Creating a Longitudinal Continuum of Access to Care

PowerPoint Presentation

Creating a Longitudinal Continuum of Access to CareAnne Willis, MADirector, Center for the Advancement of Cancer Survivorship, Navigation and Policy

Heather Kapp, LICSW, MPHDirector, Access and Quality George Washington Cancer InstituteCenter for the Advancement of Cancer Survivorship, Navigation and Policy1ObjectivesDiscuss longitudinal navigation modelsDescribe the DC Citywide Patient Navigation Network as a model of a longitudinal continuum of access to careIdentify different navigation functions across types of navigatorsDiscuss the role of quality improvement and patient navigationCenter for the Advancement of Cancer Survivorship, Navigation and Policy2GW Cancer InstituteMissionEnsure access to quality, patient-centered care across the cancer continuum through community engagement, patient and family empowerment, health care professional education, policy advocacy and collaborative multi-disciplinary research.Center for the Advancement of Cancer Survivorship, Navigation and PolicyCenter for the Advancement of Cancer Survivorship, Navigation and Policy3Longitudinal ModelsCenter for the Advancement of Cancer Survivorship, Navigation and PolicyGWCI Longitudinal Model

Center for the Advancement of Cancer Survivorship, Navigation and Policy

Colorado Patient Navigation ModelSource: patientnavigatortraining.orgCenter for the Advancement of Cancer Survivorship, Navigation and Policy6DC Citywide patient navigation network (CPNN)Center for the Advancement of Cancer Survivorship, Navigation and PolicyNetwork ConceptionNational Cancer Institute Patient Navigation Research Program (PNRP) funded nine (9) site demonstration projects & tested:Effectiveness of patient navigation from screening to time of diagnosis and treatmentImpact on patient satisfactionCost-effectiveness of patient navigation programs

Center for the Advancement of Cancer Survivorship, Navigation and Policy8Results from DC PNRP2,601 women 1,047 navigated1,554 records-based non-navigated2006-2010 at nine hospitals/clinics in DCNavigated women reached diagnostic resolution for breast cancer 17 days sooner than non-navigated womenFor those requiring biopsy, the difference between navigated versus non-navigated women was nearly 31 days

Source: Hoffman HJ, LaVerda NL, Young HA, Levine PH, Alexander LM, Brem R, et al. Patient navigation significantly reduces delays in breast cancer diagnosis in the District of Columbia. Cancer Epidemiol Biomarkers Prev 2012. Center for the Advancement of Cancer Survivorship, Navigation and Policy9Birth of DC NetworkExpand navigation beyond breast cancerExpand beyond 9 sites of PNRP to 40 clinical and community sitesFocus on service delivery rather than researchUtilize data to inform cancer control planningCenter for the Advancement of Cancer Survivorship, Navigation and Policy10Citywide Patient Navigation Network (CPNN) VisionEnsure every patient in the DC region has access to cancer care across the continuum regardless of race, ethnicity, sexual preference, socioeconomic status or geographic residencyImprove cancer outcomes among DC patientsImprove access to care across the cancer continuumEliminate barriers to careCenter for the Advancement of Cancer Survivorship, Navigation and Policy11CPNN GoalsHelp patients overcome barriers to care, with special attention to vulnerable and minority populations. Navigators help patients obtain timely, coordinated cancer care, including screening and diagnostic services, treatment, survivorship and endoflife care.Center for the Advancement of Cancer Survivorship, Navigation and Policy12Site SelectionGWCI serves as the central coordinator of CPNN which is currently comprised of 36 navigators stationed at primary care, tertiary care and community-based organizations. Several of these organizations have multiple clinics served.One navigator also navigates for the Department of Health's Project Wish, which provides qualified women with breast and cervical cancer screening at no cost. Center for the Advancement of Cancer Survivorship, Navigation and Policy13Active SitesCapital City Area Health Education CenterDC Primary Care AssociationHoward University Cancer CenterWhitman WalkerNueva VidaThe Smith Center for Healing and the ArtsMedStar Washington Hospital Center Providence HospitalCapital Breast Care CenterAfrican Womans Cancer Awareness AssociationCommunity of HopeCenter for the Advancement of Cancer Survivorship, Navigation and Policy14 Role of CPNN NavigatorsMaintain communication with patients, survivors, families, and the health care providers Ensure appropriate records and referrals are available at scheduled appointments Arrange for language, financial, transportation, child/elder care, insurance, medication, home health care and other forms of supportConnect patients to resources and support servicesHelp patients learn to navigate the health care system

