Cancer Care Patient Navigation

A Publication of the Association of Community Cancer Centers

A practical guide for community cancer centers

ACCC’s CanCer Care Patient navigation: A CAll to ACtion

Patient Navigation: A Call to Action S3

by Virginia T. Vaitones, MSW, OSW-C

ACCC’s Cancer Program Guidelines S4

Chapter 4, Section 10: Patient Navigation Services

A Conversation with Dr. Harold P. Freeman S5

An Interview with Amanda Patton, Associate Editor, ACCC

ACCC’s Patient Navigation Program Pre-Assessment Tool S8

Patient Navigation: A Multidisciplinary Team Approach S10

by David Nicewonger, MHA

Patient Navigation at Billings Clinic S15

An NCI Community Cancer Centers Program (NCCCP) pilot site

by Karyl Blaseg, RN, MSN, OCN, BC

Growing Your Patient Navigation Program S25

A step-by-step guide for community cancer centers

by Joann Zeller, MBA, RTT, CTR

A Regional Navigators’ Network S28

A ﬁrst-person perspective

by Debbie Williams, RN

Thoracic Oncology Patient Navigation S29

Creating a site-speciﬁc navigation program

by Susan Abbinanti, MS, PA-C

Broward Health’s Breast Cancer Navigation Program S32

Meeting the needs of underserved patients

by Pia Delvaille, ARNP, MSN

ACCC’s Patient Navigation Program Outcome S39

Measures Tool

Cancer Care Patient Navigation

A practical guide for community cancer centers

COVER PHOTOGRAPH AND PHOTOGRAPH THIS

PAGE COURTESY OF MULTICARE REGIONAL

CANCER CENTER, TACOMA, WASH.

ACCC Editors

Monique J. Marino

Amanda Patton

Guest Editor

Virginia T. Vaitones, MSW, OSW-C

Art Director and Designer

Constance D. Dillman

ACCC OFFICERS AND TRUSTEES

President

Luana R. Lamkin, RN, MPH

President-Elect

Al B. Benson III, MD, FACP

Treasurer

George Kovach, MD

Secretary

Thomas L. Whittaker, MD, FACP

Immediate Past-President

Ernest R. Anderson, Jr., MS, RPh

BOARD OF TRUSTEES

Fran Becker, LCSW, OSW-C

Gabriella Collins, RN, MS, OCN

Steven L. D’Amato, RPh, BCOP

Becky L. DeKay, MBA

Heidi Floden, PharmD

Thomas A. Gallo, MS

Anna M. Hensley, MBA, RT(T)

Diane M. Otte, RN, MS, OCN

Virginia T. Vaitones, MSW, OSW-C

Alan Weinstein, MD, FACP

publication may be reproduced or transmitted in any form or by any means without written

permission.

ACCC’s CanCer Care Patient navigation: A CAll to ACtion S3

entral to ACCC’s mission is ensuring timely patient access to

appropriate cancer care. Over the past decade, patient navigation

services have been emerging as an important strategy for

enhancing patient access to the full continuum of cancer care from screening to

detection, diagnosis, treatment, and beyond.

ACCC’s Patient Navigation: A Call to Action project is designed to help

community cancer programs establish or expand patient navigation services.

Included in this supplement is the newly developed Patient Navigation guideline

from ACCC’s Cancer Program Guidelines. To view ACCC’s full Cancer Program

Guidelines go to www.accc-cancer.org.

This supplement is not designed as a “how to” guide. It is a resource for

community cancer programs interested in implementing or expanding patient

navigation services. We’ve included articles describing ﬁve model patient navigation

efforts currently underway at ACCC member programs. The range in program

design and scope demonstrates that there is no one-size-ﬁts-all template for patient

navigation programs. Rather, these services can be designed to dovetail with your

program’s speciﬁc resources, community needs, and strategic objectives.

Included are sample tools from successful navigation programs, such as

pre-assessment forms, intake summaries and referral forms, navigation tracking

forms and progress notes, patient satisfaction surveys, and outcomes measures.

And, we’ve included an interview with Dr. Harold Freeman, who in 1990 ﬁrst

conceived and developed a patient navigator service to help underserved populations

access the healthcare system. Dr. Freeman talks about what he believes is essential

to any patient navigation program. He also describes the Harold P. Freeman Patient

Navigation Institute, founded in 2008, to help deﬁne patient navigation, create

standards, and develop a certiﬁcation process for people who were trained in the

patient navigation program concept.

As the model programs in this supplement demonstrate, patient navigation

in community cancer centers can be tailored to meet the unique needs of the

community, patients, and caregivers. Patient navigation services can streamline

patient access to care, enhance quality care, and increase both patient and provider

satisfaction.

With more than 30 years of experience as an oncology social worker, Virginia T.

Vaitones, MSW, OSW-C, has also been an active participant and supporter of ACCC,

serving on the Association’s Board of Trustees, and ACCC’s Program, Guidelines,

and Patient Advocacy Committees.

Patient Navigation: A Call to Action

by Virginia T. Vaitones, MSW, OSW-C

S4 ACCC’s CanCer Care Patient navigation: A CAll to ACtion

SeCtion 10

Patient Navigation Services

Guideline I

A patient navigation program is

available for patients, their families,

and caregivers to help “overcome

health care system barriers and

facilitate timely access to quality

medical and psychosocial care from

pre-diagnosis through all phases of

the cancer experience.” *

Rationale

The diagnosis and treatment of

cancer and living with the disease

may be confusing, intimidating, and

overwhelming for an individual, fam-

ily member, or caregiver. Cancer

programs have a responsibility to

assist our patients, their families, and

caregivers to navigate the continuum

of care through a navigation program

developed by the cancer program or

via a partnership with a community

agency that utilizes patient naviga-

tors. Since each cancer program

understands its unique patient

AssociAtion of community cA ncer centers

Cancer Program Guidelines

Association of Community Cancer Centers

Cancer Program Guidelines

Chapter 4: Clinical Management and Supportive Care Services

*From a deﬁnition created by C-Change, May 20, 2005. Permission granted. “Patient

navigation in cancer care refers to individualized assistance offered to patients, families,

and caregivers to help overcome health care system barriers and facilitate timely access

to quality medical and psychosocial care from pre-diagnosis through all phases of the

cancer experience.”

population and its community, indi-

vidual programs or health systems

can best create a navigator system

that suits its needs.

Characteristics

A. Patient navigation may include but

is not limited to oncology social

worker(s) and nurse(s) who may:

1. Act as a coordinator to ensure

the patient, their family mem-

bers, and caregivers move

through the complexities of

the system in a timely fashion

2. Provide psychosocial services

to patients, families, and care-

givers or refer to oncology

social worker for psychosocial

care

3. Link patients, families, and

caregivers with appropriate

community resources (i.e.,

ﬁnancial, transportation, transla-

tion services, and hospice)

4. Provide education to the

patient, families, and caregivers

throughout the continuum of

care

5. Link patients, families, and

caregivers with appropriate

post-treatment follow-up care.

B. Trained volunteers and non-clinical

paid staff may provide some of

the navigator activities and func-

tions under deﬁned conditions

and with professional oversight.

1. Cancer programs may choose

to select, train, and oversee

their own volunteers or non-

clinical paid staff.

2. Cancer programs may choose

to partner with an organization

that employs patient navigators

or uses volunteers.

a) The cancer program will

help determine who will

oversee these navigators.

b) The cancer program will

develop a contract between

the navigator(s) and the pro-

gram that clearly outlines

the role the navigator(s)

will have with patients and

families.

c) The cancer program will

develop an orientation and

training program that the

navigators must attend.

d) The cancer program will

provide an ongoing

in-service education pro-

gram for the navigators.

3. The program should provide

adequate space for conﬁdential

interviews and counseling.

4. Navigators should receive train-

ing in ethnic, cultural, and reli-

gious diversity as well as ethics.

