Nurse Navigators as the Drivers to an Enhanced Patient Referral Process

Mary Pat Winterhalter, MHA, BSN, RN, NE-BC, CCM; Kimberly Cobb, BSN, RN, OCN, CBCN;
Karen Heron, MSN, BSN, RN; Megan Metzgar, BSN, RN, OCN, CBCN; Catherine McCullough, MSN, BSN, RN;
Susan Rux, PhD, RN, ACNS-BC, CNE, CPCC, CPRW, FACHE, LNCC, NEA-BC, NPD-BC, OCN, PHN, PNAP

Fox Chase Cancer Center, Philadelphia, PA

Background: Within the structure of a center-wide patient access redesign initiative, the nurse navigators evaluated their contributions and activities as professional registered nurses. They noticed a lack of standard interview questions and a patient referral process that holistically supported patients.

Objectives: To improve new patient services for those beginning their cancer journey.

Methods: A special departmental committee was formed to examine the perception of the nurse navigators working at the full extent of their education and training, sometimes also referred to as at the top of their license. Patient advocacy advancement efforts and expediting access to cancer care propelled the committee in mobilizing priority actions.

Results: Initially, the navigation department was alerted of current data representative of the social determinants of health and barriers to care in the Philadelphia region. An education series provided a review and, in some instances, an introduction to the organization’s patient supportive services and regional nonprofit community offerings. Utilizing departmental navigation meetings, the team continued to gain momentum and capitalize on the success through an examination of the patient referral metrics. The navigation team applied the mechanics of standard documentation and electronic medical record to streamline the referral process. During 2 distinct intervals throughout the project, the nurse navigators participated in surveys to inform their perceptions of working at the full extent of their education and training.

Conclusion: The unique efforts of the nurse navigation department to improve role function advocacy have culminated in a lasting rich internal reward spanning the scope of the department.

Fox Chase Cancer Center (FCCC) embarked on an opportunity to improve a new patient access program. Senior leaders noticed delays in new patients securing their initial appointments. Current state mapping by the navigation department identified process inefficiencies, defects, redundancies, and inconsistencies among departments resulting in delayed patient appointments. As a consequence, a center-wide new patient access redesign project was initiated. Within this master access redesign project, the navigation department realized an opportunity to improve their new patient services from the perspectives of both patient care navigators and nurse navigators. There was also a curiosity around whether the nurses within the navigation department were working at the full extent of their education and training. Anecdotal conversations with their director unveiled themes suggesting that the nurse navigators believed their role was more akin to schedulers and medical record gatherers rather than highly skilled professional nurses advocating for and educating their patients.

The cancer center’s nurse navigator role, created more than 15 years ago with a business growth strategy in mind, included the need to expedite care for the complex oncology patient. That model remains relevant in today’s healthcare environment. Both nurse and patient care navigators facilitate entry of patients into our cancer center through conducting interviews and securing new patient appointments within a clinically appropriate matrix. At the time of preparing this article, the nurse navigators were scheduling initial patient appointments. The nurse navigators continue to function at the beginning of the patient’s cancer journey, with a workflow change that involves scheduling agents who manage the initial new patient appointments. The nurse navigators acknowledged the need to increase their advocacy for new patients while minimizing any socioeconomic, cultural, psychological, communication, and bureaucratic barriers at the beginning of a patient’s cancer care journey. The nurse navigators believed that they could provide more help to new patients.

Nurse navigators aim to provide patient-centric education, early diagnosis/treatment options, improve patient adherence and engagement, prevent delays in cancer treatments, and enhance clinical outcomes. The Oncology Nursing Society¹ articulates the competencies of the oncology nurse navigator to possess the skill set and requisite knowledge to conduct care coordination in a quality, patient-centered delivery modality. Effective communication with the interprofessional cancer care team promotes the goals of navigation.

According to McQueen and colleagues, an increased assessment of patients’ social needs by healthcare organizations is associated with greater comorbid conditions.² Essentially nurse navigators provide oversight and assess patients’ needs and implement care plans, coordinate care, and provide support program information. Now, more than ever, oncology clinics are evaluated on their ability to meet certain quality measures related to prevention, chronic disease management, and access to health and healthcare needs. These ideologies informed the redesign and provided a lens for focused interventions within the navigation department.

Qualitative findings from the 2019-2022 FCCC Community Health Needs Assessment (CHNA) revealed that 83% of area residents rated the overall health of the community as “fair” or “poor,” with additional barriers to care that include difficulty navigating the healthcare system, literacy, housing, safety, transportation, lack of trust, limited financial resources, language and cultural barriers, and out-of-pocket costs.