Center for the Advancement of Cancer Survivorship, Navigation and Policy15CPNN Evaluation PlanDemographic data

Barriers addressed

Resources utilized

Connectivity of network

Center for the Advancement of Cancer Survivorship, Navigation and Policy16Year One Accomplishments

Center for the Advancement of Cancer Survivorship, Navigation and Policy17Year 1 Success ExamplePatient BarrierNavigation OutcomeTransportationTokens for assistance; insurance supportCare adherenceCoordination among navigators across CPNN networkCommunicationFree cell phoneFood & NutritionFood & Friends; Abbott NutritionSubstance abuse / HousingReferral to Gift of Peace; Halfway HouseInsuranceAccess to MedicaidCenter for the Advancement of Cancer Survivorship, Navigation and Policy18Year 2 AccomplishmentsCPNN grant extended to Year Two.Goal: navigate at least 1,525 patients and educate 4,301 individuals.Total: 2,840 patients were navigated and 8,880 outreach contacts were made.

Center for the Advancement of Cancer Survivorship, Navigation and Policy19Year 2 Profile of Barriers

Center for the Advancement of Cancer Survivorship, Navigation and Policy20Year 2 Profile of Patients Served

Center for the Advancement of Cancer Survivorship, Navigation and Policy21Year 2 Profile of Insurance Status

Center for the Advancement of Cancer Survivorship, Navigation and Policy22Year 3Focus on SustainabilityQuality improvementsImproved data systemsTo date, 1,800 individuals reached and 1,368 barriers to care have been removed.Center for the Advancement of Cancer Survivorship, Navigation and Policy23CPNN Summary Since 2010Provided assistance to 6,556 individuals and impacted 19,087 through education and outreach. Removed 24,846 barriers to care. Nearly 25.79% patients were uninsured.Top barriers were social/practical support (16.02%), financial barriers (15.74%), system problems with scheduling care (13.78%) and language barriers (11.16%).

Center for the Advancement of Cancer Survivorship, Navigation and Policy24CPNN Summary Since 2010Approximately 85% of individuals served are racial or ethnic minorities, including over 50% African American and nearly 32% Latino. Patients served include the following top cancer diagnoses: breast (68%), cervical (7%), prostate (5.52%), and colorectal (4.55%) and lung (2.58%). Patients were 83% female, 14% male, and 0.1% transgender with 48% heterosexual and 1.5% LGBT (50.5% did not report sexual orientation). Center for the Advancement of Cancer Survivorship, Navigation and Policy25CPNN Summary Since 2010About a third of individuals were age 50-64, with approximately 20% age 40-49 and about 13% over the age of 65. Approximately a quarter of individuals did not report age. Almost half of individuals served live in the District of Columbia, with 29% from Maryland and 18% from Virginia. Over 1,000 were from Wards 7 and 8, the most poverty-stricken Wards in DC.