5. Mechanisms exist, when

necessary, to review the plans

and coordinate among team

members.

6. Navigators should facilitate

communication between

patient and providers.

7. Navigators should educate the

oncology staff about the naviga-

tor program and how it will be

integrated into the oncology

program.

ACCC’s CanCer Care Patient navigation: A CAll to ACtion S5

A Conversation with

Dr. Harold P. Freeman

An Interview with Amanda Patton, Associate Editor, ACCC

ﬁght their way through the system.

Often they become disillusioned and

give up hope. So if there is a strategy

which eliminates barriers for people

who don’t have the knowledge or the

resources or insurance—if there’s a

way to create a program which causes

these people to move rapidly through

the system to earlier diagnosis and full

treatment—then this is the reason

that patient navigation seems to be

working and catching on.

Q. In 1990 you developed the

patient navigation model in an

effort to remove the barriers you’ve

just described. Do you see the

primary mission of navigation still

to be to address these problems?

A. I truly believe that navigation

may beneﬁt people of all socio-eco-

nomic statuses, but it’s most impor-

tant for people who don’t have the

resources and the knowledge [about

cancer detection and treatment] and

that should be the target audience.

However, as we learn more, we are

ﬁnding that there are people who

meet barriers who are insured or who

do have knowledge [about cancer

detection and treatment]. I think it’s a

broader issue that needs to be applied

to the whole population of people

who either develop cancer or are in

the process of being diagnosed for

cancer. I think that the critical part—

and the most effective and the most

necessary part—of navigation is to

target it to populations that are under-

served or less educated or uninsured.

But I do believe patient navigation

has a universal beneﬁt for all patients

and is even being applied to diseases

other than cancer.

Q. In January 2008 the Harold P.

Freeman Patient Navigation

Institute was launched. What was

the impetus for the Institute?

A. By this time navigation had begun

to spread rather rapidly to different

sites throughout the country…. First of

all starting with the United States gov-

ernment, the NCI has funded 9 patient

navigation programs starting about 5

years ago, demonstration sites. The

Centers for Medicare & Medicaid Ser-

vices (CMS) has funded 6 patient navi-

gation sites, which is very important

because CMS oversees Medicaid and

Medicare. And thirdly, most recently,

HRSA [Health Resources and Services

Administration] has 6 sites. In 2005

the Patient Navigation Act, based on

the model in Harlem, was signed into

law by President George Bush.

In the meantime, the number

of agencies and nonproﬁts support-

ing patient navigation, such as the

American Cancer Society, the Susan G.

Komen Foundation, the Avon Founda-

tion, have rapidly increased around the

country.

So while hundreds of patient

navigation sites were developed, there

were no clear standards or deﬁnitions

for what patient navigation is. In other

Harold P. Freeman, MD, is an internationally recognized

authority on the interrelationships between race, poverty,

and cancer. In 2007 the Harold P. Freeman Patient Navigation

Institute was established to set and ensure standards for

patient navigation programs through an emphasis on the

navigation model developed by Dr. Freeman. In an interview,

Dr. Freeman shares his perspective on why patient navigation

remains a critical need in cancer care.

Q. Why do you think the use of

patient navigators is becoming

more prevalent?

A. Patient navigation is an important

concept. The American healthcare sys-

tem is fragmented. Many Americans,

especially the poor and uninsured, meet

barriers to receiving timely diagnosis

and treatment of cancer. Patient naviga-

tion programs are becoming more prev-

alent because patient navigators serve

to eliminate barriers to timely diagnosis

and treatment.

Secondly, I think the larger issue is

that there are an estimated 45 million

uninsured in America and an additional

25 million American citizens who are

underinsured and, therefore, may not

be able to pay for treatment. Healthcare

is the number one cause of bankruptcy

in America.

And thirdly, if you look at 32 mil-

lion American people on Medicaid,

a study published just a few months

ago by the American Cancer Society

showed that people on Medicaid have

no better cancer outcome as measured

by survival and mortality compared to

people that are uninsured. So when you

put together the 45 million uninsured,

the 25 million underinsured, and add

the 32 million on Medicaid—just those

categories alone add up to 100 million

people who are likely to have severe

challenges when they attempt to enter

the healthcare system. That’s one-third

of the American people.

The problem is very large and

the issue is that in communities these

people who have these barriers must

S6 ACCC’s CanCer Care Patient navigation: A CAll to ACtion

words, the term patient navigation is

being used in many ways. We saw the

need to try to create some standards

of patient navigation that people could

at least compare to or with the hun-

dreds of sites that were developing.

And these sites were developing in

very different ways throughout the

country—sometimes concentrating

on other elements such as diagnosis

and/or treatment.

We saw the need for creating

an institute that could deﬁne patient

navigation and create standards and a

certiﬁcation process for people who

were trained in the patient navigation

program concept as it was developed in

1990 and which we now have 19 years

experience with. And that was the

impetus for the creation of the Patient

Navigation Institute which has been

funded by a leadership grant from the

Amgen Foundation.

Q. What are the goals of the

Institute?

A. There are two goals: One is to set

and ensure standards for patient navi-

gation programs through an emphasis

on the Patient Navigation Model that

I initiated in 1990. A second goal is to

help others learn best patient navigation

practices by creating a national data-

base for the collection, analysis, and

dissemination of information on best

navigation practices.

Q. Can you brieﬂy describe the

Institute’s navigation training

program?

A. It’s a three-day training course

that we give usually once a month.

We have developed training mod-

ules for the course. I generally start

off the course with an Introduction

Module about the origins and evolu-

tion of patient navigation. Then we

have a module on how to create a

patient navigation program; a mod-

ule related to cultural sensitivity and

cultural issues; and a module on the

[patient navigation] database—how

it’s been formed, and suggestions for

how participants can create their own

database.

Part of the training is done with

our navigators at the Ralph Lauren

Center. We have developed a program

in which navigation is carried out

by four navigators each of whom is

responsible for a particular phase of

navigation:

1) Outreach navigator

2) Diagnostic navigator

3) Treatment navigator

4) Financial navigator.

These navigators are in close commu-

nication with each other in the manage-

ment of a given patient.

For the Institute’s training pro-

gram, all of these navigators come

in and talk about their role in patient

navigation. The idea is that there is a

continuity that should take place for

patients. It begins in the community

where they live to get them into the

center where the test is done—that’s

called outreach navigation. Then, at

the point of an abnormal ﬁnding, the

diagnostic navigator takes the patient

through the point of diagnosis and the

ﬁnding of cancer or no cancer. At this

point, we have a treatment navigator

to work with the patient through all the

forms of treatment. And ﬁnally, as a

sort of consultant to these navigators

is a ﬁnancial navigator whose work is

to make sure that the patient has

ﬁnancial coverage.

Q. How many navigators have

been trained to date?

A. Since we started the ﬁrst

Navigation Training Course in January

2008, we have trained 181 naviga-

tors from 85 institutions in 33 states,

including Alaska and Hawaii. In addi-

tion, some trainees have come from

the Caribbean and parts of Europe.

Q. And the Institute is still

accepting applications?

A. Yes. We encourage people to

apply and they can apply through our

website (www.hpfreemanpni.org). The

course gives the total picture of how

patient navigation developed, and, with

this much experience, we’ve developed

navigation to a pretty sophisticated level

at this point.

One thing to point out is that the

concept of navigation has to do with

addressing the entire continuity and

movement of the patient through

the system from the community to

the healthcare site and ensuring that

patients get the tests they need, such

as a mammogram, to ensure that

any abnormal ﬁndings will be rapidly

resolved. Timeliness is a very critical

part of navigation. And then to assure

that anyone who has cancer will get

rapidly treated by all modalities.

