1. The Navigator Matrix KarylBlaseg, RN, MSN, OCN Billings Clinic Cancer Center Tricia Strusowski, MS, RNHelen F. Graham Cancer Center Jay R. Swanson, RN, BSN, OCNSaint Elizabeth Cancer Institute

2. Objectives Understand the purpose of standardizing a navigation program Build metrics to establish the benefit of a navigation program Engage in assessing a navigation program Analyze matrix levels to determine areas of opportunity for advancement of program

3. Background Someone very wise once said: IF you have seen one navigation program, You have seen one navigation program. - Tricia Strusowski

4. Purpose Case management model Standardization Commission on Cancer (CoC) standards Provide the basic building blocks for navigation programs

6. Key Stakeholders Those people that you feel are essential to making a program work, including administration, navigators, staff, physicians (both employed and private practice). Specialty areas include medical, surgical and radiation oncology, rehabilitation, palliative care, and hospice

7. Community Partnerships Those entities that exist within and outside of your program that you need the support of or are a referral source for patient use and contribute to the support of the patient along the continuum of care

8. Acuity System/Risk Factors Ability to determine appropriate level of care/intervention based on patient need and disease process Variable associations with increased risk of complications with disease and treatment of cancer

9. Metrics/Reporting Measures Measuring activities and performance

10. Marketing of the Navigation Program How do you get the message out about your program? What programs outside of navigation are in place that you can partner with?

11. Percentage of Patients Offered Navigation Based on analytic totals or other metric Of course you would assume all patients are offered navigation, but may not be that easy

12. Continuum of Navigation Navigation functional areas include: outreach/screening, abnormal finding to diagnosis, treatment, outpatient and/or inpatient, survivorship, and end-of-life care. Navigation can occur along any or all of these. One single person may do all of these, or you may have one person designated to cover one area of the continuum. They may be disease-specific navigators, or cover all diseases within that category. The sign of a level 5 site is that navigation is continuous across the cancer care continuum.

13. Support Services Available and Used by the Navigation Team

14. Tools for Reporting Navigator Statistics Documents to help evaluate and measure a navigation program

15. Financial Assessment The expense not only for medical care and treatment but the additional costs associated with the effects on life change are dramatic Financial assessment therefore is as important as the physical assessment

16. Focus on Disparities Is any underrepresented group that your program is able to focus on. Providing outreach and effort in this population is a hallmark of navigation according to its original conception and should be continued as part of a navigation program

17. Navigator Responsibilities As a program grows, navigators start to take on different roles, while maintaining a central core responsibility of patient assistance

18. Patient Identification Process Navigators have to find a way to interact with their patients

19. Navigator Training Some form of training must be given to the navigators to ensure a high quality of care and commitment of the navigation program

20. Engagement with Clinical Trials With Clinical Trials being a major part of the advancement of cancer care, it is important that navigation work with clinical trials departments to offer patients the best possible care

21. Multidisciplinary Care Multidisciplinary team approach to care including physicians (medical oncology, radiation oncology, and surgeon) and other healthcare providers to create plan of care for patient; patient may not always be present to be considered MDC

22. Application of the Navigation Matrix to Patient Navigation at Billings Clinic

23. About Billings Clinic… Nonprofit, community governed Multispecialty group practice 300-bed hospital, cancer center, surgery center, research center, retirement community Primary and specialty care clinics Service area = 207,000 sq miles 2010 cancer registry stats 1470 new analytical cases 1635 new total cases Navigation program established in 2003

24. The Role of the Care Navigator To ensure the best cancer care experience through coordination of services

25. Our Program’s Evolution

26. Key Stakeholders Referrals received from our employed primary care and specialty providers, as well as from regional providers and state screening program

27. Community Partnerships Strong connections with: American Cancer Society Susan G. Komen for the Cure Montana Cancer Control Coalition LIVESTRONG

28. Acuity System/Risk Factors Navigation points Initial referral/ consult appointments Start of treatment Restaging (imaging) Change in treatment/new treatment End of treatment

29. Quality Improvement Patient satisfaction surveys Timeliness of care Multidisciplinary clinic quality metrics

30. Marketing of the Navigation Program Brochure/insert card Website Billboards Video News stories

31. Percentage of Patients Navigated 2010 registry: 1470 analytic; 1635 all 2010 patients navigated: 803

32. End of Life Navigation Continuum Survivorship Treatment Diagnosis Prevention & Early Detection CARE NAVIGATION

33. Support Services Social workers, licensed counselors Financial counselors Genetic counselor Dietitian Psychiatric nurse practitioner Physical therapist, lymphedema specialist, massage therapists Symptom management team Pastoral care

34. Tools for Reporting Patient database (Excel) Key information utilized for program metrics Data summarized and reported quarterly to multidisciplinary teams

35. Financial Assessment Financial counselors assigned to the cancer center Autoreferral built into computerized physician order entry, but referrals also initiated by navigator, physician, social worker, pharmacist, nurse, etc Preauthorization of all treatments

