Patient Navigation Across the Continuum

Linda Fleisher, PhD, MPHAssistant Vice President

Office of Health & Communications DisparitiesBonnie J. Miller, RN, BSN, OCN, FAAMA

Administrative Director, Women’s Cancer CenterFox Chase Cancer Center

Patient Navigation Across the Continuum

Objectives

• Discuss the roles of various types of navigators and our approach integrating both community and nurse navigators

• Describe the strategies to identify and address barriers across the continuum of care

• Describe the institutional structures and resources that support our model that support the implementation and sustainability

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Distinguished Honors & Accomplishments

• Extraordinary Contributions to Basic Science-Philadelphia Chromosome, Hepatitis-B, “Two Hit Theory,” SCID mouse, and Protein Trafficking

• International Recognition- 2 Nobel Prizes, 7-NAS, Pontifical Society, 3-ACS Gold Medals, 4-BMS Prizes, Kyoto Award

• Discovery of Hepatitis B and Vaccine Development by Baruch Blumberg, Nobel Prize, 1976

• Knudson’s “Two Hit” Theory by Alfred Knudson, Kyoto Prize for Basic Science, 2004, and the Lasker Award 1998

Distinguished Honors & Accomplishments

• The First Multidisciplinary Cancer Prevention Research Facility in the World- March, 2000

• Clinical Recognition for Excellence-Esophageal Cancer, Ovarian Cancer, and Innovative Radiation- (3-D Conformal and IMRT)

• 32 out of 80 Physicians were selected as Top Doctors-Philadelphia Magazine (April 2007)

• Magnet Award for Nursing Excellence-ANA- 2000, 2004, 2009• Fox Chase Cancer Center Ranked Top as “America’s Best

Hospitals” in the Tri-state area, and 11th in the Nation- U.S. News & World Report’s (July 2007)

Bonnie J. Miller, RN, BSN, OCN, FAAMA

• Administrative Director Women’s Cancer Center at FCCC with oversight of Clinical Navigation

• Chair Navigation Steering Committee for FCCC• Point Person: Strategic Plan FCCC: Patient Navigation• Co-author Orientation Manual for Navigation• Education Coordinator Navigator Orientation/Training • Consultant for FCCC: Program Development, Strategic

Planning, Disease Management, Quality and Education• Experienced GYN ONC Nurse Navigator

Linda Fleisher, PhD, MPH

• Implemented the NCI’s Cancer Information Service for 15 years – telephone navigation

• Founded and directs the FCCC’s Resource and Education Center• Conducted a qualitative study at Temple University in 2005 which lead to

the development of the PA Navigator Demonstration Project• Co-lead (S. Miller & Fleisher) the PA Navigator Demonstration Project – a

three year project with funds from PA DOH• Developed the Patient Navigation Resource Guide• Co-founded the PA Navigator Network• Steering Committee for the Academy of Oncology Nurse Navigators• Developed patient navigation for our community screening program• FCCC’s Navigation Steering Committee

Navigation is…a noun and …a verb

One Size Does Not Fit All

Vision of an Integrated Model of Patient Navigation

Internal Barriers to Successful Implementation

• Lack of knowledge

• Lack of clarity and need for navigation

• Poor role development

• Lack of physician champion

• Lack of Administration/leadership support

• Claiming navigator “ownership”

• System “change”

• “Blurry lines” /“plugging holes”

• No outcome measures defined

• Data management systems

• Evaluation

Strategies for Successful Implementation

• Buy-in– Education to staff/service line– Show gaps openly: Demonstrate need– Secure a physician/leadership champion (s)– Change=Progress=“it’s ok”

• Structure and Roles– Clearly define roles – Set framework, policies and timeliness for program development– Establish internal communication plan for policy and procedure

• Evaluation– Share outcomes– Center-wide data base – Develop evaluation including measures

• Sustainability– Integrate into Strategic Plan

FCCC Navigation Steering Committee

• Leadership: Clinical• Leadership Support: Academic• Representation:

– Women’s Cancer Center– Office of Health Communications

and Health Disparities– Patient Access– Hospital Administration– Nursing Administration– Social Work– Volunteers– Physician Champion– Clinical Research– Ambulatory Care– ALL Navigators

Goals: Consistency Communication Collaboration

Qualitative/Quantitative Navigation Measures

• Clinical– Number of patients– Demographics– Diagnosis – Call to NPO– Call of NPO to Navigator to Patient– Appointments kept/missed/why– Appointment falling out of 7 day

window (Strategic Goal)

• Community Screening– Demographics– Family History and Screening

History– Abnormal– Time to follow-up– Outcome

• Implementation & Tracking– Patients accepting not

accepting navigation/ reasons– Education information

provided– Barriers/Resolution– Resources (internal/

external)– Clinical Trial

opportunities/accrual– Biosample repository

recruitment– Patient Satisfaction– Downstream revenue (Retention)