Center for the Advancement of Cancer Survivorship, Navigation and Policy26Greatest Successes: Feedback from Site VisitsImproved patient access to services across cancer continuumGreater number of patients served and with more comprehensive servicesNetwork serves as forum for discussion of challenges and problem-solvingSocial and practical barriers resolved to improve adherence to treatmentNetwork addressed system fragmentation to avoid loss to follow up.Information and resource sharingRelationships developed with other navigators make process of referrals to other services seamlessCenter for the Advancement of Cancer Survivorship, Navigation and Policy27Greatest Opportunities: Feedback from Site VisitsPromote engagement/networking among the navigatorsPrograms need to be flexible and able to expand or contract given the variability of grant fundingTraining is critical to enable navigators to successfully work with patientsContinue to provide updates to resources and support groupsDedicate funds to support patient transportation to and from treatmentMost of the community organizations that navigators referred to were not in the networkCenter for the Advancement of Cancer Survivorship, Navigation and Policy28Lessons Learned:Feedback from Site VisitsBreadth of networkPromoting the program to raise awareness in the community about patient navigation and CPNNDeveloping standards for patient navigators to ensure a high quality serviceCollecting data and information to support sustainability from the beginningSimplifying paperwork Addressing patient language issues

Center for the Advancement of Cancer Survivorship, Navigation and Policy29Challenges and SolutionsMultiple changes to evaluation methodsStaff turnoverProgram coordinator is a core coordination node, providing monthly networking/training meetings and process improvements responsive to partner feedback. Keeps the network engaged!Funding and sustainability, patient navigation is not a billable serviceEnsuring a quality standard for navigation across the network Center for the Advancement of Cancer Survivorship, Navigation and Policy30Future DirectionsPilot database to improve outcomes trackingInvolve navigators in the metrics selectionCollect ROI data to show program valueCollect health equity dataProvide weekly resource newsletter to help sites better organize updates and resources, create blog?Conduct focus groups with navigatorsRevisit training preferences: Live? Webinar? Invite community organizations to participateProvide individualized technical assistance to help sites show valueCenter for the Advancement of Cancer Survivorship, Navigation and Policy31SummaryNavigation continues to show value as an important strategy for patientcentered care.

CPNN provides a critical safety net for cancer patients in the DC area that can be replicated in other urban areas and for other diseases.

CPNN has many accomplishments and successes to carry forward.Center for the Advancement of Cancer Survivorship, Navigation and Policy32Navigation Role delineation projectCenter for the Advancement of Cancer Survivorship, Navigation and PolicyRole Delineation Project OverviewDistinguish roles across CHWs, patient navigators and nurse and social worker patient navigatorsMethodsReview of literature, training curricula, grey literatureDevelopment of a frameworkExpert consensusNational survey

Center for the Advancement of Cancer Survivorship, Navigation and Policy34Existing CompetenciesCHW CompetenciesMA, MN, NM, NY, OH, TXOncology Nursing SocietyPatient navigator training programs at GWCI, University of Colorado, PNRP, FreemanCenter for the Advancement of Cancer Survivorship, Navigation and PolicyPreliminary Findings: DomainsCenter for the Advancement of Cancer Survivorship, Navigation and Policy36Preliminary Findings: Similarities and DifferencesDomainCHWPatient NavigatorNurse/Social Worker Patient Navigator Patient Empowerment: Identifying problems and resources to help patients solve problems and be part of decision-making process. Motivating individual and community to positively change health behaviors.Assisting patient with identifying administrative, structural, social and practical issues to participate in decision making and solutions.Assisting patients in decision making regarding diagnostic testing and treatment options.Assisting patients by providing them with coping strategies to deal with disease, treatment and manage stress.Ethics and Professional Conduct:Understanding scope of practice, professional boundaries, assuring confidentiality and following legal requirements. Maintains and adheres to the professional standards. It brings about accountability, responsibility and trust to the individuals the profession services.Abiding by state defined scope of practice.Understanding difference in scope of practice between licensed professionals and non-licensed professionals.Abiding by the ethical principles in the professions scope of practice and code of conduct according to licensure.Care Coordination:Deliberate organization of patient care activities to facility the appropriate delivery of health care services. Case management, service coordination and system navigation.Assessing and facilitating social and practical coordination of care along the care continuum.Assessing and facilitating coordination of psychosocial and medical/clinical care along the care continuum. Center for the Advancement of Cancer Survivorship, Navigation and Policy37Patient Navigation and quality improvementCenter for the Advancement of Cancer Survivorship, Navigation and Policy38Q/PI ToolsUnderstanding the problem:Patient Flow/Process MapFishbone DiagramPareto Chart Planning for change:PDCA (PDSA)Six Sigma DMAIC