So navigation encompasses the

concept of continuity from the commu-

nity to the healthcare setting to getting

the test, having the ﬁnding, and getting

the patient all the way through treat-

ment. Now the navigator in our concept

is the only person in the healthcare sys-

tem whose job it is to watch and guide

and assist the patient through this entire

continuum. In other words, the naviga-

tor’s job is to see the entire movement

of the patient across disciplines. One

of the problems in medicine is that

we have excellent areas—excellent

surgeons, excellent radiation depart-

ments—but the patient doesn’t easily

pass through one part into another.

So we are working across disciplines

that have to be bridged through this

navigation.

Q. So the training provided at

the Institute can help bridge these

challenges?

A. Yes. We’ve found that the four

principal barriers patients face are:

1. Financial barriers—no insurance

or not enough insurance, or lack of

ability to pay for transportation, and

other costs related to cancer care.

2. Communication barriers—people

…the navigator’s job is to see the entire

movement of the patient across disciplines.

ACCC’s CanCer Care Patient navigation: A CAll to ACtion S7

if it’s cancer, it has to resolve with the

treatment of cancer.

We’re getting the sense from

talking to people around the country

that people are working on segments

of the navigation problem without the

full continuum of care in mind. If you

have cancer, it’s not over for you until

the cancer has been treated. We’re

seeing navigators that do parts of

navigation very effectively, but we are

teaching at the Institute that while it’s

okay to do whatever your part is, we

also have an obligation to connect the

whole system for the patient. So that’s

a very important navigation concept: to

open the case and to deﬁne when your

navigation begins and to close the case

and deﬁne when your navigation ends.

We believe, in cancer care, navigation

should end at the end of treatment.

And we have to develop survivor-

ship navigation support systems for

survivors who have recurrent disease of

special areas that need to be addressed

through special training. What I see is

that navigators in various sites around

the country are taking on parts of the

navigation process and not necessar-

ily connecting to the next action that

needs to be done for the patient. And

to use an analogy from surgery, it’s not

over until you close the case.

Q. Some programs begin

navigation services with a single

disease site, such as breast cancer.

Is it your sense that this is a good

way for programs to begin to work

with navigation services?

A. I think that is generally the way it

has been happening. My wish is that

navigation programs will cover all can-

cers. We would like to encourage insti-

tutions to navigate all cancer patients.

It would be better for society if patient

navigation programs were made avail-

able to eliminate barriers to diagnosis

and treatment of all cancers, as well

as to other chronic diseases such as

diabetes, heart disease, and psychiatric

and neurological conditions.

don’t really understand the medical

information that’s been communi-

cated to them.

3. Complexity of the healthcare sys-

tem—when people have to move

from a surgeon who says you need

a biopsy to medical clearance and

then back again, or from surgery to

chemotherapy—they get lost in the

system.

4. Barriers related to fear and distrust

and emotional issues.

Our navigators work with all of these

barriers. While we use lay navigators as

the principle navigators in our system,

we realize that there’s a role for naviga-

tors who are professionals, especially

social workers and nurses, to navigate

people at more complex points. For

example, if the lay navigator ﬁnds that

the person is experiencing social prob-

lems…then that navigator will refer the

patient to the social worker. Or when

patients with cancer have challenges

with respect to understanding the dis-

ease and the options for treatment, the

navigator will call in a nurse or an oncol-

ogy nurse to navigate those issues.

But we ﬁnd that the trained lay

navigator can eliminate many barriers

faced, particularly in poor communities.

These barriers include: lack of medical

insurance, under insurance, and how

to obtain various medical and support

services.

We believe there should be an

interconnection between the lay naviga-

tor and the professionally trained navi-

gator, such as a nurse or social worker,

and that they should be working

together to move the patient through

the treatment of cancer. This approach

is also cost-effective in that highly

trained healthcare professionals are

not spending time on work that can be

handled by non-clinical staff members,

such as a lay navigator.

I know there’s been debate about

the use of lay navigators versus the

use of clinical navigators, but I think we

need to work together on who should

navigate. I don’t like the idea of any

single group of people arguing that they

“own” navigation because that’s simply

not correct. There is room for

all kinds of people to be navigators. And

certainly, if navigation is going to be

cost-effective, part of it can be done by

lay navigators who are not clinical pro-

fessionals. We should concentrate on

what has to be done for the patient as

opposed to what we want to do in our

specialty. And if we do that, we soon

come to the realization that everybody

has a role in navigation. From the lay

person, the nurse, the social worker—

all the way through to administration,

it’s a team effort with everyone having

their eyes on what has to be done for

the patient as opposed to turf issues.

We should embrace the philoso-

phy that navigation is a continuum of

actions that need to be carried out for

our patients, and that at certain levels

these actions are relatively simple and

can be done by a lay navigator, but

as cancer treatment becomes more

complex in terms of social services

or clinical services, a clinically trained

navigator should step in. It’s important

that the navigation system is set up

so that the entire healthcare institution

will embrace this as an idea so that the

team can really work together rather

than have conﬂicts over turf.

Q. From your patient navigation

database do you have any emerging

best practice information you can

share?

A. It’s too early at this point. What

we are ﬁnding is that in sites around the

country people are concentrating on

segments of the navigation problem,

working with the screening part of navi-

gation for example. The concept we’re

teaching is that you have to initiate the

navigation at some point, whatever

your deﬁnition is for when that starts,

and then you have got to ﬁnish the

navigation. Close the case. The case

isn’t over until it’s over. In other words if

you have an abnormal ﬁnding, you have

to resolve this through diagnosis. And

…if navigation is going to be cost-effective, part

of it can be done by lay navigators who are not

clinical professionals.

S8 ACCC’s CanCer Care Patient navigation: A CAll to ACtion

GOALS AND CHALLENGES

1. Goals for navigation program:

2. Barriers/Challenges to navigation program:

OPERATIONS

1. Tumor types to be covered by navigation program:

2. Will each tumor type have its own navigation program or will one navigator cover more than one tumor type?

3. Do you have team(s) to set up program(s) by disease state(s)?

4. Timeline for implementation:

5. How many patients per year will participate in the navigation program?

6. What is your anticipated patient to navigator ratio?

7. How will you identify patients eligible for the program?

Pathology reports Inpatients MD referrals Surgical reports

Other ________________________________________________________________________________________________

8. What are the biggest challenges facing the patient that need to be addressed by the navigation program?

9. Where will the navigator(s) be housed?

10. What other space is allocated for the navigation program:

Patient library/education space Counseling rooms Other ofﬁces

Other ____________________________________________________________________________________________

11. How will program be funded?

Grants Patient pays Insurance

Other ____________________________________________________________________________________________

12. Will patients be charged for any part of the service?

13. Which salaries will be supported solely by program budget (navigator, administrative assistant, etc.)?

Patient Navigation Program

Pre-Assessment Tool

This pre-assessment tool can help you assess your organization and consider all aspects of a patient navigation

program. This tool can also help you assess your readiness for implementation or identify areas that need to be

addressed before rolling out a patient navigation program.

ACCC’s CanCer Care Patient navigation: A CAll to ACtion S9

14. Which salaries will be partially supported by program budget (social work, PT/OT, etc.)?

15. What else will budget be used for (patient education materials, journals, etc.)?

16. Do you have an electronic charting system?

17. How will you communicate between practitioners?

ROLE OF NAVIGATOR

18. Who do you see as the navigator in your program?

RN Social Worker Lay person/survivor

Other ________________________________________________________________________________________________

19. When would you like the navigator to become involved with the patient?

Prior to entering the healthcare system At time of screening

At time of suspicious ﬁnding At time of diagnosis

Other (please specify) _________________________________________________________________________________

20. What are the primary functions you would like the navigator to fulﬁll? Please rank them with 1 being the most important.

_____ Community education _____ Patient education _____ Care coordinator _____ Financial counselor

_____ Psychosocial counselor _____ Other (please specify) _________________________________________________

21. What other activities would you like the navigator to be involved in? Please rank them with 1 being the most important.

