AONN+ 2021 CE Monograph: Understanding the Commission on Cancer; Precision Medicine; Technology Innovation Integration to Address Underserved Disparate Patient Populations; Navigation Certification: Overview, Value, and Preparation

March 2022 Vol 13, No 3

Categories:

AONN+
Meg Barbor, MPH

Oncology navigators from across the country attended the AONN+ 12th Annual Navigation & Survivorship Conference in November 2021. This monograph will review the proceedings from 4 key sessions at the conference covering topics of Understanding the Commission on Cancer, Precision Medicine, Technology Innovation Integration to Address Underserved Disparate Patient Populations, and Navigation Certification: Overview, Value, and Preparation.

Understanding the Commission on Cancer

The American College of Surgeons Commission on Cancer (CoC) is recognized as an effective mechanism for impacting cancer care, including patient navigation, palliative care, and survivorship. The CoC is defined as “a consortium of professional organizations dedicated to improving survival and quality of life for cancer patients through standard-setting, prevention, research, education, and the monitoring of comprehensive quality care.”

A total of 59 organizations (including AONN+) make up the CoC, while only about 24% of US hospitals (treating between 70% and 75% of all patients with cancer) have CoC-accredited cancer programs. But, even though these CoC-accredited institutions represent the minority of cancer institutions in the country, they represent the majority when it comes to actually treating cancer in the United States.

According to Frederick L. Greene, MD, FACS, past chair of the CoC, accreditation with the organization has obvious tangible benefits. For example, their CoC Standards manual offers guidance on the organization and infrastructure of a cancer program, and accredited institutions have access to huge amounts of data to assess patterns of care and outcomes. However, the intangible benefits, like team-building, leadership, and programmatic development, are just as valuable. But at its core, accreditation with the CoC is about team-building, he said.

Additional benefits of becoming CoC-accredited include access to hospital and benchmark data on cancer outcomes, participation in cancer standards development, recognition as an accredited cancer program, and coordinated compliance with state-required cancer registries and data collection.

The CoC offers a variety of robust resources for navigators, such as the National Cancer Database, a national clinical cancer registry system that includes data on more than 38 million cancer cases diagnosed since 1985. This database is meant to drive continuous quality improvement in the evaluation, management, and surveillance of patients with cancer through capturing data points such as patient characteristics, cancer staging and tumor histological characteristics, type of first-course treatment administered, and outcomes information.

Another resource offered by the CoC is participant user files, a deidentified, comprehensive data set starting in 2004 that offers site-specific data sets (ie, colon, breast, prostate, etc) from patient care research.

The resources available to CoC-accredited institutions can also be used by navigators to conduct their own research.

All CoC-accredited institutions have education and training resources available to them (ie, online education and workshops), in addition to patient education materials, such as an ostomy home skills kit and a central lines home skills kit. The latter are designed to help with reducing complications of care, improving patient participation and outcomes, supporting the transition to home, and increasing patient satisfaction.

The CoC evidence-based standards—Optimal Resources for Cancer Care—were most recently updated in 2020 and were crafted to support and enhance efforts to improve patient care. They are designed to be clearly interpretable by cancer programs and should be objectively verifiable by experienced site reviewers during site visits.

Just as staging systems must be updated in oncology, the same applies for the CoC Standards. Ongoing standards revisions are based on evidence and best practices; the standards focus on structure, process, and outcomes and aim to address the full continuum of cancer—from prevention to survivorship and end-of-life care—while addressing both survival and quality of life. For example, patient-centered standards focus on psychosocial distress, navigation, and survivorship.

The 2020 CoC Standards include 9 chapters, a notable change from the 5 chapters included in the 2016 Standards. Changes particularly relevant to members of AONN+ include updates to oncology nursing credentials and survivorship programs, and addressing barriers to care.

For example, in regard to survivorship programs (Standard 4.8), the updated standards place less emphasis than the previous standards on survivorship care plans (SCPs) and more on the importance of a team approach to survivorship led by a survivorship coordinator.

Per the requirements in Standard 2.1: Cancer Committee, a survivorship coordinator should be appointed to a survivorship program and should assemble a survivorship program team of physicians, nurses, social workers, nutritionists, physical therapists, and other allied health professionals.