To advance the navigation department and achieve the departmental mission and vision, an informal committee was formed. The committee comprised 2 long-standing nurse navigators and 3 nurse navigators who recently joined the FCCC nurse navigation department. The committee held weekly meetings to discuss strategies for enhancing the nursing value to the patient and providing patients with more help during difficult times in their life. An additional goal of the committee was to increase the nurse navigators’ perception of working at the full extent of their education and training. The nurse navigators expressed frustration with sentiments such as “we could do so much more as nurses.” The committee wanted to support and elevate the nurses in addition to giving more assistance to the patients. In September 2021, the committee completed a presentation to the entire nurse navigation department describing the proposed process changes of standardizing documentation, increasing supportive care referrals to new patients, reviewing the FCCC CHNA, and encouraging the nursing team to practice at the full extent of their education and training. The presentation described multiple initiatives as well as an implementation plan. The first intervention, determined by the committee, was to standardize nursing documentation of the new patient interview in the electronic medical record (EMR).

The goal of standardized documentation was to share accurate patient information and ensure continuity of care among care providers, thus allowing for confidential patient information to be provided to the care team in a timely, concise, and organized manner. It would also enhance communication between members of the healthcare team and improve care coordination among the patient’s clinical team while recognizing the needs and barriers of patients. Educational touchpoints and referral opportunities would reveal themselves during the interview and could be documented in a standardized manner. Each disease site contained an EMR smart phrase template that could be tailored to the patient’s specific situation and disease. Within each smart phrase, a group of questions were asked to each patient by the navigator, regardless of the patient’s type of cancer or benign process, to provide a more thorough history. The navigation department operationalized this initiative in the fall of 2021 with 100% expected compliance.

One of the goals of the standardized documentation was to better identify health disparities and barriers to receiving timely cancer care. This led to the second effort of increasing nursing interventions through pertinent education, resources, and support services referrals under the nursing scope of practice. The department started at a baseline of 2% of patients receiving referrals to supportive services. This initial goal was created to increase referrals to 7% and then, subsequently, to 15% of patients receiving supportive services referrals. Standardized questions asked during the nursing interview helped to identify barriers and disparities. For example, “Do you have transportation to your appointment?” informed the nurse whether a referral to social work was needed. Nurses received education related to submitting electronic referrals within the EMR, when possible. Education was provided during regular in-services on the resources and available services through their institution and within the community.

Review of Health Disparities and Barriers to Cancer Care

One of the US Department of Health and Human Services’ overarching goals of Healthy People 2030 is to address social determinants of health (SDOH) to improve overall health and reduce health disparities.³ FCCC completed a CHNA in 2019. FCCC compared the health status, access to services, health behaviors, and utilization of the healthcare system of residents within the FCCC service area with data for the country and state. FCCC defines its service area as the 84 zip codes near and around the area where approximately 50% of its patients reside. The results from the qualitative findings of the CHNA showed that 83% of the group participants rated the health status of the Philadelphia community as “fair” or “poor.” A key strategic priority of FCCC is to remove barriers to access care. Philadelphia, PA, comprises a diverse population totaling 1,584,064 residents. In 2020, Blacks or African Americans constituted 40% of the population base, Hispanic or Latino 15%, non-Hispanic White 34%, and Asian and others totaled 11%. According to Workforce Diversity, in 2007, Philadelphia, PA, had a staggering poverty rate of 25.7%. A more troubling statistic is that approximately half of the 25.7% reside in deep poverty.

Poverty income for a family of four in 2017 was $24,600 or less; deep poverty was $12,300 or less.⁴ Non-Whites are more likely to be diagnosed later in the disease process with a more aggressive cancer and may not utilize current standard therapies as prescribed by the physician. Numerous studies have concluded that SDOH affect cancer outcomes.^5-8 A delay in access to care leads to higher treatment costs, increased hospitalization rates, and complications related to the disease process. A longitudinal cohort to determine the impact of the cumulative effects of SDOH on cancer mortality revealed similar results as the Reason for Geographical and Racial Difference in Stroke (REGARDS) study. Pinheiro and colleagues concluded that cancer mortality increased with each additional SDOH for all participant studied.⁹

The nurse navigation team at FCCC began their redesign project by analyzing root causes and gaps in patient care for those who enter the FCCC system. The team noted an inconsistency with performed assessments that identify health disparities and barriers to cancer care. In addition, pertinent patient education, resources, and supportive care referrals were lacking.