_____ QI/PI activities _____ Community _____ Educational programs _____ Screenings

_____ Staff educational programs _____ Survivorship program _____ Help set up program(s) by disease state(s)

_____ Other (please specify) _____________________________________________________________________________

RESOURCES

22. What resources do you currently have in place?

Case managers Social workers Registered dietitians Financial assistants

Genetic counselors Chaplain Health psychologists PT/OT

Speech therapy Home care services Hospice services Palliative care services

PT/OT Patient advisory committee

Support groups (specify) ________________________________________________________________________________

Other (please specify) __________________________________________________________________________________

23. Do you currently have relationships with community patient support agencies such as ACS or local support groups other

than hospital-based groups?

OTHER CONSIDERATIONS

24. Do you have an MD champion for patient navigation program?

25. Do MDs support the program? If not, will MDs need convincing of the need for a program?

26. Administration level support/commitment or lack of support/commitment?

27. What percentage of your population has?

Private health insurance ________________________

Medicare ____________________________________

Medicaid _____________________________________

No insurance _________________________________

28. What percentage of your population is?

African American _____________________________

Asian ________________________________________

Caucasian ____________________________________

Hispanic ______________________________________

Native American ______________________________

Other (please specify) _________________________

S10 ACCC’s CanCer Care Patient navigation: A CAll to ACtion

MultiCare Health System

is a community-based

healthcare organization

based in Tacoma,

Washington, that

includes four hospitals, a

multidiscipline physician

group, and various other

service lines. MultiCare

Regional Cancer Center

(MRCC) is a hospital-based

oncology practice consisting

of ﬁve medical oncology

practices and two radiation

oncology practices.

In 2005 MultiCare entered into a

ﬁve-year strategic planning pro-

cess for cancer services. At that

time the services delivered included

basic oncology services with very little

structure beyond physician, infusion,

and radiation services. Data gathered

through a survey of patients and fami-

lies revealed a signiﬁcant unmet need

related to the support patients received

throughout their treatments. Likewise,

a survey of staff at that time showed

considerable frustration expressed over

a lack of resources to provide patients

with much needed support beyond

basic cancer treatment. Based on this

survey data and as part of the strategic

planning process, we decided that

future programs would build on four

fundamental foundations:

1. Facilities

2. Providers

3. Technology

4. Patient support systems.

Putting the Team to Work

The strategic plan ultimately approved

by MultiCare’s Board of Directors

included the development of a Patient

Navigation Team. This team would be

charged with addressing the unmet

needs identiﬁed by patients and their

families. By early 2006, patient naviga-

tor job descriptions were developed

and the ﬁrst members of the Navigation

Team were hired.

MultiCare Regional Cancer Center

(MRCC) developed the concept and

structure of its Navigation Team by

drilling into the details of the patient

and staff surveys. The most commonly

identiﬁed needs were then bundled into

four categories:

1. Care management and coordination

2. Social and psychosocial support

3. Financial support and counseling

4. Nutritional support and education.

While multiple needs and issues

existed within each of these four cat-

egories, these fundamental patient

needs drove the decision to create

a multidisciplinary Navigation Team

versus the traditional pool of case

managers. By leveraging the focused

skills of each individual on the team, we

believed that cancer patients would be

better supported and that team mem-

bers would be more satisﬁed with

their work.

The ﬁrst three members of

MRCC’s Navigation Team were an RN

navigator, a social worker, and a patient

representative who provided ﬁnancial

assistance. While we initially requested

a larger Navigation Team, the model

was untested and hospital leadership

initially approved the smaller three-

person team. This approval came with

the expectation that Cancer Center

leadership would return in one year to

report on outcomes and conclusions

regarding continuation or expansion

of the navigation program. Speciﬁc

outcomes measures were identiﬁed,

including improved patient satisfaction

and increased patient volumes for the

Cancer Center.

Growing the Team

MRCC’s Navigation Team initially

focused on helping patients through the

Patient Navigation:

A Multidisciplinary Team Approach

by David Nicewonger, MHA

ﬁrst weeks of their cancer treatment.

The team’s motto: “Patients and fami-

lies should only have to focus on heal-

ing.” The Team’s goal: to take all of the

peripheral worries out of their patients

and families hands.

One of the Navigation Team’s ﬁrst

tasks was to conduct another survey

of new patients to obtain a baseline

score measuring how well supported

patients felt before the Team started its

work (see Figure 1, page S12-13). The

results of that survey became the deﬁn-

ing structure for the Navigation Team’s

work, and over the course of the ﬁrst

year, the survey was repeated for new

patients entering the program.

By the end of that ﬁrst year,

MRCC saw signiﬁcant improvements

in all but two areas: assistance making

and/or getting appointments with other

MultiCare departments and transporta-

tion issues. Furthermore, physicians in

the clinic and nurses in the infusion cen-

ters reported that the Navigation Team

allowed them to focus on direct patient

care rather than struggling with how to

address issues such as transportation

or ﬁnancial coverage. The Navigation

Team also maintained a log of patient

stories, documenting successful inter-

ventions and the impact on the lives of

patients entering cancer treatment.

At the end of the ﬁrst year, hospital

and cancer center leadership looked at

these ﬁndings and approved the addi-

tion of three new team members: a

second RN navigator, a second patient

representative, and a nutritionist. The

expanded Patient Navigation Team sup-

ported all patients who received care

at MRCC’s main campus but another

ongoing challenge remained: how could

the Navigation Team support staff and

patients at satellite clinics where patient

volumes were signiﬁcantly lower but

needs were just as important?

To help initially address this

challenge, we adopted a model that

combined the job functions of the RN

navigator with a clinic supervisor. In

small clinical operations, where the

supervisory demands are less signiﬁ-

ACCC’s CanCer Care Patient navigation: A CAll to ACtion S11

cant, this approach provided some navi-

gation support for the patients. Later, an

organizational focus on standardization

of care across all care locations led

to the approval of an additional social

worker and patient representative in the

next budget cycle. The expanded eight-

person Navigation Team was then able

to service all clinical locations.

Disease-site-speciﬁc Navigators

Another component of the original stra-

tegic plan was a focus on four primary

disease groups: 1) thoracic, 2) urologic,

3) breast, and 4) neurologic. While our

cancer program treats all cancer types,

the decision was made to focus on

these primary disease groups with the

eventual goal of becoming a center of

excellence in those areas. Over time

it was acknowledged that this goal

would be best achieved by having

disease-site-speciﬁc navigators. And

while the general navigators continued

to function in the clinics, these new

disease-focused navigators became

a key component in MRCC’s strategy

to develop a program of excellence for

each disease site.

The disease-site-speciﬁc naviga-

tors were expected to work not only

with the patient and family, but also to

serve as a direct liaison between the

cancer program and referring physicians

and surgeons. Our expectation was that

navigator services would be valued by

both patients and referring physicians;

therefore, providers would be more

likely to direct their patients to a Multi-

Care facility. Accordingly, we projected

substantial volume increases in cancer

services during our 2008 budget plan-

ning process.

So, in addition to the two general

RN navigators, our Navigation Team

would now include four disease-site-

speciﬁc navigators. While three of the

disease-site-speciﬁc navigators would

be RNs with an oncology background,

we decided to ﬁll the other position

with an ARNP who could provide

service at a different level. Under this

model, the ARNP navigator provides

PHOTOGRAPH COURTESY OF MULTICARE REGIONAL CANCER CENTER

9 Ways Patient Navigation Can Beneﬁt Your Cancer

Patients

1. Patient navigators become the initial contact point for all patients who come

into contact with the healthcare system. They remain an ongoing, consistent

point of contact for patients and families through the full continuum of their

care.

2. Patient navigators support patients as they move through different points of

the healthcare system, including hand-offs between inpatient and outpatient

settings, specialty consultations, research, hospice, and/or palliative care.

Smoother hand-offs across all phases of care translate into fewer delays in

treatment, improved communication between caregivers, and less confu-

sion for the patient and family.