Responsibilities of the survivorship program team include determining a list of services and programs (offered on-site or by referral) that address the needs of cancer survivors, and formally documenting a minimum of 3 services offered each year at their institution (eg, nutritional, psychiatric, or rehabilitation services).

While the CoC recommends that patients receive an SCP, this is no longer a required component of this standard. However, delivery of SCPs may be counted as one of the services offered to survivors to meet the requirements of this standard.

Precision Medicine

The terminology used in conversations about precision medicine can be confusing for both patients and their providers. Inconsistent terminology has made this important concept even more difficult to understand, but as precision medicine becomes more and more impactful in oncology, the need for patient-friendly, consistent terminology has become abundantly clear.

According to Claire Saxton, vice president, Patient Experience at the Cancer Support Community (CSC), the way that healthcare providers talk about precision medicine varies significantly from provider to provider, and the level of detail discussed is often determined by the questions that the patient asks. This leaves patients and their caregivers feeling overwhelmed and confused, but empowering them with knowledge of precision medicine—so that they can participate in shared decision-making with their healthcare team—is critically important to helping them receive appropriate testing and optimal treatment.

The Precision Medicine Plain Language Lexicon, designed by CSC, was developed to meet this need. It includes a set of plain-language terms and definitions that help explain precision medicine, biomarker testing, and genetic testing to patients, caregivers, and the general public.

This initiative was born out of a common sentiment being voiced among patients with cancer: they felt like they needed “a PhD in cancer” to understand conversations about precision medicine. This sentiment was particularly strong among patients with cancer types in which biomarker testing and precision medicine have gained a strong foothold (ie, lung and breast cancers).

For many patients, undergoing biomarker testing can show which treatments might work best for them. However, biomarker testing should usually be conducted near the time of diagnosis, and at that point patients and their caregivers are particularly overwhelmed.

But as the complexity of precision medicine has grown, so has the confusion, so the need for easily understood, patient-friendly language became impossible to ignore.

With the help of patients, caregivers, and experts, Ms Saxton and her team at the CSC came up with a list of commonly confused concepts about precision medicine that needed to be explained. They defined those concepts, then used feedback from patients and caregivers (through focus groups and discussion boards) to make sure the definitions were easy to understand. These terms and their definitions then became the Precision Medicine Plain Language Lexicon.

In developing the lexicon, patients and caregivers were asked questions about whether they had heard of specific terms like “precision medicine,” “genomic,” “genetic,” or “targeted therapy.” If they had heard of these terms, they were asked to provide unaided responses further explaining them so researchers could gauge how well they were understood.

Some of the important takeaways included:

  • While participants are hopeful about the concept of precision medicine and think that they know what it is, few patients and caregivers could clearly describe “precision medicine”
  • “Genetic” and “genomic” were found to be too similar, causing widespread confusion (CSC no longer uses the term “genomics,” instead opting for “biomarker testing” or telling patients that a cancer is “tested for mutations”)
  • Patients’ unaided descriptions of targeted therapy were often actually descriptions of radiation therapy (CSC now refers to targeted therapy as “targeted therapy drugs”)
  • Patients and caregivers are confused by the “alphabet soup” of biomarkers, specifically by terms that come across as jargon, like HER2, ALK, and EGFR. Using less jargon lessens confusion but may actually require more words to explain clearly. For example, telling a patient: “If you have a positive HER2 test result (HER2+), Herceptin is likely to work well for you,” is typically well understood. However, “Herceptin targets HER2” is confusing jargon.

Based on these findings, Ms Saxton urges providers to use biomarker acronyms (alphabet soup) sparingly, to focus on what the patient needs to know to be an active member of their healthcare team, and to wait until biomarker testing is actually conducted to explain findings. In other words, focus on the test results that make a difference for that patient rather than talking about all of the things they could test positive for up front.

Remember that this is a stressful time for patients and their caregivers, and that the same result might elicit different reactions from different patients. For example, some patients are afraid to hear that their cancer has a specific mutation, while others find it frightening that they don’t have a mutation and feel that no additional treatments can be offered to them. Remind patients that biomarker testing reveals which treatments will not work for them, so it is critical in leading doctors toward the treatments that will work best for their specific cancer type.