Center for the Advancement of Cancer Survivorship, Navigation and Policy39Q/PI Tools: Patient FlowHow many times is the patient passed from one person to another (hand-off)?Where are delays, queues and waiting built into the process?Where are the bottlenecks?What are the longest delays?What is the approximate time taken for each step (task time)?What is the approximate time between each step (wait time)?What is the approximate time between the first and last step?Wow many steps are there for the patient?How many steps add no value for the patient?Are there things that are done more than once?Look for re-work loops where activities are taken to correct situations that could be avoided is work being batched?Where are the problems for the patients?At each step is the action being undertaken by the most appropriate staff member?Where are the problems for staff?Understanding the Patient Journey-Process Mappinghttp://www.scotland.gov.uk/Resource/Doc/141079/0036023.pdfCenter for the Advancement of Cancer Survivorship, Navigation and Policy40Q/PI Tools: Patient Flow 1. Screening2. Diagnosis3. Treatment4. Post-treatmentHow/where are patients screened? What happens when there is an abnormal finding? How are patients notified? How do they get to your institution?What happens after treatment begins? Are psychosocial needs assessed and resources made available? How are medical, psychosocial and practical needs managed and by whom? What happens during the diagnosis meeting? How are treatment decisions made? What do patients do when and after treatment options are discussed?

What happens when treatment ends? Is there communication with the primary care provider? How are medical, psychosocial, and practical needs managed and by whom?Center for the Advancement of Cancer Survivorship, Navigation and Policy41Q/PI Tools: Patient Flow

Blasberg. ACCC Cancer Care Patient Navigation: A Call to Action http://accc-cancer.org/education/pdf/PN2009/s15.pdfCenter for the Advancement of Cancer Survivorship, Navigation and PolicyQ/PI Tools: Patient Flow

Sandoval et al. 2013. J of the Society for Healthcare Improvement Professionals.Center for the Advancement of Cancer Survivorship, Navigation and PolicyQ/PI Tools: Fishbone DiagramProblem Categories of problemsCauses of problems

Why? Why? Why? Why? Why?

Center for the Advancement of Cancer Survivorship, Navigation and Policy44Q/PI Tools: Fishbone Diagram

Center for the Advancement of Cancer Survivorship, Navigation and Policy45Q/PI Tools: Fishbone Diagram

Center for the Advancement of Cancer Survivorship, Navigation and Policy

Q/PI Tools: Fishbone DiagramBlasberg. ACCC Cancer Care Patient Navigation: A Call to Action http://accc-cancer.org/education/pdf/PN2009/s15.pdfCenter for the Advancement of Cancer Survivorship, Navigation and Policy47Q/PI Tools: Pareto ChartWhen analyzing data about the frequency of problems or causes in a process.When there are many problems or causes and you want to focus on the most significant.When analyzing broad causes by looking at their specific components.When communicating with others about your data.

Center for the Advancement of Cancer Survivorship, Navigation and PolicyQ/PI Tools: Pareto ChartCenter for the Advancement of Cancer Survivorship, Navigation and PolicyQ/PI Tools: PDCAPlanPlan a changeDoTest/pilot changeCheck/StudyAnalyze resultsActMake a decision: expand, alter, abandon CAP-DoCenter for the Advancement of Cancer Survivorship, Navigation and PolicyQ/PI Tools: Six Sigma DMAICDefineDefine problemMeasureWhat is happeningAnalyzeAnalyze resultsImprove Make changeControlContinually monitor Center for the Advancement of Cancer Survivorship, Navigation and Policy51Key pointsCenter for the Advancement of Cancer Survivorship, Navigation and Policy52Strategies for Community EngagementInvolve navigators in the data; move from outputs to outcomes to truly show the public health impact/value of the interventionCome together to decide the visionInstead of competing over funds, find ways to work collaboratively Center for the Advancement of Cancer Survivorship, Navigation and Policy53Questions for Florida CHW NetworkWhat do you want to see your network accomplish?What is your baseline for health disparities? Where do you want to be? How will you measure change?What resources do you need to accomplish your goal?How will you sustain your network?Who are your stakeholders?What do your stakeholders value and how will you demonstrate that value?