3. Patient navigators provide valuable education to patients and families on a

variety of treatment, nutritional, ﬁnancial, or social issues.

4. Patient navigators can help decrease ER visits associated with complications

in care by identifying complications sooner and directing earlier interventions

at the clinical level.

5. Patient navigators link patients and families to community resources such

as transportation, housing assistance, ﬁnancial assistance, and/or support

groups.

6. Patient navigators optimize access to ﬁnancial resources to assist patients

and families with treatment-related costs, including drugs. This access is

particularly critical for indigent, uninsured, and under-insured patients.

7. Patient navigators offer emotional support to patients and families during

difﬁcult and stressful times.

8. Patient navigators can help match patients to potential research protocols.

9. Patient navigators can provide a valuable link between the cancer center and

the community physicians referring into the cancer center.

some direct patient care and works

directly with community physicians

and surgeons to provide support and

intervention on cases earlier—often

before the patient even enters the

actual oncology clinics. Some of the

services performed by our ARNP navi-

gator, such as ofﬁce visits for ongoing

care, are billable. And while the billable

charges do not fully support the ARNP

salary, the additional revenue stream is

enough to make up for the difference

between the salary of an ARNP versus

using an RN in the same position. With

an ARNP navigator, the level of connec-

tion and collaboration with surgeons

is enhanced. Again, our assumption is

that improving those relationships and

making the navigators indispensable to

community surgeons will foster loyalty

and increase patient volumes.

A True “Team” Effort

The multidisciplinary Navigation Team

model is working well at MRCC. Our

model is both cost effective and

MultiCare Regional Cancer Center’s multidisciplinary Navigation Team.

S12 ACCC’s CanCer Care Patient navigation: A CAll to ACtion

comprehensive in scope. In other

words, our multidisciplinary Naviga-

tion Team is more cost effective than

hiring only one discipline such as RNs.

Likewise, if the team consisted only

of social workers or volunteers, there

would be an absence of qualiﬁed exper-

tise to work through the complex medi-

cal issues associated with cancer care.

Instead, social workers are available to

address issues such as assistance with

transportation, linkages to community

support groups, or assisting in comple-

tion of documentation for enrollment in

alternative funding sources, freeing up

the RNs and ARNP to deal with issues

such as coordination of medical care

and patient education. Augmenting the

team with patient representatives to

offer ﬁnancial assistance has not only

helped our cancer patients, it has also

helped the cancer program by decreas-

ing payer denials and improving patient

access to funding alternatives.

While our patient navigation model

is still evolving, early indications are

that the program is a success. Look-

ing back at our outcome measures,

we have improved patient satisfaction

and increased patient volumes. In fact,

since the inception of the ﬁrst Naviga-

tion Team in 2006, the volume of cases

across all locations has increased more

than 30 percent. While it is difﬁcult—if

not impossible—to deﬁnitively cor-

relate these volume increases to the

work of the Navigation Team, when

coupled with the improvement in

1. A member of our staff informed you of the details of your

insurance coverage prior to the start of treatment.

2. I was contacted by an oncology clinic staff member prior

to my initial physician consult to answer any questions or

concerns.

3. I was given written information regarding my medications

and an opportunity to speak with the pharmacist.

4. My questions about my treatment plan and the potential

impact to my life were answered by the nurse.

5. I was given assistance making appointments and getting

appointments with other departments at MultiCare.

6. A dietitian was available to me to discuss nutrition and diet

during my treatment.

7. I was provided information about access to community

support services.

8. I had no transportation issues during my treatment.

0 20 40 60 80

100

2006

2007

37%

65%

Figure 1. Percentage of Patients Giving a Score of 4 on MRCCs Cancer Patient Survey*

0 20 40 60 80 100

2006

2007

50%

80%

0 20 40 60 80 100

2006

2007

95%

100%

0 20 40 60 80 100

2006

2007

85%

90%

0 20 40 60 80 100

2006

2007

89%

85%

0 20 40 60 80 100

2006

2007

37%

50%

0 20 40 60 80 100

2006

2007

42%

85%

0 20 40 60 80 100

2006

2007

55%

45%

continued on page S14

Patients asked to use 1-4 point scoring on all questions with 1= Disagree; 2= Somewhat Disagree; 3= Somewhat Agree;

and 4=Completely Agree.

ACCC’s CanCer Care Patient navigation: A CAll to ACtion S13

13. I understood potential side effects of my treatment and

how to manage them.

14. I understand when I need to call my physician.

15. All of my questions were answered understandably.

16. I know who to call when I have problems or questions.

9. My pain was monitored and managed during my

treatment.

10. My family was well supported by the clinic staff.

11. My quality of life was maintained through my treatment.

12. I knew what to expect through each stage of my care.

Practical Tips for Developing and Growing

a Patient Navigation Team

■ Start small. Although your needs may be great, consider

implementing a smaller navigation program with deﬁned

boundaries and objectives that can then be used as

benchmarks for success and justiﬁcation for program

expansion. It’s better to do a few program elements

successfully and use that success to validate expansion

than to allow the program to struggle with measurable

outcomes due to “scope creep.”

■ Use a multidisciplinary model. Bringing together RNs,

ARPNs, social workers, nutritionists, ﬁnancial counselors,

and other professionals can provide a depth of expertise

in a cost-effective manner. Clearly deﬁne roles for each

discipline on the team.

■ Survey your cancer patients. Conduct a baseline survey

of patient satisfaction administered prior to initiation of the

navigation program so that success can be measured and

reported to leadership.

■ Listen to your cancer patients. Keep a log of patient

success stories. These anecdotal accounts provide faces,

emotions, and reality to patient navigation beneﬁts that

are not easily quantiﬁed. These human interest success

stories help gain and sustain support for navigation

programs and services.

■ Control program growth. Evolving the program

structure and scope in small intervals with demonstrated

successes through each stage can garner conﬁdence and

support for continued expansion.

■ Expand the navigator role. Asking patient navigators to

liaise with your community referral base—patients and

referring physicians—can help increase patient volumes

and grow your navigation program.

■ Establish an advisory council. An advisory council of

providers, patients, and family members can help direct

the goals and work of your Navigation Team.

■ Set up a foundation to help fund the program. A

foundation can accept community donations and other

funds to pay for supplies, materials, and programs

associated with the work of your navigation team.

Figure 1. Percentage of Patients Giving a Score of 4 on MRCCs Cancer Patient Survey*

0 20 40 60 80 100

2006

2007

67%

100%

0 20 40 60 80 100

2006

2007

95%

100%

0 20 40 60 80 100

2006

2007

79%

85%

0 20 40 60 80 100

2006

2007

74%

80%

20 40 60 80 100

2006

2007

89%

95%

20 40 60 80 100

2006

2007

95%

20 40 60 80 100

2006

2007

79%

95%

20 40 60 80 100

2006

2007

85%

*The 2006 survey established a baseline before the initiation of the Navigation team.

S14 ACCC’s CanCer Care Patient navigation: A CAll to ACtion

patient satisfaction, it is reasonable to

assume that there is some correlation

between patient volumes and the

Navigation Team.

For example, preliminary ﬁndings

related to our lung cancer patients may

support the positive beneﬁts of disease-

site-speciﬁc navigation. The ARNP has

only been in the position for six months;

however, in that time there has been

a sudden and deﬁnite increase in lung

cancer patients entering the program.

Preliminary data for the past four months

show a 20 percent rise in referrals for

lung cancer, and the ARNP has had early

success developing close relationships

with the leading pulmonology and

cardiothoracic practices in the area.

Today, our Navigation Team con-

sists of six navigators (ﬁve RNs and

one ARNP). Four of these navigators

are disease-site-speciﬁc and two are

generalists who provide care manage-

ment support for those patients whose

cancer does not fall into one of the

four focused disease sites. The team

also includes two social workers, a

nutritionist, and three patient represen-

tatives. Our plan is to add an additional

nutritionist and an additional patient

representative in the next 12 months.