Cancer patients reported financial toxicity at a much higher rate than the general population. Finances impact cancer patients’ ability to maintain continuity of care.¹⁰ This year the cost of cancer care to the American public is expected to reach $158 billion. Since 2010, the price of health premiums has increased by 66%; however, wages have only increased by 10%. A single oncology medication can cost up to $120,000 annually. A study from Doshi and colleagues uncovered that even for the most robust insurance plans, out-of-pocket expenses were associated with higher rates of oral prescription abandonment and delayed initiation across cancers. Furthermore, sustainable financial strategies to improve patient access to cancer medications and treatments are warranted.¹¹ Food insecurity for cancer patients mimics that in the general population. Research demonstrated a link between food insecurity and poor health outcomes. A report from Feeding America showed that approximately 66% of households receiving food resources from a network of food banks had to choose between paying for food and medication or medical care.¹²

Wolfe and associates acknowledged that millions of people miss planned medical appointments due to the lack of transportation. In a longitudinal study from 1997-2017, 5.8 million people in America missed or delayed medical appointments due to transportation problems.¹³ Transportation challenges affected people with lower incomes who have chronic illness and functional limitations. Reasons may include the person does not have access to a personal vehicle or is prohibited by the distance and cost to drive to the center. There are no efficient public transportation options. Cancer patients report a lower quality of life compared with the public.¹⁴ Cancer patients report more psychosocial severe difficulties, such as depression, anxiety, and isolation. The role of the oncology navigator is to provide the cancer patients, their families, and caregivers with the necessary resources to remove barriers and facilitate timely access to care. Nurses use their clinical expertise to promote the referral process for essential services under their scope of practice. Nursing referrals to supportive services are inclusive of nutrition, financial counseling, chaplain, social work, physical therapy, genetic counseling, and nonfertility. By assessing SDOH during the intake process, the team works to position the cancer patient to receive optimal care and achieve the best outcome. Friedman and Banegas¹⁵ discussed the importance of identifying patients during intake for SDOH through electronic records, which is documented through a case study completed at Kaiser Permanente North West Health System. During the study period, 2016-2018, more than 18,000 community referrals were made. Research has shown formal nurse navigation programs improve patient outcomes in cancer patients.^16-18

To increase patient referrals to FCCC and provide patients with community resources as well as additional help, the team initially needed to educate and familiarize the entire team of the available resources. A speaker series was created with invitations distributed from various navigators. FCCC social work, nutrition, and psychology departments, as well as the oncofertility committee and smoking cessation program, were invited to speak with the navigation team during staff meetings. The collaborative meet and greets provided an introduction as well as a review of the available services to novice and proficient navigators. The navigation team learned how to use EMR functionality to independently refer patients to FCCC services. Subsequently, the team shared community resources and websites among the group and stored the information in a shared electronic folder. Speakers from community nonprofits, such as CancerCare and Cancer Support Community Greater Philadelphia, were invited.

Nurse navigators with a practice focus on breast cancer traveled to Pine2Pink, a local breast cancer support group, to learn more about the services provided. The gynecological nurse navigators participated in the Wellness Day of Unite for Her, a nonprofit organization that offers wellness services to breast and gynecological cancer patients. All these educational efforts assisted the nurse navigators in gaining confidence to share information with new patients.

Multifaceted social barriers facing lung cancer patients result in delayed diagnoses, treatment, and access to complex healthcare systems. A study by Hunnibell and colleagues shows that the average time from suspicion of a lung cancer diagnosis to treatment was 136 days. Nurse navigators can bridge this care gap by producing process enhancements and affect timely access to care improvements.¹⁹

As described at the beginning of this article, the committee was curious whether increasing knowledge around supportive resources, standardizing navigation documentation, and empowering the nurses to place their own referrals to ancillary in-house departments and community organizations would increase the perception of working more to the full extent of their education and training. The committee surveyed the nurses to determine their perceptions. The results of 2 nurse navigator surveys, as shown in Figures 1 to 4, administered in October 2021 and April 2022, respectively, demonstrate an improvement across multiple survey questions. The survey question asking the nurse navigators if they believe patients are getting the full benefit of their education and nursing experience resulted in an undesirable response, indicating that the nurse navigation department still has work ahead to address this perceived gap. In summary, the committee found that when nurses feel empowered to advocate for patients, nurses also receive positive effects from this advocacy. This initiative increased their perception of working more to the full extent of their education and training.

FCCC’s new patient access redesign project is currently fully operational. A new EMR scheduling system, implemented in October 2022, provided a unique workflow for new patients with access center scheduling agents for the patient’s initial contact. Nurse navigators now interview the patient after the first appointment has been scheduled and before the first appointment is completed. Early anecdotal reports by nurse navigators indicate patients are engaging more during the navigation interview and new workflow. The nurse navigators reported that patients are more settled knowing their initial appointment is scheduled, which promotes the nurse–patient engagement and offers supportive services.

Moving forward, the committee and the entire nurse navigation department realize that there is more work to accomplish. The next step is to increase the use of SDOH questionnaires built into the EMR. The addition of SDOH questions will benefit new patients and increase the nurse navigators’ confidence in the benefit of their education and experience to the patients they serve. We intend to resurvey the nurse navigators, using the same questions about their perceptions of working at the full extent of their education and training, after implementation of the SDOH features within our EMR.

Acknowledgment of Non-Author Contributor

We thank Kathleen Wolf, MBA, BSN, RN, NEA-BC, for her expertise and writing assistance, technical editing, language editing, and proofreading of the manuscript.

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