Erica Shasteen, MSN, RN, OCN, NPD-BC; Amogh Rajan, MA, MS
Oncology Consultants PA, Houston, TX
Background: The H.O.P.E. Initiative aims to improve care access and financial hardships exacerbated by social determinants of health for patients through navigation services at an independent oncology practice. To demonstrate a sustainable business case, H.O.P.E. adopts a unique, payervalidated process to measure the impact of the navigation program on health outcomes.
Objective: In collaboration with Vantage Health Technologie’s SocialHealth360 solution, H.O.P.E. conducted a pilot to study the impact of whole person care navigation utilizing CHWs on care outcomes like experience of care and cost of care for cancer patients.
Methods: Under H.O.P.E., patients are contacted by CHWs during the week of their first oncologist visit. CHWs screen patients using a validated Health Communities Health-Related Social Needs Tool to uncover barriers to care. Patients with barriers can opt in to H.O.P.E. to receive navigation support from CHWs. Guided by “next best actions” through the SocialHealth360 solution, CHWs assist patients with barriers, including financial strain, utilities, substance use, mental health, food, and transportation. Referrals are made, and their outcomes are tracked by the solution. Patients also respond to a monthly, payer-validated electronic patient-reported outcome survey called Healthy Days. This helps measure the impact of the CHW’s work on the patient’s experience of care and acts as an early warning system, directing CHWs to patients needing additional support when poor Healthy Days are reported. The study by Humana found a 1-day change in Healthy Days to significantly reduce inpatient visits and cost of care for a population of 100,000.1
Results: H.O.P.E. has a target to maintain or exceed 20 Healthy Days for its patient population, with the current all-population average being 22.5, exceeding the set target. In the last 30 days, the Healthy Days measurements for Hispanic/Latino ethnicity, Asian race, and White race have exceeded 22.5 days, and that reported by Black patients is 20 Healthy Days. In the past, reprioritization of outreach to patients with below-average Healthy Days has demonstrated a significant improvement in their Healthy Days (44% in Black patients and 61% in Vietnamese patients). The tech-integrated approach benefits H.O.P.E. by:
Encouraged by these results, we are in the early stages of partnering with Dartmouth College to study the impact of H.O.P.E. on additional patient outcomes.
Conclusion: Early findings support efficacy of person-centered oncology care navigation services in improving patient outcomes, total cost of care, and patient experience of care. We are hopeful that a study of this nature will help oncology communities across the country make a business case for reimbursements for navigation services with more payers.
Candace Bashaw, MSN, RN, OCN; Kris Blackley, MSN, RN, BBA, OCN; Jill Hyson, MSN, NP-C, AOCNP; Emily Ann-Marie Copus, MSW, OPN-CG; Carla Strom, MLA; Laura Kabrich, MSN, RN, BA Psych, ACM; Laura Hayes, MSN, RN, OCN
Atrium Health Levine Cancer, Concord, NC
Background: Data collection and reporting are essential to the sustainability of oncology navigation programs. Inconsistent data collection and reporting are some of the biggest threats to supporting a navigation program.1 This information can be used to capture navigation outcomes that align with AONN+ standards to help emphasize the importance of and support expansion of current navigation programs. Levine Cancer (LC) and Wake Forest Baptist (WFB) are dependent on accurate and detailed data to demonstrate productivity and request additional positions.
In 2022, LC transitioned electronic medical record (EMR) platforms from Canopy to Epic. The new navigation documentation tool available in Epic provided minimal ability to capture consistent measurable data. The data were limited to the number of contacts, average acuity level, and time spent with the patient. Navigators were documenting most of their assessment and interventions in narrative form, making data extrapolation impossible. Documentation was also inconsistent across the organization. Shortly after the EMR transition, Atrium Health also merged with WFB, requiring navigation teams across the Southeast region to create a new shared documentation tool.
Objective: To create a comprehensive oncology navigation documentation tool to capture tailored, detailed, and measurable data to enhance program evaluation and outcome reporting.
