transitions/Psychosocial Support Services, and Assessment/Survivorship and End of Life
  • ONS: Assesses patient needs upon initial encounter and periodically throughout navigation, matching unmet needs with appropriate services, referrals, and support services, such as palliative care, dietitians, medical providers, social work, pre/rehabilitation, and legal and financial services
  • AONN+: Finding community resources/Referrals to psychosocial support/resources
  • ONS: Communication/AONN+: Patient Advocacy/Patient Empowerment
  • ONS: Advocates for patients to promote patient-centered care that includes shared decision-making and patients’ goals of care with optimal outcomes
  • AONN+: Patient/family center education (screening, diagnosis, treatment, side effects and management, survivorship/end of life)/Patient and family center education (assess educational needs)
  • ONS: Education/AONN+: Patient Advocacy/Patient Empowerment
  • ONS: Assesses educational needs of patients, families, and caregivers by taking into consideration barriers to care (eg, literacy, language, cultural influences, and comorbidities)
  • AONN+: Patient/family center education (assess educational needs)
  • ONS: Professional Role/AONN+: Professional Role/Quality and Performance Improvement/Operational Management
  • ONS: Promotes lifelong learning and evidence-based practice to improve the care of patients with a past, current, or potential diagnosis of cancer
  • AONN+: Value/role of nursing research to validate practice and build evidence-based practices, research quality metrics (selection of metrics, develops measure, and creates dashboards), performance improvement (methodologies-PDSA, SMART goals), role in identifying quality needs, areas of quality improvement, role in improving the process

AONN+ Metrics in Support of ONS Competencies and AONN+ Domains

Literature reviews demonstrate that navigation improves patient satisfaction, decreases barriers to care, increases timely access to care, improves continuity of care and symptom management, and provides emotional support and patient empowerment.3 Prior to the introduction of the AONN+ Standardized Metrics, the role of the navigator in regard to outcomes and navigation program success had not been accurately measured. Metrics are needed to evaluate whether patient navigation can improve quality-of-care delivery, health outcomes, and overall value in healthcare during diagnosis and treatment of cancer.4 In its published report, Ensuring Quality Cancer Care, the Institute of Medicine recommends that quality care is measured using a core set of metrics: “To ensure the rapid translation of research into practice, a mechanism is needed to quickly identify the results of research and quality-of-care implications and ensure that it is applied in monitoring quality.”5

Metrics and quality measures are essential to the world of healthcare and are defined by the Centers for Medicare & Medicaid Services (CMS) as tools to “measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality healthcare and/or that relate to one or more quality goals for healthcare.”6 The collection and monitoring of data in the arena of healthcare and oncology navigation in regard to specific outcomes can be helpful in creating a workflow; assisting in program development, evaluation, and sustainability; identifying new issues/barriers; evaluating community needs; and providing a mechanism for resource allocation. The CMS definition as well as a literature review on navigation metrics identified 3 main categories of metrics: PE, CO, and ROI/business performance.

PE is increasingly emerging as a more enhanced method for measuring navigation success. The results from the 2013 Consumer Assessment of Healthcare Providers and Systems cancer survey revealed that patients’ expectations were exceeded when they felt their healthcare provider actively listened and incorporated their personal psychosocial goals into the treatment plan. The results from this survey also confirm the importance of ensuring navigators and support staff know how to provide the appropriate level of education. Asking patients about their experience and encouraging patients’ active participation in their treatment discussions increased the level of understanding and satisfaction of the patients and their family. Examples of metrics that support the AONN+ knowledge domains/ONS navigation competencies and evaluate PE in regard to navigation include:

  • Psychosocial Distress Screening: Number of navigated patients per month who received psychosocial distress screening at a pivotal medical visit with a validated tool
  • Barriers to Care: Number and list of specific barriers to care identified by the navigator per month
  • Cancer Screening, Follow-up to Diagnostic Workup: Number of navigated patients per month with abnormal screening referred for follow-up diagnostic workup
  • Survivorship Care Plan (SCP; although no longer mandated by CoC): Number of navigated patients with curative intent per month who received an SCP and treatment summary
  • Patient Goals: Percentage of analyzed cases per month that identified and discussed patient goals with the navigator
  • Identifying Learning Style Preferences: Number of navigated patients per month whose preferred learning style was discussed during the intake process

CO metrics are much more familiar to healthcare providers, as clinicians have always measured success and the provision of quality patient care, such as fall risks and infection rates. Navigators can have an impact on COs through measuring their services and interventions. Examples of navigation metrics include pathway compliance and timeliness of care. Examples of metrics that support the AONN+/ONS navigation competencies and evaluate CO in regard to navigation include:

  • Completion of Diagnostic Workup: Number of navigated individuals with abnormal screening who completed diagnostic workup per month/quarter
  • Diagnosis to Initial Treatment: Number of business days from diagnosis (date pathology resulted) to initial treatment (date of first treatment)
  • Treatment Compliance: Percentage of navigated patients who adhere to institutional treatment pathways per quarter
  • Palliative Care Referrals: Number of navigated patients per month referred for palliative care services
  • Oncology Navigator Annual Core Competencies: Percentage of staff who have completed institutionally developed navigator core competencies annually to validate core knowledge of oncology navigation