Center for the Advancement of Cancer Survivorship, Navigation and Policy54Contact InformationHeather KappCPNN Program ManagerDirector, Access and Quality George Washington University Cancer [email protected] 202-994-2062

Mandi Pratt-ChapmanCPNN Principal InvestigatorAssociate Director, George Washington University Cancer [email protected] for the Advancement of Cancer Survivorship, Navigation and Policy55Chart12860245024421631114011121096995919887330298274179128118

Mandi's CalculationsDEMOGRAPHICSGENDERRACESEXUAL IDENTITYPOINT OF ENTRYRISKMaleFemaleTransgenderNAfrican AmericanAfricanHispanicWhiteIndianAsianUnreportedNLesbianGayBisexualQueerHeteroUnreportedNOutreachScreeningAbnormal FindingDiagnosisTreatmentSurvivorshipPalliativeUnreportedNBreastProstateColorectalCervicalLungOtherUnreportedNNo Insurance/IneligibleNavigated to insuranceFFSMCOMedicarePrivatePCP YPCP NNCE22165618784197931365319-208781500504368878523597219334110318783345097184261266187813468192129184565153Q1/2161101821181532334788721534118116390680473118163479233159240170-10118183153539829585911812272020136311920855863Q318668808743395739461111118741142351034487439414125941821417-11874569544078287827874334330252120105298149Subtotal568236232933129016911852136452529332812113169411852933154125243027275642171029331734157190360832621476951212018073684971421365%0.19365837030.80531878620.00102284350.43982270710.05762018410.40402318450.07262188890.0020456870.01534265260.00852369590.01841118310.57756563250.40402318450.4793726560.23934538020.25775656320.01431980910.00579611320.59120354590.05352881010.06478008860.12274122060.02829867030.13944766450.6218888510.12546880330.169451074overreporting accounted for by multi-racial individuals10080.49744289120.3436754177BarriersNCEQ1/Q2Q3Subtotal%RankTransportation26038346911120.065958835Housing4549241180.0069992289Social/Practical727139973428600.16964232751Language78117437916310.09674357914Literacy54951813300.0195741147Dependent care588351280.0075923839Location of facility2288019410960.0650097871Financial436132867824420.14484844893Employment4991917211400.067619669Communication concerns1505092609190.0545109437Fear/negative perceptions1434133318870.0526128477Co-morbidities641191152980.0176760187Disability221211312740.0162524468System problems155163166424500.14532297292Anxiety1481841790.0106174743Other2103724139950.0590189216SUBTOTAL243495614864168591

GraphsTransgender3Male568Female2362African American1290African169Hispanic1185White213Indian6Asian45Unreported25Lesbian28Gay12Bisexual11Queer3Heterosexual1694Unreported1185Outreach154Screening1252Abnormal Finding430Cancer Diagnosis272Treatment756Survivorship42Palliative17Unreported10Social/Practical2860Other State Medicaid807System problems2450No insurance (ineligible)695Financial2442Private497Language1631Medicare368Employment1140Fee for Service201Transportation1112No insurance but navigated to insurance121Location of facility1096Other995Communication concerns919Fear/negative perceptions887Literacy330Co-morbidities298Disability274Anxiety179Dependent care128Housing118

Graphs

Sheet3

Chart11290169118521364525



Graphs

Sheet3

Chart1807695497368201121



Graphs

Sheet3

Documents

Creating a Longitudinal Continuum of Access to Care