Methods: Representatives from LC and WFB met routinely to merge documentation tools. LC used their previous Canopy documentation tool and compared that with the current WFB Epic documentation tool. Comprehensive flowsheets were adapted to capture a barrier and needs assessment, acuity level, referrals made, education performed, type of contact, and the time spent with each patient. Emphasis was placed on discrete data fields and a core set of standard documentation to allow for streamlined utilization across multiple types of navigation and minimized documentation in narrative form. Once the tools were merged, LC and WFB met with the Information Systems team to build the documentation flowsheet in Healthy Planet, a population health module in Epic, and provide a data reporting framework. A small team of navigators piloted the documentation flowsheet and provided input for changes before it was officially launched.
Results: Previous reports for documentation across legacy sites had limitations and varied in the number of data elements. The new documentation tool provides multiple flowsheets that allow collection of extensive information about patients’ barriers and needs and interventions performed by the navigator and is now utilized by over 50 nurse and patient navigators across the Southeast region. Development of flowsheets with discrete fields makes information more readily available, accessible, and utilizable. Customizable reports from flowsheets enabled the analysis of data used to find gaps in care and request additional site-specific resources. Consistent documentation across the organization also increases integrity in data reporting.
Conclusion: By creating a concise and thorough way to collect information in the EMR, it is more readily available to members of the healthcare team and allows for better workflow. Streamlining this information provides site-specific trends and allows for larger evaluation, research, and outcome reporting. Future plans include further adaptation to additional forms of navigation, such as screening navigation.
Ebonie Siemer, RN, HN-BC; Emery Bergey, MSN, APRN, AGCNS-BC, OCN
H. Lee Moffitt Cancer Center, Tampa, FL
Background: Patients presenting to consultation visits with incomplete diagnostic testing frequently experience delays in care. Coordinating additional appointments to obtain the necessary tests creates significant mental, emotional, and financial stress for patients and caregivers. Recognizing the need to proactively initiate testing, a standardized process was created and trialed at an NCI-designated comprehensive cancer center with the goal of utilizing the specialized role of the oncology nurse navigator (ONN) to mitigate this gap.
Objectives: Using a defined workflow to initiate orders for testing, the ONN aimed to facilitate more informed appointments, shorten time to treatment, and subsequently prevent delays in care.
Methods: Baseline data were collected from a retrospective chart review of navigated patients in February 2023. After establishing exclusion criteria for patients who did not return to the center for treatment and/or had their staging completed prior to meeting with the RN navigator, February baseline number decreased from 21 to 10. Orders by policy were created in conjunction with genitourinary surgical oncology physicians based on NCCN staging recommendations for patients with prostate cancer. Upon initiation of the intake call, the ONN assessed for the presence of incomplete diagnostic tests, lab work, and outdated biopsies and initiated orders by policy to facilitate completion of these items.
Results: From March to June 2023, 29 orders by policy were implemented as part of the ONN’s intake call. An average reduction of 32 days (73.5–41.15) from consultation to start of treatment was noted over the course of data collection. The process has been expanded to other clinics within the cancer center, and the policy has been expanded to include an additional subset of patients.
Conclusion: The results of this pilot project demonstrate the positive implications of providing ONNs with the autonomy to utilize their full scope of practice, thus solidifying the importance of their role in early identification of potential barriers to care. Positive patient outcomes result from reduced travel time and improved coordination of care. The process is easily implemented in ONN practice and may be generalizable to care pathways for other complex patient populations.
Gordils-Perez J, Schneider SM, Gabel M, Trotter KJ. Oncology nurse navigation development and implementation of a program at a comprehensive cancer center. Clin J Oncol Nurs. 2017;21:581-588.
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Prostate Cancer. prostate.pdf
Oh J, Ahn S. Effects of nurse navigators during the transition from cancer screening to the first treatment phase: a systematic review and meta-analysis. Asian Nurs Res (Korean Soc Nurs Sci). 2021;15:291-302.
Wright A, Comella K. Rectal, esophageal and pancreatic cancer stacked testing. Journal of Oncology Navigation & Survivorship. 2021;12(11):387.
