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Launching the Navigation Program that Is Best for You... Continued from cover “When we launched our breast cancer navigation program at Fox Chase, we did a gap analysis regarding the entire breast service line and we found a great opportunity in the intake systems. We had wonderful schedulers, but they were finding that the patients were asking so many clinical questions, that support was need up front. That way the scheduler could work on scheduling an appointment and getting the demographic and the financial data. We connect the nurse navigator on the phone to the patients that day. It was an immediate gap, and an immediate opportunity.” Existing staff should be consulted. Any good program will need buy-in from the physicians and participation from other clinical staff. You need to “identify the fact that the navigator will not take their job, or the nurse educator job, or the scheduler job. The navigator is a layer laid on top of the existing program to connect the dots with patients through the continuum,” Miller noted. One way to promote success and avoid pitfalls, she suggested, is to define the navigator’s role clearly, realizing that it will evolve over time.
tional travel time and lost time from work,” DeAntonio noted. In addition, in rural eastern North Carolina, there are barriers such as delays in care, fragmentation of care, distrust of the healthcare system, fear or refusal of care, lack of insurance and transportation, and cultural beliefs. The program began with just one navigator. An experienced RN case manager was chosen specifically because she “was well-versed in identifying the medical, psychosocial, and emotional needs of her patients as an RN case manager,” according to DeAntonio. Navigation usually begins at the point of the suspicious finding, because “this is when our patients need the most information and guided support on what to do, especially someone who has never been sick or has never been active in the healthcare system.” The goals of the program were set and the role of the navigator defined. DeAntonio encouraged “anyone who wants to develop a navigation program, to develop criteria from the start of the program to make sure the nurse is focusing on her role and the other members of the healthcare team are focusing on theirs. This keeps from muddying the waters, especially if the volumes increase.” Goals of navigation include improved illness status, improved coordination of services for patients, increased patient adaptation to her illness, and timelier delivery of services. The navigator’s duties include: • Educate patients and their families • Participate in community education health fairs, screenings, and other prevention and early detection programs • Participate in educational events and tumor conferences • Create liaison between healthcare team members and patient • Link patients with appropriate resources and services throughout the community • Address survivorship issues, contributing to the survivorship care plan.
Pitt County Memorial Hospital Greenville, North Carolina Pitt County Memorial Hospital (PCMH), the largest of six hospitals in the University Health Systems of Eastern Carolina, is a teaching hospital accredited by the American College of Surgeons Commission on Cancer. PCMH has 861 licensed beds, and in addition to cancer, provides heart, women’s, children’s, trauma, neuroscience, and bariatric services. It serves a 29-county referral area and, with some of its tertiary services, that area increases to 55 counties. PCMH is also affiliated with the Brody School of Medicine, East Carolina University. In October 2007, PCMH “recognized the need to address patients’ needs across the continuum, from diagnosis to survivorship,” explained Phyllis DeAntonio, RN, MSN, FAAMA, the cancer services administrator who presented the model used at her center. The navigation program was pilot-tested to serve gynecology and Patient- and family-centered care The nurse navigator at breast cancer patients, who PCMH educates not only were among the groups idenpatients but also their famitified as having many issues lies. Education topics include with continuity of care and their diagnosis and treatment, care coordination. as well as how to avoid secThe registered nurse (RN) ondary cancers. For family navigator’s duties were develmembers, she stresses prevenoped to meet the needs of the tion and early detection and population. “Our service area coordinates specific services a is quite extensive, and patients may travel 2 to 3 Phyllis DeAntonio, family may need. For examhours to our facility. If a RN, MSN, FAAMA ple, a breast cancer patient may fear that her family patient is seeing two to three specialists, it is more convenient to see members are at risk. The navigator can them on the same day, to eliminate addi- bring in a genetic counselor while they
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are at the clinic. The navigator considers the immediate needs as well as the future needs of the patient. “If a patient is on her service, the navigator follows that patient from inpatient to outpatient to home and back. She may even follow the patient to hospice or homecare,” DeAntonio said. The navigator also links patients with appropriate resources and services throughout the community, such as support groups. She promotes healthy lifestyles with patients who have cancer and also with their families. She helps patients adapt to their illness and follow the treatment plan by utilizing their coping mechanisms to help them move forward and survive their cancers, according to DeAntonio. For patients who need support because of their socioeconomic situation (eg, illiteracy, uninsured, underinsured), the navigator works to remove those barriers. “She looks at their financial resources; she looks at educational materials for them from the National Cancer Institute or the American Cancer Society; she addresses their survivorship issues.”
hospitals, CKHS diagnoses a little more than 2000 cancer cases per year. After an initial setback, CKHS restarted its program by establishing goals and defining what would be considered success. To start, “we looked at outreach,” explained Marie DeStefano, RN, MSN, FAAMA, administrative director of oncology, who presented the CKHS model for navigation services. “We wanted to look at early screening and diagnosis, and we focused on the barriers—financial, internal systems, and communication.” Physicians were involved in the design of the program from the beginning, which she emphasizes is important for any such program. The first positions were the breast care patient navigators.
Breast navigators CKHS currently has three breast navigators. Criteria were developed as to when they would become involved with patients. CKHS captures data on patients during mammography screening. The navigator intervenes when a patient’s BI-RADS score is 4 or 5, even before she knows if the patient has a The “right” navigator malignancy. There is one breast navigaA nurse navigator is a role requiring tor at each of the main hospitals and a a high level of interpersonal skills, third who works exclusively with empathy, and coordination ability. uninsured and underinsured women. “You need to find someone who knows This nurse is an expert at getting about the disease/disease process, is patients medical assistance, developing compassionate, and most important— extensive knowledge of the support is a good listener,” DeAntonio services and financial services available. advised. The job duties are the same Because the navigator for the two navigators of position requires the nurse insured patients: patient eduto serve as a liaison between cation and navigating patients the physicians and the through the health system. patients and the rest of the However, each has her own healthcare team, hiring method of helping patients someone who can handle traverse the system. “At one of these relationships is very the campuses, the nurse naviimportant, she said. The Marie DeStefano, gator is contacted if there is a nurse she hired was an expe- RN, MSN, FAAMA patient with an abnormal rienced RN case manager finding or who is BI-RAD 4 or with 12 years of oncology experience. 5. She comes down and walks the “Sometimes she can anticipate what the patient right up to the breast surgeon’s physician is going to say about a patient’s office. If the breast surgeon is not availplan of care, before she even makes the able but the nurse practitioner is, the call. She knows the physicians very well. nurse practitioner sees the patient the She knows how they treat their same day. Together they are able to get patients,” DeAntonio said. The naviga- the patient scheduled with the surgeon, tor also needs the fortitude to advocate and then to get a biopsy,” DeStefano for the patients and do whatever is in the explained. “The navigator at the other patients’ best interest. site goes with everyone to get a biopsy and then communicates with them Crozer-Keystone Health System once the pathology findings are final. In Delaware County, Pennsylvania addition, both navigators go to the hosCrozer-Keystone Health System pital to see their patients when they are (CKHS) is a five-hospital health system hospitalized. in a very competitive market located The navigators are also responsible near several major medical centers in for community outreach activities. For the Philadelphia area. The largest hos- example, they work with local soccer pital, Crozer-Chester Medical Center, leagues to raise awareness of breast canhas 371 beds, a cancer center, trauma cer and encourage women to schedule unit, and burn center. Across the five mammograms. www.AONNonline.org