Clinical Navigation

History

• Started in Women’s Cancer Center– Breast– 3-month PILOT– 1.2-2.0 FTE Navigators– Launch GYN 7 months

later

• Multiple Service Lines and Departments– Head & Neck– Thoracic– Infusion – GI

Rationale for Nurse Navigator Role

• Service Line Enhancement• Disease Specific Model of Care• Complexity of Health Care System• Access to FCCC and Retention Goals• Complexity of Cancer Care• Gaps/Barriers• Opportunity in WCC, Head and Neck Service Line,

Thoracic and Infusion Room• Linkage to Clinical Research/Mission of FCCC• Response to Patients

Key Institutional Factors

• Champions• Senior Leadership support• ROI – proof of concept• Integration into strategic plan• Transitioning existing staff • Coordinated and consistent training and data collection• Screening Treatment Survivorship• Academic opportunities

Service Line Concept Enhances Role of Disease Specific Nurse Navigation• Organ/Disease Specific focused teams• Program development in alignment with strategic

priorities• Processes to improve patient satisfaction• Increase Clinical Research accrual from Prevention

through Survivorship• Physicians, APCs, Navigators, Administration, Social

Service, Protocol Office

Service Line Goals/Governance/Accountability

• Quality Improvement• Clinical Research, Performance and Priority Setting• Strategic Growth Planning• Clinical Practice Standards: Include algorithms for patient

intake, scheduling, improve patient satisfaction, multidisciplinary/solo practice, use of Navigators and APCs

• Regulatory - CoC• Coordinate processes for services delivered within Facility• Input in budget and fiscal oversight

Navigation Process

Prevention Early Detection Diagnosis Treatment Survivorship

Community Navigator

New Patient Office Navigator First

Appointment

Ideal Patient Navigation Model

Differences in Navigation Services

• Proportionate with acuity/needs of patients– Changes with disease specific navigation– Changes with specific sssignments of Navigation (Infusion Room)– Service level declines as volumes rise– Low volume/high acuity= ie: Head and Neck

population– High volume/different needs=ie: Breast population

Focused Areas of Data Capture

• Improved coordination of high-quality care• Enhanced access to services for patients• Removal of barriers to care• Improved outcomes• Improved sharing of resources• Enhanced relationships with the community• Increased patient satisfaction• Increased referrals of patients to the system

Impact of Navigation: Retention Rates with Disease Specific Navigation

Retention Rates (2011 yields Downstream Revenue)Average retention rates across all disease sites = 68%Breast 72.58%GYN 75.62%Head/Neck 80.80%Thoracic 74.09%

Impact of Navigation: Increase in Clinical Trial Accrual

Disease Specific Site Increase in Therapeutic trial accrual FY11Breast 66%GYN 27%

Navigation Database Evolution

• Transition/Development– Excel Spreadsheet– ACCESS Database– Web Based Application

• Links with current systems at FCCC— Scheduling, Chemo, Radiation, Coding/Billing

• Less Time and Effort from Navigations• Reports Built in (Updated Daily)• Home Grown/Updated/Navigation Input• Integrated into current system: “We created something

pretty good!”

Navigation Database

Internal/External Marketing/Education

• Center wide Navigation Steering Committee• Presentation to Management Team• Service Line Meeting Format• Physician Champions• Community Advisory Committee• Presentation to Partner Organizations• Consistency in messaging….• External: Website, Print Materials, Commercial,

Webisodes

Marketing: WCC Brochure

Communications: Web Page

Women’s Cancer Center Commercial Featuring Navigators

Next Steps

• Expand navigators role in research– Biospecimen collection– Clinical trials (esp. underrepresented groups)

• Develop and conduct systematic patient satisfaction and impact evaluation

• Expand Navigator role in Service Line Design• Continued education about the role & scope of

navigation• Grant/Research Opportunities• Ever Changing…Ever Evolving….Patient Focused

Community Navigation

Programs & Research• Community Outreach & Education

– PA Cancer Education Network

– Neighbors Program

– General & Minority Outreach

– State CCC

– Dissemination of Body & Soul

– New Partnerships

– Targeted Media

• Health Communications – Health Literacy

– Resource and Education Center

– Patient Education

– Patient Navigation

• Community Cancer Screening–Corporate and Community

–Breast, Skin and Prostate

• Research & Evaluation– NCI’s Community Health Education

Network

– CIS Research Consortium

– Prostate Cancer Decision Tool –Healing Choices

– Research Studies: E-health, Community, Survivorship

– P20 Lincoln Partnership – NCI’s Geographic Management

Program– Health Disparities Research Work

Group

Office of Health Communications and Health Disparities, 2011

Office of Health Communications & Health Disparities

Programs

Cancer Education & Outreach

Community Screening

Health Communications

Research

Research Projects

Research Collaboration &

Support

Community Engagement & Partnerships, Fundraising & Grants, Evaluation, Communication, and Training

Breast CancerRelief Fund

Philadelphia

Foundation

Pt. Navigator Pilot

New Database

Funding for underserved

Programs & ResearchpotentialLinkage to FCCC

Breast CancerSkin CancerProstate Cancer

Community Screening

In the News….