Collectively this multidisciplinary team

supports all cancer patients at ﬁve

clinic locations.

Lessons Learned

We are still working to understand the

appropriate workload for the Navigation

Team and the right mix of disciplines.

In addition, the Navigation Team’s work

continues to evolve; as one segment

of identiﬁed needs is addressed, more

needs are identiﬁed.

One critical decision made early in

the process was to deﬁne boundaries

for the Navigation Team to work within.

We communicated those boundaries

to physicians and other staff in an effort

to keep our Navigation Team focused.

Without clearly deﬁned boundaries,

“responsibility creep” can easily pull the

Navigation Team in so many directions

that team members cannot be effective

in their supportive roles and there will

be no measurable success points that

can then be used to help justify

expansion of the team. Even today,

with the expanded Navigation Team,

the deﬁnition of boundaries is crucial to

sustain focus and experience success.

Another important step taken

in the program’s early stages was

conducting the baseline survey of

patient satisfaction in key areas, and

then focusing the Navigation Team on

improving those speciﬁc indicators.

As success benchmarks are achieved

through patient satisfaction scores

or increased patient volumes and the

team is expanded, the boundaries can

likewise be expanded.

Our model is still evolving and being

reﬁned. The structure of MRCC’s Navi-

gation Team is deﬁned based on suc-

cess and continued unmet need as the

next iteration is taking shape. Figure 2

illustrates the direction that our program

appears to be taking. In addition to meet-

ing the support needs of patients and

driving patient volumes, another impor-

tant factor that comes into play is the

increasing shortage of oncology physi-

cians. With this new model, the disease-

site-speciﬁc ARNPs will continue to

liaise with referring physicians, but they

will also start to become responsible

for routine follow-up care of patients,

freeing the oncologist to focus his or

her expertise on initial consultations and

management of complex cases. In this

model the RNs, social workers, nutrition-

ists, and patient representatives continue

to play their supportive roles. This model

is still a concept, but in looking at the

unique contributions of the ARNP in our

current thoracic model it seems there

are advantages in patient care and care

delivery economies in moving toward

this next iteration.

Reﬂecting back over the evolution

of the Navigation Team, several key

actions contributed to the team’s

success, including:

■ Starting small

■ Using a multidisciplinary model

■ Surveying patients and listening to

what they had to say

■ Controlling program growth

■ Expanding the navigator role

■ Establishing a patient advisory coun-

cil and listening to their experiences

and advice in setting priorities and

identifying unmet support needs

■ Establishing a foundation to help

fund some of the resources of the

program.

For more information, see “Practical

Tips for Developing and Growing a

Patient Navigation Team” on page S13.

As 2007 survey results show,

MRCC’s Patient Navigation Team

has clearly beneﬁted our patients

and our cancer center. Today, we call

the navigation program at MultiCare

Regional Cancer a successful “work in

progress.” Our hope is that other com-

munity cancer centers can learn from

our program as we continue to evolve

to meet the needs of our patients, fami-

lies, physicians, staff, and community.

David Nicewonger, MHA, is Administra-

tor, Cancer Services Careline, MultiCare

Health Systems in Tacoma, Wash.

Figure 2. Possible Future Directions for Targeted Disease Group Navigation Teams

Research

Neurology

ARNP

Breast

ARNP

Urology

ARNP

RN Navigator

Medical Oncologists

Lung

ARNP

RN Navigator

Social Work

Patient Representatives/Financial Counselors

Nutrition

Administrative Support

ACCC’s CanCer Care Patient navigation: A CAll to ACtion S15

the many successes and contributions

navigation brought to comprehensive

cancer care and was successful in

championing the initiation of a patient

navigation program at Billings Clinic by

engaging senior leadership’s support

and relating program beneﬁts to poten-

tial effects on existing market share.

Our Navigation Model

Billings Clinic launched its patient

navigation program in 2003 with one

navigator. The model put patients at the

center of decision making; with patient

navigation to assist them as they

move through the cancer treatment

continuum (see Figure 1). Over the last

six years, the navigation program has

grown in an organized, phased manner

into today’s team of eight navigators

(see Figure 2). This phased approach

allowed Billings Clinic to build upon

incremental successes, expanding the

scope of the program with a focus on

navigating a majority of patients served

in our vast geographic service area (see

“Serving, the Underserved in the Last

Frontier, page S22). The overall goal

of our navigation program is to ensure

seamless and coordinated care among

the physicians, the diagnostic tests, and

the cancer treatments, while offering

education, support, and guidance to

help patients and families cope with

their challenges.

All of our patient navigators are

registered nurses with oncology experi-

ence. The navigator’s primary focus: to

provide one-on-one support and coor-

dination of services for cancer patients

and their families as they move through

the care pathway. Speciﬁcally, Billings

Clinic patient navigators:

■ Assess for clinical, emotional,

spiritual, psychosocial, ﬁnancial, and

other patient needs

■ Coordinate the timely scheduling of

tests, procedures, appointments,

and treatments

■ Help eliminate barriers to obtaining a

deﬁnitive diagnosis

■ Ensure patients receive a treatment

plan that is understandable and

feasible

■ Reinforce patient education and

direct patients and families to avail-

able resources and supportive

services

■ Facilitate access to clinical trials.

Phase I—2003

As stated above, our program started

with a 1.0 FTE patient navigator who

received referrals for patients requir-

ing complex coordination of care after

diagnosis and upon treatment initia-

tion. At the outset, the navigation

Patient Navigation at Billings Clinic

an NCI Community Cancer Centers Program (NCCCP) Pilot Site

by Karyl Blaseg, RN, MSN, OCN, BC

A cancer diagnosis often produces an overwhelming

emotional response, including feelings of shock, denial, fear,

anxiety, anger, grief, and/or depression. Because a multitude

of medical tests and consultations typically are needed to

determine a deﬁnitive diagnosis and course of treatment, a

cancer patient’s path through the healthcare system can be

complicated and confusing. Even worse, some patients may

not fully comprehend the importance of prompt evaluation

and treatment of their disease. To address these challenges,

more and more cancer programs are looking to assist patients

through this process. Here’s how Billings Clinic embarked on

its journey to create a care navigation program to meet the

unique needs of the people it serves.

hen medical

oncologist

Thomas

Purcell, MD, joined Billings Clinic in

2003, his vision was to create a regional

comprehensive cancer center designed

to be a premier destination facility char-

acterized by an interdisciplinary team

approach to cancer treatment. Based

on his previous experience with patient

navigation at the Sidney Kimmel Com-

prehensive Cancer Center at Johns

Hopkins, patient navigation was central

to this vision. Dr. Purcell had witnessed

The Billings Clinic disease-site-speciﬁc patient navigation program employs

eight RN navigators.

PHOTOGRAPH COURTESY OF BILLINGS CLINIC

S16 ACCC’s CanCer Care Patient navigation: A CAll to ACtion

program focused on two primary

areas. The ﬁrst goal: to establish an

understanding of navigation within

the Cancer Center among the medi-

cal oncologists, staff, and support

services. The second goal: to develop

standardized educational and support

materials for patients.

Phase II—2004

Phase II of the program brought a

second 1.0 FTE patient navigation posi-

tion to the team, as well as a clearer

focus on site-speciﬁc navigation. We

assigned each navigator two of the

most common cancer types—breast

and colorectal cancers and lung and

prostate cancers. At this point, it

SUPPORT DEPARTMENTS

SITE-SPECIFIC PROGRAMS

Breast

Gastrointestinal

Genitourinary

Thoracic

Dermatology

Gynecologic

Hematologic

Radiology

Pathology

Wellness

Center

Screening

Programs

Regional

Network

Community

Forums

Outreach

Clinics

Guest

Suites

COMMUNITY PROGRAMS

Cancer

Library

Cancer

Control Trials

Urology

General Surgery

OB/Gyn

Dermatology

ENT

Neurosurgery

Pulmonology

Quality of Life

Program

Cancer Care Navigation

CORE SERVICES

Radiation

Oncology

Medical

Oncology

Surgical

Oncology

Stem Cell

Transplant

Cancer

Research

Infusion

Center

Cancer

Wellness Center

Tumor

Boards

Tumor

Registry

Patient

and

Family

Figure 1. Billings Clinic Patient Navigation Model*

*This ﬁgure depicts patients as the center of decisions with patient navigation to assist them as they move through the cancer

treatment continuum rather than responsibility for coordination and communication between multiple disciplines and specialists being

left to the patient alone. ©Billings Clinic

We found that the mere presence of a patient navigator

on a consistent basis within these departments enhanced

communication, trust, and provider referrals for

navigation services.