Cyndi Lemery, MSN, RN, OCN; Joseph Terrell, MS; Andrew Bailey, MS; Sumanth Bail, MS
Clearview Cancer Institute, Huntsville, AL
Background: Lung cancer is the second most diagnosed cancer in both men and women.1 Lung cancer screening (LCS) guidelines have demonstrated significant reduction in lung cancer mortality when high-risk individuals are screened annually. However, even in practices with dedicated LCS programs, gaps exist in identifying eligible patients.
Objective: Clearview Cancer Institute (CCI) will lead an initiative to improve the identification of eligible LCS patients, educate providers, and refer appropriately concordant with the US Preventive Services Task Force (USPSTF) Screening Guidelines.2
Methods: Our Thynk Health LCS software identified that outside providers referred more patients than internal providers. This opportunity allowed research into whether internal patients were being properly identified and referred, along with gaps in the process. To better identify LCS candidates and with the assistance of the software developer, an automated weekly report was created based on age, smoking status, and new CCI patient appointments. The LCS director and navigator review patients from the report, who are then moved into either Oncology Patient, Does Not Qualify, Already Specialty Patient, or Refer to LCS. If Refer to LCS is selected, an automated order will be dropped on the patient’s next scheduled visit. This order, titled Potential Lung Screening Candidate, includes the current USPSTF guidelines and is a reminder to providers to consider LCS. If at that point the provider determines the patient is eligible, they will place an order in our OncoEMR for Initial LCS.
Results: In the 6-month trial period, 1781 new patients were identified up front as potential screening candidates. From those patients, 425 were referred to LCS. The data have been transferred to a Power BI dashboard for analytical analysis. Further data regarding how many patients followed through with screening and the results will be analyzed. From those data, we will compare average referrals per month and assess the impact of the initiative.
Conclusion: A process change was necessary based on the initial review. Patients who were LCS eligible were not properly referred. Navigators can contribute by flagging those at risk and streamlining the referral process, alleviating provider time constraints. The referral rate will no doubt increase, leading to improved patient outcomes. As an oncology/hematology practice, the standard of care should always be met. In this case, the standard of care is to screen high-risk individuals for lung cancer so that it may be detected in the earliest stage to improve quality of life and overall mortality.
Melinda Ellis, BSN, RN, OCN; Donna Shelor, BSN, RN; Jennifer Evans, MSN, RN; Martha Tenzer, BA; William Fintel, MD
Carilion Clinic, Roanoke, VA
Background: As with many healthcare systems, Carilion Clinic recognizes a need for navigation support to mitigate access barriers, improve timeliness of care, allay fear, and provide guidance through a complicated health system for oncology care. In October 2023, Carilion Clinic embarked on an oncology-specific navigation program with the mission to ensure timely follow-up for cancer findings and oncology treatment. The oncology navigation team consists of 2 service line coordinator advanced practitioners, 2 registered nurses, and 2 nonclinical patient service coordinators. The department tracks new cancer diagnosis from pathology reports, ensuring appropriate and timely follow- up, and receives referrals to navigate from PCPs, specialist, and coordinators in local emergency departments.
Objective: To assess if the navigation department improved healthcare access from cancer diagnosis to treatment using data collected to evaluate ways to improve the program in the future.
Methods: Our oncology navigators review all Carilion Clinic pathology reports with positive findings. Not all patients with positive pathology results proceeded to treatment, and not all patients were assessed by a navigator. However, we sought to assess the overall impact of our program on the turnaround time from diagnosis to treatment. To examine the preliminary impact of our program since its inception in October 2023, we queried our cancer registry to compare 4 months of patients during the program time of November 1, 2023, to February 29, 2024, with a similar preprogram time frame to allow for 3 months of outcome measurements. We also tracked the type of assistance the patients required in arranging treatment.