The lexicon is offered as a free resource for all—including providers, oncology professional associations, industry partners, and patient advocacy organizations—with a goal of increasing communication between patients, caregivers, and their care teams. It is considered a living document, and it will be updated periodically as cancer care changes, and as more feedback is received.

The Precision Medicine Plain Language Lexicon is available at www.CancerSupportCommunity.org/PMPlainLanguage.

Technology Innovation Integration to Address Underserved Disparate Patient Populations

Although it may be difficult for some to acknowledge, systemic, institutional-level racism is inherent in healthcare systems. Navigators can play a significant role in addressing this issue, but to do that successfully, they must actually work within those affected communities to determine barriers, appropriate outcome measures, and real-time interventions.

Technology can be a major asset in the interventions designed to mitigate these disparities, and the real-time digital data provided by electronic health records can successfully be used as the foundation. But for these types of technology-based interventions to increase equity in cancer treatment, navigators, clinical teams, and health-system leaders must keep their communities engaged in addressing healthcare barriers and ensuring accountability. And importantly, these innovative technologies do not work without dedicated, trained navigators to act on the technology and add a human touch.

In the United States, healthcare is an institution, and the outcomes of individuals within that institution vary by race. Even after controlling for socioeconomic status, age, and comorbidities, racial disparities in care and in outcomes still exist. And according to researchers, despite improved diagnostic testing and treatments leading to better results in cancer, these disparities do not seem to be improving.

But when racial disparities in care are addressed through the use of technology, health outcomes improve for all patients, not only for minorities.

Although socioeconomic factors like insurance status, education level, and income do make a difference, other racial and ethnic disparities exist well beyond these issues. For example, uneven interpretation of comorbid illnesses (implicit bias) has demonstrated that some non–African American physicians were not willing to perform risky procedures on patients with whom they felt less comfortable. Additionally, poor perceptions of communication on the part of patients (ie, African American patients were less inclined to go to surgery if they rated shared communication more poorly), and unacknowledged nonmedical beliefs that tend to be higher among certain minority populations (ie, prayer alone can cure) also contribute to disparities in care.

Importantly, even with all of the progress being made in precision medicine, significantly fewer black patients are undergoing molecular testing compared with white patients and are therefore being offered treatment less often with biologic agents.

These disparities in care translate to an increase in mortality in minority populations, despite a similar incidence of disease.

Addressing these longstanding racial disparities in cancer care requires system-level, innovative solutions, and the use of technology is imperative.

Technology-based interventions should be based around real-time transparency rather than potentially outdated secondary data from studies of disadvantaged and minority populations. According to researchers, the real-time transparency using digital data from electronic health records might be the key to addressing some of these racial and ethnic disparities.

In addition to transparency, these interventions must have accountability (outcomes should be measured according to race or other disadvantaged population) and should use enhanced, understandable communication. Often, healthcare providers rely too heavily on medical lingo and do not connect with patients about their personal lives and families, but using understandable, relatable language is extremely important to overcoming systemic bias and barriers. Importantly, navigators tend to be especially accustomed to using this type of enhanced communication and can help their oncology colleagues overcome their own hesitations with using that style of language with their patients.

One successful technology-based intervention designed around navigation and enhanced communication was the ACCURE Project. This patient-centered intervention used navigators specially trained in particular barriers and beliefs that limit care for African Americans.

This intervention relied heavily on community involvement, providing navigators with health equity training, and educating them about appropriate protocols and barriers specific to the disadvantaged patients in these communities. Through these trainings, navigators gained an understanding of structural racism and barriers that are more likely to affect people of color. In addition to the training modules, becoming an ACCURE-specialized nurse navigator also involved carrying out data-informed patient follow-up through the use of a real-time registry that utilized an alert system within the software (navigators were alerted when patients missed appointments or other important milestones).

The health equity trainings and software technical support provided through the intervention allowed navigators to have early contact with patients (important to developing rapport), to identify barriers to care quickly, and to follow up with prompt interventions to those barriers.