ROI/business performance metrics look to measure the success of a navigation program in supporting the infrastructure of the cancer program to ensure financial strength. Navigation programs have been incorporated into cancer programs over the past 2 decades to support the Institute of Medicine report, Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis, and the CoC’s Cancer Program Standards.7,8 Oncology programs and hospital administrators must measure ROI for the navigation program and report metrics and outcomes to ensure sustainability of the program. Navigators can have an impact on ROI through measuring their services and interventions. Five major areas in which navigation can have an impact and support program ROI are:

  • Removal of Barriers to Care: Allows for patient to undergo diagnostic/staging workup and treatment
  • Promote Treatment Adherence: Demonstrates cost-effectiveness, as navigators can impact treatment adherence through patient education and promote shared decision-making, thus allowing for increased continuity of care
  • Enhance Revenue: Navigators can impact revenue by facilitating referral to downstream revenue-generating services, monitoring no-shows, and decreasing outmigration
  • Decrease Preventable ER Visits
  • Decrease Preventable Hospital Admissions: Through education and early intervention for symptom management, navigators can help keep patients from frequenting the ER or being readmitted to the hospital for avoidable reasons (nausea, constipation, vomiting), allowing healthcare to become more cost-effective

Of note, metrics do not intersect with all settings. For example, to have an ROI, the referrals to revenue-generating services need to be within the same system. The same is true for referrals to support services and palliative care services. Thus, when a hospital-based patient navigation program refers cancer survivors to a community-facilitated cancer support group, that referral is not ROI, but when referred to internal support groups, it is. Sometimes, it is appropriate for the referrals to go outside the system, such as for a Latina-specific support group or an American Indian–specific support circle. The needs of the patient supersede the need to generate revenue. Examples of metrics that support the AONN+/ONS navigation competencies and evaluate ROI/business performance in regard to navigation include:

  • Patient Education: Number of patient education encounters by navigator per month
  • Social Support Referrals: Number of navigated patients referred to support services per month
  • Referrals to Revenue-Generating Services: Number of referrals to revenue-generating services per month
  • Navigation Program Validation Based on Community Needs Assessment: Monitor 1 major goal of current navigation program annually as defined by the cancer committee
  • Interventions: Number of specific referrals/interventions offered to navigated patients per month
  • Palliative Care Referrals: Number of navigated patients per month referred for palliative care services

Metrics can be used to accurately measure performance, show value, and evaluate the success of the navigator role in cancer programs. They improve the care of patients by monitoring and measuring outcomes and are necessary to sustain the role of the navigator. They also identify competencies for which the patient navigator may need more training or supervision. Data collection, analytics, and reporting outcomes in the form of metrics are an essential part of the professional role of navigation. With standardized metrics that align across the organizations of CoC, NAPBC, ONS, and AONN+ and reference with value-based care, cancer programs will be able to demonstrate the success of their oncology navigation program on a national level. By utilizing standardized metrics, navigators can truly partner and will be on the same page with the same mission and vision to enhance the care of oncology patients and their families.

CoC Standard 8.1

The 2020 CoC Standard 8.1 addressing barriers to care relaxed the rigor specified in the previous 2015 Standard 3.1. This new Standard does not specify the patient navigator role per se but does focus on barriers to care. Since a primary role of patient navigators is to help the patient overcome barriers, the patient navigator’s role is implied within the Standard. These standards are relevant to community, nurse, and social work patient navigators and are relevant to diverse settings: hospitals, community clinics, rural and reservation clinics, and community organizations that provide patient navigation services.

Standard 8.1 shifted from the mandated triennial community needs assessment and navigation processes conducted to address a specific barrier each year and focused on processes for identifying and addressing barriers.9 Examples of procedures that may be used include steps such as:

Step 1. What data collection strategies exist to clarify which data may document whether a barrier exists (patient self-identified, needs assessment findings, patient satisfaction scores, focus groups).

Step 2. Review the data and determine where there are gaps in community resources and prioritize underserved or unserved communities.

Step 3. Select a high priority or common barrier and create, implement, and evaluate potential strategies to address.

Step 4. Provide a summary to cancer committee, grand rounds, or other comparable groups (clarify the barrier chosen and procedure used to reduce or eliminate the barrier).