Results: Pulling from our cancer registry, from November 1, 2022, to February, 28, 2023, Carilion had 598 positive pathology reports for cancer, with 327 patients proceeding to treatment within an average of 37 days, compared with November 1, 2023, to February 29, 2024, where Carilion saw 779 positive pathology reports for cancer, with 346 patients proceeding to treatment within an average of 29 days. The navigation department touched, in some way, over 695 patients from November 1, 2023, to February 29, 2024. Since the creation of the oncology navigation department, we have coordinated care, scheduled appointments, managed records, reviewed charts for appropriate follow-up, and been the single point of contact for oncology patients.
Conclusion: Due to the program’s nascency and the need for a significant length of time to allow for outcomes, we examined only a short period of time. We will rerun the data and perform statistical analyses prior to presenting. With a limited time for data collection, it cannot be concluded that our new navigation department was the reason for any improvement in access to care from diagnosis to treatment in the given time frame. There were improvements in access and wait times for those receiving navigation, but not every patient with a positive cancer diagnosis had a navigator follow them. As this program develops, we will continue to assess and adjust for our patients’ needs and develop processes to improve access and mitigate barriers. This new data will be presented in the future.
Shockney LD. Oncology Nurse Navigation: Transitioning into the Field. Jones & Bartlett Learning; 2019.
Jennifer Jacobs, MPH, BSN, RN1; Margaret Rummel, RN, MHA, OCN, NE-BC, HON-CG1; Marc Henschel, DDS2
1Penn Medicine; 2Advanced Education in General Dentistry
Background: Access to dental care is extremely difficult for oncology patients as multiple barriers impede care.1,2 The inability to find dental care often affects outcomes.3 The ONNs at Penn Medicine’s Abramson Cancer Center (ACC) identified this gap in care, which led to a process improvement project to enhance access to dental care.
Objective: To identify current barriers to obtaining dental care, evaluate available resources, and develop a process improvement plan to eliminate those barriers for patients being treated at ACC.
Methods: The initiative began in 2021 when the ONNs identified a lack of dental care for oncology patients. The ONNs engaged the Penn Dental providers to collaborate on the project to better understand the referral process and access challenges, as well as to identify opportunities for improvement. Using the Plan-Do-Check-Act process, the ONNs led the process improvement project with the Penn Dental providers to identify the issues at the ACC surrounding dental care and develop a solution to improve this process.4 The major barriers identified were a lack of understanding of the importance of dental care by patients and the absence of a centralized care location. The biggest barrier was the lack of insurance coverage for dental care. Patients needing treatment often did not have coverage, and the Penn Dental providers did not take dental insurance.
Results: The ACC did not have a direct referral process for obtaining dental care. The process was inconsistent among the multiple dental departments. In addition, dental insurance was not accepted in these practices. This collaboration resulted in the development of an oncology dental clinic that provides a 1-step process for all oncology patients to receive care.
As of March 2024, 71 patients have been seen in the dental clinic, with 55% having head and neck cancer and 25% having hematologic malignancies. Most patients were seen within a week of the referral, and head and neck patients were able to have their simulation within 2 weeks of receiving dental clearance. Another benefit of this project was the heightened awareness regarding nonparticipation in insurance plans. The ACC was able to negotiate with the insurance carriers to participate in many dental plans, thereby benefiting our patients.
Conclusion: With persistence and identifying the right stakeholders, ONNs can make a difference in improving outcomes for patients. ONNs saw the big picture surrounding access to dental care and were able to navigate the multiple barriers identified to change practice. As a result of this project, referrals were streamlined, insurance barriers were decreased, and financial resources were identified resulting in the development of a specific oncology dental clinic. Both providers and patients are happy with the improved process as care is not being delayed.
Rochelle Waddell, RN
Appalachian Regional Healthcare, Hazard, KY
Background: Smoking remains the number one cause of lung cancer, according to the American Lung Association. Kentucky has the second highest smoking rate in the nation behind West Virginia.1 ARH leadership and the cancer committee recognized the need for a quality early detection lung cancer program and implemented the Low-Dose CT Lung Cancer Screening Program, which began to track data in November 2016.