The project’s 6 themes were centered around transparency (patient-centered advocacy, addressing system-level barriers to care, and connecting patients to resources)and accountability (reengaging patients after lapsed treatment, addressing symptoms and side effects, and emotional support). In keeping with these themes, some of the navigators’ roles included advocating for patients to receive mental health services during treatment, bridging the gap in communication between patients and oncologists, setting up transportation, and celebrating milestones.

According to the researchers involved in the project, the ACCURE intervention eliminated multiple barriers (not only in regard to cancer care) and resulted in better engagement between patients and their care team, better adherence to treatment, and better patient outcomes.

Higher rates of both black and white patients completed their cancer treatment in the ACCURE intervention group compared with the control group, providing further evidence that addressing racial disparities in care improves health outcomes for all patients, not only for minorities.

Navigation Certification: Overview, Value, and Preparation

Navigation certification offered by the AONN+ Foundation for Learning (FFL) has gained a lot of attention in the navigation community, but along with that attention comes questions. The director of certification at AONN+ FFL provided attendees with an overview of navigation certification, explained the value of receiving certification through an accrediting body, and offered insight into the details and preparation involved with sitting for one of these exams.

Nurses and social workers are likely quite familiar with certification, but lay and community navigators may not be as well acquainted with the concept. First and foremost, certification comes from an organization and will be presented as a formal attestation: an official document from an organization to the person who completes the certification.

It is a formal step, attesting to the fact that a person is professionally competent based upon parameters that have been set.

The certification exam is built on those parameters. If a person passes that exam, they will receive assurance of professional competency declared on behalf of the professional organization, and credentials designating certified individuals from those who are noncertified. These are the letters behind a name that show that a person is at the top echelon of his or her profession.

Over the years, the certification process has evolved at AONN+/AONN+ FLL. When the AONN+ certification exams premiered in 2016, they were nonaccredited. Then, in 2019, an announcement was made that the two certified generalist exams available (Oncology Nurse Navigator–Certified Generalist [ONN-CG] and Oncology Patient Navigator–Certified Generalist [OPN-CG]) had received accreditation through ANAB (American National Standards Institute [ANSI] National Accreditation Board), the largest accrediting body in North America. This led to the creation of AONN+ FFL.

In 2021, Lisa Hartman, MS, MA, BSEd, BSN, RN, was hired as full-time director of certification at AONN+ FFL. This move to full-time staffing supports the future of certification and ensures that the annual audits required to maintain a high level of professionalism within an accreditation are maintained.

AONN+ FFL exams are now accredited through ANAB, and ANAB also provides services in more than 75 countries, allowing AONN+ FFL the opportunity to grow internationally.

AONN+ FFL is a sister organization to AONN+, but it is a completely separate business with a separate leadership, website, policies, and procedures. This creates the required firewall between certification and training initiatives (eliminating any unfair advantage for members of the organization). According to Ms Hartman, the certification process must always be fair; everyone interested in certification needs to have the exact same access, whether they’re a member of AONN+ or not.

Accrediting bodies are very particular about this firewall; while this does not mean that practice exams and preparatory courses cannot be offered through the organization, it does mean that they must be made available to everyone. They cannot echo anything specific from the certification exam, and they cannot provide anyone with an unfair advantage at performing better on the exam. This can be a challenge, particularly in a specialized field such as navigation, but anytime accreditation is involved, know that a governing body will be constantly monitoring activities, she noted.

Maintaining independence from AONN+ also allows AONN+ FFL to concentrate fully on long-term, certification-focused strategy development.

“This allows our focus to be 100% on things that are certification-related, versus all of the other amazing work that goes on within the organization,” she said.

