Implementing the Patient-Centered

Navigation Process Carol Walter, MSN, RN

Pulling teeth to get a new thing started in your cancer

program, which is just like my cancer program.

AKA……

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Objectives

The participant will be able to:1. Understand and use the guidelines of meaningful use,

CoC and other certifications to push their processes forward.

2. Assess who they have around them and the resources available to assist in the process of navigation and survivorship.

3. Use survivorship tools at the beginning of a patient’s journey that will help the participant create a survivorship care plan (SCP).

4. Strengthen patient-centered navigation to promote survivorship. (What’s best for the patient)

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Our Process:

How it started……

Long ago in a galaxy far, far away……

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PCRMC – Rolla, MO

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PCRMC – started in 1955 (young by hospital standards)255 bed hospital3 medical oncologists1 radiation oncologistRolla, MO 17,000+

Cancer – 440 (have analytical and non-analytical) new diagnosis per year

Treat 380 average per year (diagnosed and/or treated here)

Largest health care system in a 90 mile radiusSt. LouisColumbia (University of Missouri)Springfield, MO (3rd largest city in MO)

PCRMC Summary & History

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2002 - Lost in Transition2010 - PCRMC first CoC-accredited2013 – (Jan) - I was hired

• Navigation required for 2015• Varian/Aria/Equicare purchased

2013 – (Jan – July) • Learning, training• Start oncology patient portal• Distress Assessments with breast cancer patients only

2013 – July• Added MSW to our program• Distress Assessments added for all patients

**November, 2013** – My first memo to our program outlining CoC guidelines and what we needed to do in our organization

How We Got Started…

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How We Got Started…

• 2015 – May - Radiation Oncology starts sharing patient portal with patients

• 2015 – June – Social worker adds survivorship care plans

• 2015 – October - First Dr. (Radiation Oncologist) provides Survivorship Care Plan to a patient

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Overview: How to Introduce or Improve Services within Your System

1. Use regulations & mandates to move your process along

2. Use existing opportunities & timing to move your process

3. Use existing staff to assist in the process4. Start survivorship at the beginning of the patient’s

journey5. Focus on patient-centered care

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Patient Navigation Process (S3.1)

A patient navigation process, driven by a triennial Community Needs Assessment, is established to address health care disparities and barriers to cancer care. Resources to address identified barriers may be provided either on-site or by referral.

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Navigation is a Process

From AONN conference 10-1-15 from Dr. Aaron Bleznak – current CoC surveyor and member of Program Review Subcommittee

“3.1, 3.2, 3.3 is not about navigators, but about the process and outcomes.”

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Navigation - Process, not a personNavigation process - patient access to the care they needCancer Committee - must a have a policy on the navigation process Report annually to the Cancer Committee:

• Health disparities• Navigation process• Potential for changes• Populations being served• Barriers that still need to be overcome

Navigation Process (S3.1)

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Community Needs Assessment (CNA)

Resources for the information needed: • Hospitals required to have a CNA• County Health Departments • Cancer Registry

‒ Talk with your Registrar‒ Access to immense information

• CDC• National Cancer Institute• State of Missouri• ACS

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Community Needs Assessment (CNA)

• Must be done every 3 years. (once every survey cycle)

• Must address cancer in the community. • Cancer committee must:

• Define the scope of the CNA• Be involved in the design of the assessment• Include CANCER-related questions

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Community Needs Assessment (cont’d)

• Cancer Committee (CC) must be involved and review the results yearly – not just every 3 years

• CC must assess if navigation meets the barriers or do new goals need to be established

• Each year the process must address a different, additional barrier• Your program may repeat a barrier IF your CC

determines it is the most important area of concern• Must document discussion in CC minutes if you chose

to do the same barrier

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Psychosocial Distress Screening (S3.2)

Each calendar year, the cancer committee develops and implements a process to integrate and monitor on-site psychosocial distress screening and referral for the provision of psychosocial care

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Requirements

The CC will:• Develop and implement a process to provide and

monitor distress screening either on-site or by referral

• Determine pivotal medical visit(s) during which a patient will be screened for distress

• Review evaluation of findings and document in CC meeting minutes.

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Documentation

Annual psychosocial services summary documenting:

• Methods used to monitor and evaluate distress screening activities

• CC minutes documenting discussion of process and tools implemented to provide, monitor, and evaluate distress screening

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Improving The Process

How can we improve process, documentation and evaluation?• Example: Algorithm to address distress scores: • 1 – 3 – steps to do??• 4 - 6 – plan – re-evaluate• 7 – 10 – plan (any one with 7-10 automatically

populates to Social Worker)https://www.cancercare.on.ca/toolbox/symptools/patient_symptom_management_guides

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Resources for Distress Assessment

• NCCN• Equicare• ACS

Our program has incorporated and adapted these resources to make our own distress assessment

Documentation can be entered into: • Aria• Varian and • Equicare

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© American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.

© American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.

A process to develop and implement a comprehensive care summary and follow-up plan for patients. The process must be monitored and evaluated at least yearly. CoC says this process is to focus on the sub-set of patients with curative intent (not necessary to do stage 4 at this time – however we do most of the time.)

3.3 – Survivorship Care PlanStage 1, 2, 3

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“Within the SCP processes are policies identifying the appropriate healthcare provider(s) from the patient’s oncology care team who will be responsible for approving and discussing the SCP.”