Objective: ARH aimed to build a navigation co-led multidisciplinary team that standardized lung cancer screening (LCS) care, then incorporate streamlined follow-up of incidentally detected pulmonary nodules (IPNs). This was an ARH system and cancer committee initiative with the added goal to obtain systemwide GO2 Center for Excellence LCS Program designation.2
Methods: In 2019, the LCS Program team formed a triad of leadership, including navigation, a primary care physician champion, and administration. The navigator and physician champion had the trusting relationships with providers to form a multidisciplinary team (MDT). This team included representation from pulmonary, medical oncology, radiology, thoracic surgery, and radiation oncology.3 The MDT streamlined the LCS process and improved standardization of the entire early detection program. In 2022 Thynk Health Software, a natural language processing–based LCS program management and incidental findings tracking tool, was added to the early detection program. MDT discussion included nodule review and IPN identification and follow-up. Physician liaisons were also added to the MDT to help communicate the opportunity for and benefits of LCS in the community.
Results: Since its beginning in 2019, the LCS Program has seen growth by standardizing a process for confirming that patients meet the Centers for Medicare & Medicaid Services criteria for LCS, which was accomplished with the assistance of the MDT, including physician liaisons and efforts to keep the trusting relationships with all ordering providers. Baseline and annual LCS exams have increased 20% to 30% each year. In 2023, 3065 LCS exams were completed, a 175% increase compared with the 1111 LCS exams performed in 2020. Most recently all 14 hospitals within the ARH system obtained the Screening Center of Excellence designation from the GO2 Foundation for Lung Cancer.
Conclusion: ARH has a vision to improve lung cancer early detection rates and quality of life for patients by increasing LCS volume and continuing appropriate IPN identification and management. With the growth of the early detection program, ARH has been able to add additional nurse and patient navigators over the past 3 years. One barrier that was identified is the lack of a tobacco cessation specialist within the program. Additional staff continue to be added to improve the early detection program and overall patient care.
Tonya Bohl, BSN, RN, OCN; Stephanie Bonfilio, MSN, RN, OCN, ONN-CG; Jennifer Mulholland, BSN, RN, OCN; Karen Burke, BSN, RN, OCN; Katherine Barrett, BSN, RN, OCN; Jeanene Robinson, MSN, RN, AOCN; Stacey Ritter, BSN, RN, OCN; Ashley Coleman, APRN, AOCNP
St. Elizabeth Healthcare, Edgewood, KY
Background: According to the Centers for Medicare & Medicaid Services, oncology patients frequently face hospitalizations due to treatment-related side effects, many of which are manageable in outpatient settings and should not require hospital admission. However, existing literature lacks predictive tools for identifying patients at risk for hospitalization for such side effects.
Objective: To create and validate a predictive risk-scoring tool for thoracic oncology patients undergoing systemic therapy, correlating patients’ risk scores with hospital admission rates, with a secondary goal of utilizing this tool to reduce admissions for at-risk patients, if validated.
Methods: Literature was reviewed to identify factors known to increase the risk of cancer patients being admitted. Risk factors included patient age, comorbidities, specific chemotherapies, performance status, malignancy type, prior admissions, lab values, barriers to care, and distress screening.1 The predictive risk scoring tool, called PREVENT (Preventing Re-admission & ED Visits through Established Nursing Triage) was created within the electronic medical record using evidence- based literature to capture the variables known to impact oncology patients’ risk for admission. Each risk factor was assigned points, with the total score ranging from 0 to 20. A score of 0 indicated low risk and 20 indicated the highest risk for admission. A retrospective chart review of chemotherapy cycle 1 day 1 (C1D1) and cycle 3 day 1 (C3D1) was completed to determine individual patient risk scores and hospitalizations. The data were reviewed by statisticians for statistical analysis and to determine clinical significance. Statistical analysis and interpretations were completed with the assistance of the Northern Kentucky University Burkardt Consulting Center.