ACCC’s CanCer Care Patient navigation: A CAll to ACtion S17

became important for navigators to

collaborate with other departments

within Billings Clinic, including Gastro-

enterology, Pathology, Primary Care,

Pulmonology, Radiology, Surgery, and

Urology. This ongoing collaboration

allowed us to:

■ Promote a better understanding of

patient navigation

■ Simplify referral and care processes

■ Identify system impediments to

timely and optimal cancer care.

We found that the mere presence of a

patient navigator on a consistent basis

within these departments enhanced

communication, trust, and provider

referrals for navigation services.

Phase III—2005

Two additional 1.0 FTE patient navigator

positions were added during phase III.

Each of the patient navigators assumed

primary responsibility for one major

cancer site (breast, colorectal, lung, and

prostate), with hematological cancers

distributed among three of the naviga-

tors due to the intense needs of these

patients. Major goals during phase III

included:

■ An increased focus on processes to

clarify role expectations

■ The development of a variety of

ﬂowcharts and ﬁshbone diagrams

(see Figures 3 and 4)

■ A navigator orientation manual to

ensure consistency among the

patient navigators.

Marketing and public relations promo-

tions continued to increase community

awareness of the program. In addition,

we designed and carried out a patient

satisfaction survey to obtain feedback

on the effectiveness of our navigation

program (see Figure 5).

Phase IV—2006

Phase IV of our patient navigation pro-

gram involved the largest expansion

yet—three additional 1.0 FTE patient

navigator positions. One navigator was

assigned to hematological malignan-

All navigated patients receive automatic refer-

rals to the dietitian, social worker, ﬁnancial

counselor, and multidisciplinary tumor confer-

ence. As appropriate, patients navigated will be

referred to:

■ Medication assistance programs

■ Subsidized programs

■ Support groups

■ Integrative medicine

■ Genetic counseling

■ Cancer research

■ Home health and/or hospice

■ Lymphedema program.

Some of the most common roles and

responsibilities of patient navigators

at Billings Clinic include:

■ Acting as the single point of

contact for patients and families,

including telephone triage regard-

ing symptom management

■ Accompanying patients to initial

appointments during diagnosis

and treatment planning period

■ Assessing patients’ physical,

emotional, psychosocial, spiritual,

and ﬁnancial needs

■ Initiating referrals (both internal as

well as connecting patients with

community resources)

■ Coordinating diagnostics, pro-

cedures, and specialist appoint-

ments

■ Providing patient education

■ Collaborating with physicians and

following up on multidisciplinary

tumor conference recommenda-

tions

■ Contributing to multidisciplinary

program development, such as

education materials, clinical

pathways, and quality studies.

Referrals

■ Breast (cancer)

■ Breast (diagnostic)

■ Gastrointestinal

■ Genitourinary, Head

and Neck, Sarcoma,

Skin

■ Gynecologic

■ Hematological

■ Lung, Neurological,

Unknown Primary

■ Regional

Current

Navigation

Assignments

Current Scope of Navigation Services

Figure 2: Evolution of patient navigation positions using

a phased approach

A Historical Perspective

2003 2004 2005 2006 2007 2008

S18 ACCC’s CanCer Care Patient navigation: A CAll to ACtion

cies, another to gynecologic cancers,

and the third focused on breast diag-

nostic navigation. Our program was

now seven navigators strong, with one

navigator assigned to the organization’s

Breast Center rather than the Cancer

Center. The breast diagnostic navigator

guides patients from abnormal mam-

mogram through diagnosis:

■ Ensuring timely scheduling of diag-

nostic procedures

■ Providing appropriate patient educa-

tion and support during procedures

■ Notifying patients promptly of diag-

nostic results.

Patients with a cancer diagnosis are

then transferred to the breast cancer

navigator who further coordinates ser-

vices related to treatment and survivor-

ship.

Major program efforts during

phase IV included the development and

advancement of multidisciplinary teams

led by physician leaders in collaboration

with the site-speciﬁc navigators for

breast, gastrointestinal, genitourinary,

gynecologic, hematological, and lung

cancers.

Expanding to seven navigators

allowed us to focus on establishing

meaningful program metrics. In addi-

tion, our physicians expressed a strong

desire to have a designated navigator

for all patients undergoing multimodal-

ity treatment. With this request, work

Figure 3: Care Navigation Referral Process

DischargeFollow-upSuspense FilePatient Contact

Referral IntakeReferral Sources

Call to

CN via

phone

or pager

monitors

activities

computer

several

times a

day

Physicians

- Primary Care

- Specialty Care

- Oncologist

Other Staff

- Office Staff

- Infusion Staff

- Case Managers

- Research Staff

Cerner

- Pathology

Reports

- Hospital Lists

Cerner

- Physician

Schedules

gathers

patient

data via

Cerner

or Mysis

(appointments,

diagnosis,

other)

Receive

referral?

CN schedules the

patient

appointment in

their calendar

Assemble

Guidebook

Yes

CN monitors

appointments

in Mysis and

attempts to

decipher type

of appointment

Patient is placed

on the “patient

suspense list” — CN

to watch for future

activity

Patient has future

appointment?

Patient is placed on

active list and note is

placed on CN calendar

for follow-up with

physician

Yes

Physician

approves CN

visit?

Attend

appointment —

Provide education

and assess for

other needs

Patient requires

referral to Social Work,

Dietary, or other?

Consult completed

Yes

Documentation

and all other

follow-up is

completed for 2-6

months as needed

Patient discharged

Continue to

monitor

patient as

needed

Referred to

patient?

Yes

©Billings Clinic

ACCC’s CanCer Care Patient navigation: A CAll to ACtion S19

began on establishing a patient acuity

system whereby navigation assign-

ments could be determined based on

estimated workload rather than mere

navigator-to-patient ratios. One lesson

learned throughout the previous three

phases of program implementation

was that patients’ needs varied widely

based on tumor site, stage at diagnosis,

treatment(s) chosen, and existing sup-

port systems. Because of these vari-

ables, we felt that distributing the vari-

ous tumor sites based on volume alone

was unrealistic. Instead, we completed

a workload analysis and deﬁned seven

different acuity levels (see Figure 6).

Next, we evaluated the previous

year’s cancer registry data, including

number of cancer cases by type and

stage. In consultation with the patient

navigators, we matched deﬁned acuity

levels with the various stages of dis-

ease by tumor site. Then an acuity cal-

culation was created (volume multiplied

by acuity level = estimated workload).

While the acuity system was not scien-

tiﬁcally validated, it served as an effec-

tive mechanism to distribute the various

tumor sites so that all patients undergo-

ing multimodality treatment could be

assigned a patient navigator.

Phase V—2007

In 2007 Billings Clinic was one of

ten organizations across the United

States chosen to participate in the

DischargeFollow-upSuspense FilePatient Contact

Referral IntakeReferral Sources

Call to

CN via

phone

or pager

monitors

activities

computer

several

times a

day

Physicians

- Primary Care

- Specialty Care

- Oncologist

Other Staff

- Office Staff

- Infusion Staff

- Case Managers

- Research Staff

Cerner

- Pathology

Reports

- Hospital Lists

Cerner

- Physician

Schedules

gathers

patient

data via

Cerner

or Mysis

(appointments,

diagnosis,

other)

Receive

referral?