Mobile Mammography on 6ABC News

Screenings July 2010 thru April 2011

Funding Sources (non-private insurance):• Breast Cancer Relief Fund – 20 Latina + 26 Asian women =

$9,500• Wawa (coin box collection) - 91 uninsured @ $90,700 for

screening and diagnostic services• HealthyWoman (CDC Breast and Cervical) = 221• Keystone Mercy Health Plan = 203

Corporate N Days

Community N Days

Total Screened

Mammography 1878 84 989 55 2867

Skin 0 0 31 1 31

Prostate 39 1 12 6 51

Total 1917 85 1032 62 2949

Community Navigators

• Seasoned health educators• Extensive community work• Collaborate with community

partners – co-navigate• Role

– Ensure follow-up care– Emotional support– Appointments– Transportation– Insurance/financial support– Translation– Referrals to support services

Mobile Mammography Navigation

• Pilot program focused on underserved• All women with an abnormal finding are contacted

by navigator• Navigator assesses & addresses barriers to follow-up• Provide support to return to FCCC or other

appropriate facility for follow-up

Mammography Navigation PilotDecember 2010 – April 2011

Purpose: Navigate uninsured women with additional services as neededSelection Criteria: Uninsured, Healthy Woman

29 uninsured women received diagnostic mammograms Clinical Outcomes

– 17 had ultrasounds– 3 had stereotactic biopsies– 1 woman diagnosed– 1 six-month follow-up

Challenges– Language – 19 women (Spanish, Chinese, Korean)– Transportation – 5 (we paid $125 for transport to FCCC)– Unable to reach participant– Obtain needed prescriptions for services

Successes– 29 women navigated for continuity of care. Included assistance

with appointment scheduling and transportation. – Average of 12 days between initial screening and diagnostic testing

Race EthnicityWhite 11% Hispanic/Latina 47%

Black/AA 25% Not Hispanic/Latina 47%

Asian 50% Unknown 8%

Unknown 14%

Project REACHPilot for Community-Based Prostate Risk Assessment Program

• Collaboration between OHCHD and Prostate Risk Assessment Program; funded by The Philadelphia Foundation

• Community partners provide location for mobile van where screening takes place

• Full PRAP services (DRE,PSA, research bloods and educ)• Navigation services and funds for uninsured men• 12 men screened/1 biopsy

– 9 Black/ African American– 1 Caucasian– 1 Trinidadian

Future Plans

• Navigate all community screening participants as needed

• HealthyWoman – expand agreement to include diagnostic testing and treatment

• Health Partners – establish a comprehensive agreement to cover women with this Medicaid insurance

• Seek IRB approval to conduct quality improvement and outcomes analyses

Prostate REACH Navigation

• Advertising through community partners

• Men call into PRAP office, if no insurance they are referred to the navigator & scheduled for upcoming community program

• Navigator assesses barriers, works with financial services and addresses other barriers

• Navigator is present at screening

• Navigator follows all men with an abnormal result and facilitates access to follow-up care at Fox Chase

• Funding for navigator, screening and biospy through foundation funding

Lessons Learned

Lessons Learned

• Infrastructure– Champions– Senior Leadership support– ROI – proof of concept– Integration into strategic plan– Steering Committee across all domains

• Staffing– Transitioning existing staff – Coordinated and consistent training and data collection– Coordination across all navigators

• Promotion & Marketing• Evaluation

– Consistent data collection – with a goal to evaluation and research

Lessons Learned: The Five Cs

• Committee Oversight– Infrastructure across domains – Steering Committee

• Center wide component of Strategic Plan– Alignment with Strategic Goals for Center (Enhancing

Patient Experience)

• Coordination across all navigators– All one “Team”

• Comprehensive Education, Promotion & Marketing• Consistent data collection

– All Navigators– Goal to evaluation and research

Contact InfoBonnie J. Miller, RN, BSN, OCN, FAAMA

Fox Chase Cancer CenterWomen’s Cancer Center

333 Cottman AvenuePhiladelphia, Pa. [email protected] (Office)

215-728-3100 (Adm Office)

Linda Fleisher, PhD, MPHFox Chase Cancer Center

Office of Health Communications and Health Disparities

510 Township Line RoadCheltenham, PA 19012

[email protected] (Office)