NAPBC

NAPBC is a consortium of national, professional organizations focused on breast health and dedicated to the improvement of quality outcomes of patients with diseases of the breast through evidence-based standards and patient and professional education.10 NAPBC was founded in the 1970s, shortly after the passage of the 1971 National Cancer Act that declared “war on cancer.” NAPBC was paramount in drawing attention to breast cancer experiences and strategies to improve care through coordinated and multidisciplinary teams of healthcare providers. Using evidence-based interventions, NAPBC was among the initial national organizations to implement accreditation processes to breast cancer centers. NAPBC Standard 2.2 states “A patient navigation process is in place to guide the patient with a breast abnormality through provided and referred services.”10 This standard specifies “the patient navigation process includes consistent care coordination throughout the continuum of care and an assessment of the physical, psychological, and social needs of the patient. The anticipated results are enhanced patient outcomes, increased satisfaction, and reduced costs of care.”10

As described previously in this article, both ONS and AONN+ have competencies and knowledge domains that are focused on overcoming barriers to care and support both the CoC 8.1 and NAPBC 2.2 standards. The metrics for these include:

  • Barriers to Care: Number and list of specific barriers to care identified by the navigator per month
  • Interventions: Number of specific referrals/interventions offered to navigated patients per month
  • Social Support Referrals: Number of navigated patients referred to support services per month
  • Referrals to Revenue-Generating Services: Number of referrals to revenue-generating services within the system per month by navigator
  • Referrals to Support Services at the Survivorship Visit: Number of navigated patients per month referred to appropriate support services
  • Palliative Care Referrals: Number of navigated patients per month referred for palliative care services within the system

To illustrate how such metrics can be used, Lillie D. Shockney, RN, BS, MAS, HON-ONN-CG, and co-founder of AONN+, provided an example on the AONN+ website. “The CoC wants to know what specific barrier to care you are focusing on in any given year, and how you decided to choose that specific barrier. It also wants to learn how you are measuring your ability to reduce the barrier, as well as what outcomes it has produced. Here is an example: Patients are missing radiation appointments due to lack of transportation. This results in patients with ‘XYZ’ cancers not receiving radiation treatment in accord with NCCN [National Comprehensive Cancer Network]11 treatment guidelines. The incidence of missing appointments is 27%. Your solution was to get a grant from a local advocacy organization to provide free taxi vouchers. You tracked compliance with usage of the taxi vouchers and also calculated the percentage of missed radiation appointments after the taxi voucher process was implemented. The new percentage for missing appointments was 9%.”12

Of note is the strong alliance in patient navigation concepts from multiple national organizations and their direct link and recommendations for how to track and document accomplishments using the same evaluation metrics. Such metrics are essential to reinforce competencies and knowledge domains that subsequently are used for competency-based training, resulting in an accredited patient navigation workforce that helps cancer patients obtain access to quality and timely care and services.

Summary/Discussion

This document provides a concise illustration of the ONS core competencies, the AONN+ knowledge domains, the 35 AONN+ evidence-based navigation metrics, and the 2020 CoC and 2018 NAPBC national standards that support navigation. This document should be utilized for creation of oncology navigation job descriptions, performance improvement outcomes, dashboards, orientation, and annual competencies.

References

  1. Strusowski T, Sein E, Johnston D, et al. Standardized evidence-based oncology navigation metrics for all models: a powerful tool in assessing the value and impact of navigation programs. Journal of Oncology Navigation & Survivorship. 2017;8(5):220-243.
  2. Oncology Nursing Society. 2017 Oncology Nurse Navigator Core Competencies. www.ons.org/sites/default/files/2017-05/2017_Oncology_Nurse_Navigator_Competencies.pdf.
  3. Bellomo C. The effect of navigator intervention on the continuity of care and patient satisfaction of patients with cancer. Journal of Oncology Navigation & Survivorship. 2014;5(6):16-20.
  4. Guadagnolo BA, Dohan D, Raich P. Metrics for evaluating patient navigation during cancer diagnosis and treatment: crafting a policy-relevant research agenda for patient navigation in cancer care. Cancer. 2011;117(15 Suppl):3565-3574.
  5. Hewitt M, Simone JV, eds. Ensuring Quality Cancer Care. Washington, DC: National Academies Press; 1999.
  6. Centers for Medicare & Medicaid Services. Quality measures. www.cms.gov/Qualitymeasures.
  7. Institute of Medicine. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: National Academies Press; 2013.
  8. American College of Surgeons. Commission on Cancer 2020 Operative Standards. www.facs.org/quality-programs/cancer/coc/standards/2020/operative-standards. 2020.
  9. Venner E, Kirby M. Your guide to the updated CoC accreditation standards for 2020. Advisory Board. www.advisory.com/research/oncology-roundtable/oncology-rounds/2020/02/coc-2020-accreditation-standards. 2020.
  10. American College of Surgeons. National Accreditation Program for Breast Centers: Standards Manual. 2018 edition. https://accreditation.facs.org/accreditationdocuments/NAPBC/Portal%20Resources/2018NAPBCStandardsManual.pdf. 2020.
  11. National Comprehensive Cancer Network. www.nccn.org/profession als/physician_gls/default.aspx.
  12. Academy of Oncology Nurse & Patient Navigators. What Would Lillie Do? www.aonnonline.org/general?view=article&secid=165:what-would-lillie-do&artid=2750:commission-on-cancer-standard-8-1-addressing-barriers-to-care. 2020.
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Last modified: April 26, 2021

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