AONN+ set out to receive accreditation for their exams because accreditation adds value. Factors that set accreditation apart from nonaccreditation include:

  • Robust Standards: ANAB provides AONN+ FFL with a robust set of standards, for which they must enact formal policies and processes (ie, the process by which candidates must apply for certification)
  • Continued Quality Improvement: constantly evaluating processes for quality and efficiency
  • External Audits
  • Psychometric Analysis: performed by statisticians who specialize in certification exams and make sure questions are fair, there are no signs of cheating in the exams, the exam is weighted appropriately, etc
  • Defined Policies and Procedures: structure, structure, structure

Ms Hartman also pointed out the important difference between a certificate and a certification:

Certificate

  • Training workshop/course on a specified topic
  • Assessment is related to the workshop/course information
  • No credentials; no renewal

Certification

  • Standardized exam based on defined industry standards
  • Accredited provider
  • Provides credentials attesting to professional competence
  • Commitment to growth/profession is required for renewal

Ms Hartman detailed the specific application and renewal requirements for the ONN-CG and OPN-CG certifications, respectively:

ONN-CG (Oncology Nurse Navigator–Certified Generalist):

Application Requirements

  • Active RN license in good standing
  • CV or résumé showing current employment as a navigator and at least 3 years of direct navigation experience
  • Documentation of at least 15 continuing education (CE) credits within the past 12 months (CE must consist of education within the defined navigation knowledge domains)
  • Current official job description from your place of employment
  • Reference letter written and signed by your employer, verifying your role and recommending you for certification

Renewal Requirements (certification valid for 3 years from date of testing)

  • Completion and documentation of at least 45 CE credits every 36 months (CE must consist of education within the defined navigation knowledge domains)
  • Maintain direct navigation position
  • Maintain RN license in good standing
  • Submit updated CV or résumé and official job description
  • Submit new reference letter from employer

OPN-CG (Oncology Nurse Navigator–Certified Generalist):

Application Requirements

  • Résumé showing current employment as a navigator and at least 1 year (or 2000 hours) of direct navigation experience
  • Current official job description from your place of employment
  • Reference letter written and signed by your employer, verifying your role and recommending you for certification

Renewal Requirements (certification valid for 3 years from date of testing)

  • Completion and documentation of at least 24 CE credits every 36 months (CE must consist of education within the defined patient navigation knowledge domains)
  • Maintain direct navigation practice
  • Submit updated resumé and current official job description
  • Submit new reference letter from employer

She noted that renewal is part of the commitment involved in certification. If renewal of any certification is not completed by the designated expiration date, continued use of professional credentials is not permitted on a person’s professional signature or documents.

Importantly, a person interested in moving into the field of navigation, who has no navigation experience, cannot apply for one of these certifications.

These navigation certifications are about demonstrating expertise in the field of navigation, Ms Hartman stressed. The level and amount of direct navigation experience required varies from ONN-CG to OPN-CG, but that knowledge and experience is absolutely a prerequisite.

Related Articles
Defining the Complexity of Patients Through an Acuity Tool: A Scoping Review
Danelle Johnston, MSN, RN, HON-ONN-CG, OCN, Tricia Strusowski, RN, MS
|
April 2022 Vol 13, No 4
The National Acuity Initiative presents their findings from a scoping review of the literature. These results informed the creation of case studies on which the acuity tool will be tested and validated.
AONN+ 2021 Midyear CE Monograph: Smoking Cessation, Making a Business Case for Financial Navigation, Screening in the COVID Era, Geriatric Oncology
Meg Barbor, MPH
|
September 2021 Vol 12, No 9
Earlier this year, oncology navigators from across the country attended the AONN+ Virtual Midyear Conference. This monograph will review the proceedings from 4 key sessions at the conference covering topics of smoking cessation, making a business case for financial navigation, screening in the covid era, and geriatric oncology.
AONN+ Annual Conference Monograph: A Study of Key Sessions
Meg Barbor, MPH
|
May 2021 Vol 12, No 5
At the recent AONN+ Annual Conference, experts in oncology navigation convened virtually with conference attendees to offer their insights in furthering the efficacy of navigation. This monograph will review the proceedings from 4 key sessions covering the timely topics of telehealth, mental health and the oncology patient, prehabilitation and rehabilitation, and value-based oncology care.
Last modified: March 24, 2022

Subscribe Today!

To sign up for our print publication or e-newsletter, please enter your contact information below.

I'd like to receive:

  • First Name *
    Last Name *
     
     
    Profession or Role
    Primary Specialty or Disease State

    Please enter your mailing address.

    Address
     
    Address Line 2
    City
     
    State
    Zip Code
    Country