*Physicians*Registered Nurses*Advanced Practice Nurses*Physician Assistants*Credentialed clinical navigators (???? – definition)

(does not include lay navigators)

Survivorship Care Plan

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© American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.

© American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.

Survivorship Care Plan

Standard of Care:

“Upon discharge from cancer treatment, every patient and their primary health care provider should receive a written follow-up care plan incorporating available evidence-based standards of care.“

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CoC also says the process can be phased-in:

• 2015 – 10% of patients must have a comprehensive care plan and survivorship visit

• 2016 – 25%• 2017 – 50%• 2018 – 75%• 2019 – 100%

Survivorship Care Plan

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This should include at a minimum:

• Likely course of recovery from treatment toxicities, as well as need for ongoing health maintenance/adjuvant therapy

• Diagnostic tests and results• Tumor Stage and characteristics of their cancer• Date of diagnosis• Treatments provided – surgery, chemotherapy, radiotherapy,

transplant, hormonal therapy, gene therapies, clinical trials, treatment responses, toxicities experience

• Agents, doses, regimes of treatments• Support Services provided – psychosocial, nutrition, etc• Contact info of all providers and institutions• Coordinator of care

sources – Livestrong, ASCO, IOM

What Goes into a SCP

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What Goes into a SCP (cont’d)Standard of care Follow-up plan:• Recovery plan and health maintenance• Recommended cancer screenings and other testing with schedule of when they

should be performed and who should provide them• Possible late and long-term effects of treatment and symptoms• Possible insurance, employment, and financial consequences and referrals as

needed for counseling, legal aid, financial assistance• Information on effective chemo-prevention strategies for secondary prevention

(tamoxifen, ASA)• Referral to specific follow-up care providers, support groups and PCP• List of cancer-related resources and information• Healthy behaviors• Genetic Counseling• Chemo prevention• Referrals to resources and rehabilitation services• Stop-smoking and other health services

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CoC Guidelines and Meaningful Use Requirements:

**Use regulations and mandates to move your process forward**

Advice from the Trenches…

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How to Get There in Less than 2 Years…

1. Evaluate existing staffing strengths2. Understand program staff requirements

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Begin at the beginning!

• Start your survivorship care plan when you have a new patient

• Find technology that supports you‒ For us that is Equicare –

We add patients in Equicare We get them signed up for the portal Their care plan is started…

Advice from the Trenches….

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Our current process…

Navigation - Nurse (*generally starts at diagnosis)• Distress assessment (DA)• Packet of information• Referrals as needed• Support and visits as needed• Entry into system (that leads to survivorship)

Navigation - Social Worker (*generally starts at first visit) • DA if not already done • Referrals and support as needed

Navigation & Survivorship - Beginning to End

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First visit – Radiation oncology• RN entry into the EMR system (if not already in)• Gives the patient the print out

‒ Portal invitation‒ List of Care-givers

First Visit - Medical Oncology• CMA entry into the EMR system (if not already in)• Gives them the print out

‒ Portal invitation‒ List of Care-givers

TIPS: • Use who you have and who will be most likely to do this for the patient• For Meaningful Use - document who has a computer, who will log &

who refuses

Patient Portal Survivorship Care Plan

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© American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.

Our SCP

• Welcome letter - Congrats! You are a Survivor• Patient Portal instructions (again)• Treatment Summary• Education • Follow-up plan• PCRMC Care team names and contact info• Local support group info• Rehab assessment and referral• Distress Assessment (final)

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Our EMR feeds everything from MO/RO (Aria/Varian) into Equicare (the portal, survivorship EMR).

If you start this process at the point of patient admission to services, you will have a complete document at the end of treatment.

Survivorship Process - Technical

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© American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.

© American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.

© American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.

© American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.

© American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.

Our Survivorship Care Plan

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What does the patient want?

When do they want it?

Who else can get it?

Being flexible: • Is the patient too sick at the first meeting?• Is there too much info? (Overwhelmed)• Tech savvy? Computer or internet at home?

What works?What doesn’t?

Ever-changing…

Patient-Centered Care

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Delbert Day Cancer Institute

ResourcesNCCN - http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#supportive Livestrong - http://livestrongcareplan.org/ ACS – www.cancer.org Equicare Health - http://equicarehealth.com/ GW Cancer Institute: https://

smhs.gwu.edu/gwci/survivorship/ncsrc/national-cancer-survivorship-center-toolkitCancer Care Ontario -https

://www.cancercare.on.ca/toolbox/symptools/patient_symptom_management_guides ASCO - http://www.asco.org/sites/www.asco.org/files/survivorcompendium2014_web.pdf IOM - http://

www.nationalacademies.org/hmd/Reports/2005/From-Cancer-Patient-to-Cancer-Survivor-Lost-in-Transition.aspx

NCCS – National Coalition for Cancer Survivorship www.canceradvocacy.org www.canceradvocacy.org/toobox.

Academy of Oncology Nurse & Patient Navigators – www.AONNonline.orgSTAR Program – Survivorship Training and Rehab – http://starprogramoncologyrehab.com Nurses Guide to Cancer Survivorship Care plans – www.curemagazine.com

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Thank You!