Best Practices: Needs Assessment Process, Data/Metric Tracking, and Survivorship Care Planning

Best Practices:Needs Assessment Process

Data/Metric Tracking

Tricia Strusowski, MS, RNDirector, Cancer Care Management

Helen F. Graham Cancer CenterChristiana Care Health System

Needs Assessment Process

• Objective – To assess the needs of your navigation program– To assess the needs of the patients and the

families in your navigation program – To assess and create navigator job responsibilities

Needs Assessment Process

• Anyone want to share their intake processes?

• Barriers?

• Challenges?

Data/Metric Reporting

• Objectives – To review the documentation of support services

provided by the navigator– To review performance improvement outcomes

for a navigator program – To document patient and physician satisfaction

with a navigation program

Helen F. Graham Cancer CenterNurse Navigation/Support Service

Satisfaction Survey

• Example questions

– The nurse navigator was friendly and helpful to me

– The nurse navigator answered all my questions in a manner I could easily understand

– The nurse navigator helped me to understand my course of treatment

– The nurse navigator informed me of services available through the Cancer Care Management (CCM) program

Helen F. Graham Cancer CenterNurse Navigation/Support Service

Satisfaction Survey

• Were you seen by any of the following support services?– ___Social Worker– ___Dietitian– ___Financial/Transportation Coordinator– ___Health Psychology– ___Wellness Team– ___Survivorship Team– ___Pain/Palliative Care Team

• Was friendly and helpful to me? • Answered all my questions in a manner I could easily

understand?

Helen F. Graham Cancer CenterNurse Navigation/Support Service

Satisfaction Survey

• CCM has the resources and tools to provide the best care/services to my patients

• CCM is committed to continuous quality improvement

• The staff from CCM whom I interact with are competent in their role

• CCM demonstrates a concern for patient safety

• Communication by CCM with me regarding my patients is timely and clear

Data/Metric Tracking

• Anyone want to share their tracking or reporting programs?

• Concerns with reporting?

• Questions regarding reporting?

Patient Testimonials

“Having my nurse navigator was critical to keeping my brain focused on healing and not on all the little worries that kept popping up.”

“Whenever I had a question or concern I’d call and she would always get me an answer.”

Always remember that you make the journey for the patients

and their families so much easier.

YOU DA BEST!!

Best Practices:Survivorship Care Planning

Sharon Gentry, RN, MSN, AOCN, CBCNBreast Health Navigator

Derrick L. Davis Forsyth Regional Cancer Center

Survivorship Care Planning

• Definition

• Where does definition fit in care continuum?

Who Is a Survivor?

• The National Cancer Institute considers a person to be a survivor from the time of diagnosis until the end of life

• Includes others who are affected– Family– Friends– Caregivers

US Population of Survivors Is Medically Diverse

Female Breast

Prostate

ColorectalGynecologic

Hematologic (HD, NHL, leukemia, ALL,

myeloma)

Urinary Tract (bladder, kidney,

renal, pelvis)

Melanoma

Thyroid

Other

Distribution by Site of Cancer

15%

19%

9%8%

8%

7%

7%

4%

22%

Patient Navigation Is Part of the Cancer Care Continuum

Suspiciousfinding Diagnosis Treatment

Follow-up, long-term care

Surveillance and rehabilitation

End of life/palliative care

Survivorship

Patient Navigation

Transition Multiple TransitionsTransition

Sample Questions for Needs Assessment

• How do you define cancer survivorship?• How do patients within your practice currently

obtain survivorship services?• What types of survivorship services do your

patients currently utilize?• What types of survivorship services would you like

to provide within your clinical practice?• If you need to refer a patient for survivorship

services, what are some of the local resources you utilize?

Survivorship Care Planning

• Physical effects

• Psychosocial effects

Medical and Physical Effects of Cancer Treatment May Persist

• Neuropathy• Osteoporosis• Second primary tumors• Lymphedema• Chronic pain• Menopausal symptoms

• Lung disease• Cataracts• Infertility• Heart disease• Kidney failure• Endocrine issues (thyroid)

Significant Psychosocial Concerns May Persist

• Depression• Heightened sense of

vulnerability• Fear of recurrence,

death• Adjustment to physical

problems (eg, infertility)

• Sexual function/sexuality

• Parenting• Alterations in social

support• Concerns about

finances, employment, disability, insurance

Patient Navigation Supports Patients with Assessment, Education, and Coordination

“Which/what type of doctor should I see?”

“Can I still get health insurance?”

“What tests should I be having?”

“What kinds of services are available?”

“How can I manage my symptoms?”

“Who can help with end-of-life planning?”

Survivorship Care Planning

• American Society of Clinical Oncology

• National Comprehensive Cancer Network

Patient Navigation Can Help Survivors Receive the Care They Need

• Facilitate recommended surveillance for development of new cancers– Risk 14% higher than in general population– Risk highest in first 5 years after diagnosis– Risk higher in females– Survivors of childhood cancer at highest risk

Patient Navigation Can Help Survivors Receive the Care They Need

• Facilitate recommended surveillance for spread or recurrence of cancer– Example – For all breast cancer survivors:

• Careful history and physical examination every 3 to 6 months for the first 3 years, every 6 to 12 months for years 4 and 5, and yearly thereafter

– Example – For survivors who have undergone breast-conserving surgery:• Posttreatment mammogram 1 year after the initial

mammogram, at least 6 months after completion of radiation therapy, and yearly thereafter, unless otherwise indicated

Patient Navigation Can Help Survivors Receive the Care They Need

• Provide personalized support– Help educate survivors about health needs and

concerns– Ensure adherence to treatment and follow-up

activities– Connect survivors with appropriate resources– Track delivery of care and payment for services

Initiate the Program

• Take stepwise approach– Begin with services/programs likely to demonstrate success

• Perform Outreach• Utilize referral pathways and report back to those

referring• Collect data on all outcomes variables– Patients served, referrals– Services utilized– Cost– Involved providers

Community Outreach

• DC City-wide Patient Navigation Research Program

• University of Medicine and Dentistry of New Jersey