36. Focus on Disparities Underserved population Rural and American Indians 22 outreach clinics per month Telemedicine technology Representation on advisory boards Numerous outreach activities Cultural sensitivity training for staff and providers; also offered throughout the region Collaboration with American Indian organizations

37. Navigator Responsibilities Providing guidance through the system Initiating referrals to MDC and case conference Coordinating appointments Providing education Connecting patient to resources for insurance, financial, and social concerns, as well as to supportive services Co-chairing multidisciplinary program meetings Tracking metrics for MDC outcomes Facilitating support groups and/or educational offerings Assisting with community outreach events

38. Patient Identification Referrals received from primary care and specialty physicians, as well as nursing and ancillary staff New appointment type scheduled in the cancer center triggers a printout to the navigator office Technical assistance previews clinic schedules

39. Navigator Training Orientation by lead navigator Initial competencies Annual competencies Attendance at case conferences Quarterly navigation retreats with education PRN training/in-services Online training for site-specific cancer care Support to attend national conferences Specialty certification

40. Clinical Trials NCI clinical trials education Awareness of trials available Referral of patients to research coordinators Partnership with research coordinators

41. MDC Involvement Referral comes to navigator Pre-visit work-up needs determined Appointments coordinated with MDC team Navigator attends each MDC appointment Patient is presented at next case conference Preliminary plan document is completed and sent to patient, as well as referring MD

42. CoC Standard 3.1 (drafted) The cancer committee conducts an assessment of barriers to care for patients with cancer. A patient navigation process is established to address barriers to care for patients with cancer and healthcare disparities either on site or by referral. The cancer committee evaluates and reports on the process annually.

43. CoC Standard 3.1 (drafted) Criteria to meet drafted standard Needs assessment conducted to guide navigation services Navigation services provided on site or by referral to address healthcare system barriers Cancer committee evaluates the navigation process annually

44. Advancing Your Program Open discussion What creative ideas do you have about advancing your navigation program? Do you have concerns or barriers regarding advancing your program in any of the categories? Other thoughts?

46. Once navigation program is developed, many sites need assistance with next steps

47. Cancer centers need to constantly assess and develop new goals for their program…keep it fresh

48. Include your physician champions and other key stakeholders when assessing the program

50. References The Advisory Board Company: Patient Navigation 2008-17647. ADAHPT Case Management Model. www.health.nsm.gov.au/resources/adahps/pdf/case_mgt_model.pdf. 2011. Blaseg K. Patient Navigation at Billings Clinic: An NCI Community Cancer Centers Program (NCCCP) Pilot Site. ACCC’s Cancer Care Patient Navigation: A Call to Action. 2009:15-24. Campbell C, Craig J, Eggert J, Bailey-Dorton C. Implementing and measuring the impact of patient navigation at a Comprehensive Cancer Center. Oncol Nurs Forum. 2010;31(1):61-68. Centers for Disease Control and Prevention. Health disparities in cancer. www.cdc.gov/Features/CancerHealthDisparities. 2011. Commission on Cancer: 2009 Standard 2.7. Dohan D, Schrag D. Using navigators to improve care of underserved patients. Cancer. 2005;104:848-855. Freun KM, Gattaglia TA, Calhoun E, et al. National Cancer Institute Patient Navigation Research Program: methods, protocol and measures. Cancer. 2008;113:3391-3399. Gilbert JE, Green E, Lankshear S, Hughes E, Burkoski B, Sawka C. Nurses as patient navigators in cancer diagnosis: review, consultation, and model design. Eur J Cancer Care. 2011;20:228-236.

51. References (cont.) Harold P. Freeman Institute for Patient Navigation. Harold P. Freeman Patient Navigation Program/Model, Patient Navigation. 2011. Koh C, Nelson JM, Cook PF. Evaluation of a patient navigation program. Clin J OncolNurs. 2011;15(1):41-48. Koutnik-Fotopoulos E. Implementing and growing a navigation program. J OncolNavig Survivor. 2010;1:6-7. Case Management Society of America. http://cmsa.orgau/definition.html. NCCCP Disparities Subcommittee White Paper, 2010. http://ncccp-intra.nci.nih.gov/programs/Disparities% 20White%20Paper%20draft%2008%202010.pdf. National Institutes of Health. NIH Publication No. 10-7605. Peersen A, Hack T. Pilots of oncology health care: a concept analysis of the patient navigator role. OncolNurs Forum. 2010;37:55-60. Schafer J, Swisher J. Cancer Care Coordination with Nurse Navigators. Sg2 Health Care Intelligence. 2006. Schwaderer KA, Itano JK. Bridging the healthcare divide with patient navigation: development of a research program to address disparities. Clin J OncolNurs. 2007;11(5):633-639. Swanson JR, Koch LM. The role of the oncology nurse navigator in distress management of adult inpatients with cancer: a retrospective study. OncolNurs Forum. 2010;37(1):69-76. Wells KJ, Battaglia TA, Dudley DJ, et al. Patient navigation: state of the art or is it science? Cancer. 2008;113:1990-2010.