This article is the third in a 10-part series highlighting the work of the Alliance for Equity in Cancer Care, a national initiative focused on expanding access to high-quality cancer care for underserved communities.
Each installment will spotlight a different Alliance grantee site, exploring how healthcare teams are partnering with community organizations to break down barriers to care and reimagine what navigation looks like on the ground.
Through these stories, we’ll see how tailored, community-informed solutions are making cancer care more accessible.
Since its formal launch in 2018, the RWJBarnabas Health (RWJBH) Navigation Program has evolved from a fragmented, site-by-site model into a coordinated, system-wide approach that proactively supports patients across the cancer care continuum.
With institutional support and investment from the Alliance for Equity in Cancer Care, the program strengthened its navigation efforts through critical new workflows to improve early intervention methods and address social determinants of health (SDOH).
These workflows have drastically reduced delays in care, improved patient follow-up, and bolstered communication among primary, emergency, and oncology providers.
When the RWJBH Navigation Program was formally established in 2018, the goal was to standardize and streamline cancer navigation services across 11 siloed sites. Navigation efforts were previously fragmented and inconsistent, with each site managing its own approach; and with limited infrastructure to support system-wide navigation, navigators were often pulled into tasks outside of their core responsibilities.
A multimillion-dollar institutional investment to expand navigation services reflected a commitment to better support navigators and remove barriers to treatment for patients. As a result, the navigation workforce has grown by a staggering 289% since the program’s inception. The program works two-fold, with clear role delineation between clinical navigators focused on diagnosis and treatment, and nonclinical patient navigators supported by the Alliance who tackle practical challenges and barriers related to SDOH, such as limited transportation, unstable housing, and the inability to afford medications.
“Our robust oncology nurse navigation program ensures that every patient has a navigator to provide personal support and culturally compassionate guidance through their cancer journey, serving as an important member of their healthcare team.” —Steven K. Libutti, MD, senior vice president of Oncology Services, RWJBH
“Our robust oncology nurse navigation program ensures that every patient has a navigator to provide personal support and culturally compassionate guidance through their cancer journey, serving as an important member of their healthcare team,” states Steven K. Libutti, MD, senior vice president of Oncology Services, RWJBH.
The Navigation Program kickstarted a key milestone the following year: the launch of the Oncology Access Center (OAC). The OAC was established to support patients at the moment of a new cancer diagnosis, serving as a centralized hub for coordinating oncology services across the health system.
After getting scheduled with an oncologist, patients are connected to a virtual nurse navigator and an Alliance patient navigator who conducts standardized SDOH screenings embedded in the patient’s electronic medical record (EMR).
As a result, the OAC model improved communication between referring providers and oncology teams and helped navigators operate more clearly within their defined roles. Nurse navigators are freed up to focus on clinical aspects of the visit, while Alliance navigators ensure that every patient, regardless of socioeconomic status or background, can enter the cancer care continuum.
“The streamlined workflow has allowed us to step in early and identify barriers that often go unaddressed or hinder further care, whether it’s lack of insurance, transportation, or follow-up care,” says Alliance patient navigator Samantha Davis.
“The OAC is a crucial touchpoint where we can begin breaking down those obstacles and help patients move forward with the support they need within an impressive time frame,” she adds.
Despite these advances in the workflow, a critical gap remained: Individuals with incidental or uncertain findings, particularly those discharged from the emergency department (ED), were often left without guidance or follow-up. Many were referred to primary care prematurely or left to navigate the complexities of the healthcare system on their own.
Underserved and vulnerable patients often rely on the ED for care due to barriers like limited access to primary care or lack of insurance, and because other clinics typically cannot address all of their needs in a single visit.1 This group accounts for approximately 30% of hospitalized patients and faces greater risks after discharge, such as readmission or worsening illness, due to SDOH.2
Yet, because the OAC had no structured referral process from the ED, patients who potentially had cancer were falling through the cracks. It was the ED who escalated the issue to executive leadership, and the oncology service line responded by integrating the Navigation Program and OAC specifically to address and support high-risk patients who present to the ED.
“The ED marks the first time many patients hear the word ‘cancer.’ It can be frightening and disorienting and overwhelming. The ED referral pathway gave me the opportunity to identify, connect, and guide patients to oncology. This touchpoint is invaluable for timely and appropriate care and leads to better outcomes for the patient.” —Caprina Tomlinson, RN, OCN, ONN-CG, RWJBH nurse navigator
“The ED marks the first time many patients hear the word ‘cancer.’ It can be frightening and disorienting and overwhelming. The ED referral pathway gave me the opportunity to identify, connect, and guide patients to oncology. This touchpoint is invaluable for timely and appropriate care and leads to better outcomes for the patient,” says Caprina Tomlinson, RN, OCN, ONN-CG, RWJBH nurse navigator.
The team continued to look for ways to make that critical handoff from the ED to follow-up care even more seamless. Initial OAC referrals were made via EMR order or phone call, and at times, patients were discharged from the ED with follow-up instructions they never acted on. The introduction of a single-click referral radio button in the EMR streamlined the process by adding auto-populated key patient information lacking from the previous EMR order, including the critical area of suspicion, saving ED staff time and allowing them to focus on patient care. This enhancement enabled navigators to receive referrals promptly and initiate timely navigation to services.
However, as referral volumes increased, RWJBH quickly identified pressure points that required refinement. The evaluation revealed that oncologist new-patient appointment slots were often occupied by ED referrals that were ultimately benign, resulting in unintended delays and reduced access for patients with biopsy-confirmed cancer who required timely oncology consultations.
To address the ED incidental findings and uncertain cases, RWJBH launched the health system’s first ever Undiagnosed Clinic (UDC) in late 2023, led by an institutionally funded advanced practice provider. Located at the system’s largest site, the UDC serves as an ambulatory diagnostic hub, coordinating imaging, biopsies, and labs in an outpatient setting while efficiently sorting patients into appropriate care pathways. Confirmed cancer patients transition to the OAC, where they are supported by disease-specific navigators; benign cases (which make up approximately 50% of UDC referrals) are returned to primary care. Complex cases receive further workup or specialty consultation.
Since integrating new referral pathways from the ED and the UDC in partnership with the Alliance, RWJBH has seen measurable improvements in timeliness and care coordination (Figure 1). Between September 1, 2023, and August 31, 2024, 572 ED referrals were successfully routed to the OAC, and 29 patients were seen through the UDC. Of these 29, 14 were diagnosed with cancer and referred to oncology. These efforts have reduced unnecessary ED revisits, streamlined referrals, and ensured patients are directed to appropriate care pathways more efficiently.
Importantly, the navigation program is now supported by systemic infrastructure that promotes consistency and accountability across the continuum. A Standard Operating Procedure aligns navigation efforts across the ED, OAC, and UDC, defining timelines for referrals, outreach, and follow-up. With these improvements, the support of navigators demonstrated a 23-day reduction in the average time patients wait for an oncology consult compared with wait times tied to no navigation support.
As the navigation infrastructure has expanded, early implementation efforts offered valuable insights that shaped ongoing refinements, making each iteration more responsive, efficient, and equity-driven (Figure 2). Rather than a one-time intervention, this work reflects a dynamic and continuous evolution toward a truly multilevel approach—addressing needs at the patient, provider, and health system levels.
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