Results: One hundred fifty-one charts were reviewed. Using logistic regression, the relation between C1D1 score and the chances of being admitted was evaluated. A score of 2 resulted in an estimate for chance of admission of 4.59%; a score of 20 resulted in a 57.86% chance (chisquare= 8.02, P=.005). Similarly, for C3D1, a score of 2 resulted in a point estimate for chance of admission of 4.37%, while a score of 20 resulted in a 50.43% chance (chi-square=7.66, P=.006).
For C1D1, the ECOG Performance Status score, whether the patient had chronic liver or kidney disease, and treatment considerations had the most clinical significance in determining risk, while previous hospital admissions and pain had more clinical significance in determining risk for C3D1.
The confidence intervals in reported data for both cycles were wide, so while the strength of the model poses limitations, these data could be used for setting boundaries.
Conclusion: PREVENT integrates risk factors to assess admission risk. This retrospective study correlated patients’ risk scores with hospitalizations, indicating significant predictive value for factors like ECOG status, comorbidities like kidney disease and pain, and previous hospital admissions. Further research on this topic is needed, and additional work is needed to further characterize risk. This tool could also be modified for other disease sites.
Zilipah Cruz, MSN, RN; Selena Baker; Kaamela A. Davis; Rebecca Donnenberg; Andrew D. Nguyen, PhD; Terra Warner, RN; Pablo Arnoletti, MD; Catherine Mercado, MD; Omar Kayaleh, MD; Amy Laughlin, MD, MSHP
Orlando Health Cancer Institute, Orlando, FL
Background: Oncology nurse navigation programs have demonstrated improved outcomes for patients from time to treatment, compliance with evidence-based therapy, and patient experience.
Objective: To assess the impact of nurse navigation on outcomes among patients with pancreatic adenocarcinoma by studying a time frame where real-world circumstances led to a gap in available nurse navigation, leading patients to receive or not receive services in 2019 and 2020.
Methods: As part of the standard work of nurse navigation, the nurse navigator interviews patients, assesses and addresses barriers to care, and serves in a care coordination role for the multidisciplinary team. Fifty-nine patients met inclusion criteria of pancreatic adenocarcinoma diagnosed between 2019 and 2020, receiving first course of treatment at our center. Between 2019 and 2020 nurse navigation services were unavailable February to April 2019 and February to April 2020, which was a 6-month period. The impact of nurse navigation and palliative care was evaluated on survival from first treatment, survival from last treatment, survival from palliative care consult, and overall survival. For these survival analyses, a Cox proportional hazard regression model was fitted with the covariates of nurse navigation, palliative care, age, sex, insurance, treatment sites, and cancer stage. To evaluate diagnostic testing and ancillary referrals, we fitted a logistic regression with the covariates of nurse navigation, insurance, and treatment location.
Results: For overall survival, survival from first treatment, from last treatment, and from palliative care consult, patients with stage IV cancers had a shorter survival than patients with stage III cancers (hazard ratio [HR]=2.75- 3.45, P<.05). There was a clinically meaningful trend toward a survival benefit among patients with a nurse navigator compared with those without (HR=0.44, P=.046; median overall survival 9.39 vs 6.65 months). Patients with palliative care had a clinically meaningful trend toward lower survival from last treatment compared with those without palliative care (HR=2.24, P=.062; median overall survival 1.43 vs 2.73 months). Across 59 patients, nurse navigation did not impact the odds of completing genetic testing, molecular testing, presentation at tumor board, or receiving nutrition consult. For genetic testing, patients with Medicare/Medicaid had lower odds of completion than patients with commercial/other insurance (odds ratio=0.28, P<.05).
Conclusion: Having a nurse navigator increased mean survival by 2.74 months when tracking patients for a year; this effect was seen after the first few months among patients with advanced pancreatic adenocarcinoma. This fits with the conceptual model of how nurse navigation impacts survival by allowing patients to stay on evidence-based treatments over time while there will be a subset of patients where the biology of the disease is treatment refractory, leading to early up-front decline. Additional work is needed to understand the mechanism and interval steps to achieving this outcome. These findings reinforce prior research showing the benefit of nurse navigation for patients with cancer and justify ongoing resource dedication to these services.
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