Pre-Conference: The Navigator Matrix

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

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

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

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

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

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

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

Metrics/Reporting Measures Measuring activities and performance

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?

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

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.

Support Services Available and Used by the Navigation Team

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

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

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

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

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

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

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

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

Application of the Navigation Matrix to Patient Navigation at Billings Clinic

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

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?

Wrap-up/Lessons Learned ,[object Object]

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

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

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

Pre-Conference: The Navigator Matrix

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Pre-Conference: The Navigator Matrix