CN schedules the

patient

appointment in

their calendar

Assemble

Guidebook

Yes

CN monitors

appointments

in Mysis and

attempts to

decipher type

of appointment

Patient is placed

on the “patient

suspense list” — CN

to watch for future

activity

Patient has future

appointment?

Patient is placed on

active list and note is

placed on CN calendar

for follow-up with

physician

Yes

Physician

approves CN

visit?

Attend

appointment —

Provide education

and assess for

other needs

Patient requires

referral to Social Work,

Dietary, or other?

Consult completed

Yes

Documentation

and all other

follow-up is

completed for 2-6

months as needed

Patient discharged

Continue to

monitor

patient as

needed

Referred to

patient?

Yes

S20 ACCC’s CanCer Care Patient navigation: A CAll to ACtion

National Cancer Institute’s (NCI’s)

Community Cancer Centers Program

(NCCCP) three-year pilot project. As

part of this pilot, Billings Clinic Cancer

Center added a regional navigator to

assess the rural and frontier regions

served through the extensive oncol-

ogy outreach program. This navigator

advocates for the individuals in those

regions and identiﬁes the needs of

those cancer patients. A signiﬁcant

portion of the regional navigator’s time

involves traveling and relationship-

building through face-to-face interac-

tions with community physicians,

agencies, and organizations. As a

result of this networking, the regional

navigator has hosted two navigator

training programs for individuals who

recently assumed patient navigator

roles within their own organizations

in the region. The regional navigator

also helps connect patients with local

resources and collaborates with com-

munity-health ofﬁces and tribal leaders

to promote community education and

increase prevention awareness and

early-detection screening programs

(e.g., mammograms, Pap smears,

fecal immunohistochemical testing,

and prostate speciﬁc antigen screen-

ing) in the rural and frontier regions. To

date, seven Cancer 101 programs have

Well cared for and

satisfied cancer patient

Financial Counselor

Social Worker

Treatment Nurses

Office LPN

Physicians

Care Navigator

Other

Licensed Counselor

Assess/Order

Manage Patient Care

Clinic Flow

Physician

Schedule

Tests

Room

Patients

Medication

Refill

Office

Communication

Phone

Triage

Financial

Assessment

Financial

Counseling

Payment

Schedule

& Follow-up

Coordinate

Specialist

Appointments

Ca Patient

Education

Follow-up on

Tumor Board

Recommendations

Refer Patient to

Tumor Board

Single Patient

Contact for

Entire Tx Course

Telephone

Triage

(Symptom

Complex Care)

Communication/

Outreach

Resource

Multidisciplinary

Program

Development

(Pathways, Education,

Quality Studies)

Support Groups

(General, IP,

Hope for

Tomorrow)

Intake Assessment

(Financial Screening,

Social Support,

Emotional State,

Community Resources)

Counseling

Evaluation

(Refer as

needed)

Placement

(LTC, Assisted

Living, Temporary

Housing)

Ca Patient

Education

Treatment

Delivery

Therapeutic

Counseling

Management,

Figure 4: Multidiscplinary Cancer Patient Care

©Billings Clinic

ACCC’s CanCer Care Patient navigation: A CAll to ACtion S21

been offered to Native American com-

munities in Montana and Wyoming.

During this phase, patient naviga-

tors looked again at program quality

metrics. Previously metrics had focused

largely on patient satisfaction and pro-

gram volume, including the number of

new patients navigated by cancer type

and referrals initiated. Now, we began

to evaluate additional data related to

timeliness of care (time from abnormal

ﬁnding to diagnosis and time from

diagnosis to treatment initiation) and

appropriateness of care (compliance

with clinical pathways).

Phase VI—2008

For the ﬁrst time since we initiated

the patient navigation program, no

additional positions were added during

2008. However, program enhance-

ments throughout the year included:

■ Developing an electronic version

of the patient navigation intake

worksheet

■ Reﬁning existing electronic docu-

mentation templates

■ Successfully launching a multidisci-

plinary lung clinic coordinated by the

lung patient navigator in collabora-

tion with pulmonologists, thoracic

surgeons, medical oncologists, and

radiation oncologists

■ Planning for two additional multidis-

ciplinary clinics (rectal and prostate).

The success of the program has led

other clinical departments to request

information regarding the development

of patient navigation programs for other

chronic diseases.

Future Directions

Upcoming endeavors for patient

navigation at Billings Clinic include the

implementation of two additional multi-

disciplinary clinics (rectal and prostate),

which will be coordinated by the site-

speciﬁc navigators in collaboration with

involved physician specialties. In addi-

tion, each multidisciplinary program

will establish ongoing quality measures

that span the continuum of care for

breast, colorectal, lung, prostate,

Well cared for and

satisfied cancer patient

Financial Counselor

Social Worker

Treatment Nurses

Office LPN

Physicians

Care Navigator

Other

Licensed Counselor

Assess/Order

Manage Patient Care

Clinic Flow

Physician

Schedule

Tests

Room

Patients

Medication

Refill

Office

Communication

Phone

Triage

Financial

Assessment

Financial

Counseling

Payment

Schedule

& Follow-up

Coordinate

Specialist

Appointments

Ca Patient

Education

Follow-up on

Tumor Board

Recommendations

Refer Patient to

Tumor Board

Single Patient

Contact for

Entire Tx Course

Telephone

Triage

(Symptom

Complex Care)

Communication/

Outreach

Resource

Multidisciplinary

Program

Development

(Pathways, Education,

Quality Studies)

Support Groups

(General, IP,

Hope for

Tomorrow)

Intake Assessment

(Financial Screening,

Social Support,

Emotional State,

Community Resources)

Counseling

Evaluation

(Refer as

needed)

Placement

(LTC, Assisted

Living, Temporary

Housing)

Ca Patient

Education

Treatment

Delivery

Therapeutic

Counseling

Management,

…we began to

evaluate additional

data related to

timeliness of care…

and appropriateness

of care…

continued on page S24

S22 ACCC’s CanCer Care Patient navigation: A CAll to ACtion

Signiﬁcant healthcare disparities exist in the region served

by Billings Clinic Cancer Center, a vast geographic area of

207,000 square miles encompassing the state of Mon-

tana, the northern half of Wyoming, and the western edge

of North Dakota. This service area is 33 percent larger than

the entire state of California, with a population of approxi-

mately 1.25 million people (compared to over 33 million in

California). A lack of access to primary care physicians is a

well-known characteristic of the region with approximately

87 percent of Montana counties (some as large as entire

states) designated as Health Professional Shortage Areas,

Medically Underserved Areas, and/or Physician Scarcity

Areas.

Cancer rates are driven by a complex set of social,

economic, cultural, and health system factors. The lack of

local medical care, including cancer prevention information

and screening, affects the stage at the time of cancer

diagnosis—an important predictor of the outcome of

treatment. Between 2002 and 2006, less than half of all

cancers (48 percent) in Montana were diagnosed at the

local stage. Twenty percent of all cancers diagnosed were

regional and 22 percent were diagnosed at a distant, or

metastasized, stage.

Regionally, Billings Clinic has long been dedicated

to working collaboratively with communities to address

healthcare disparities in remote and frontier areas. Each

month, the Billings Clinic Cancer Center provides 21

outreach clinics in 9 rural communities (see map below).

References

Montana Central Tumor Registry. (2008). Cancer in Montana

2002-2006: Montana Central Tumor Registry Annual Report.

(Montana Department of Public Health and Human Services).

Helena, MT.

Serving the Underserved in the Last Frontier

ACCC’s CanCer Care Patient navigation: A CAll to ACtion S23

Bladder

Breast

Cervical

CNS

Colon & Rectum

Esophageal

Head & Neck

Leukemia

Lymphoma

Lung & Bronchus

Melanoma/Skin

Peritoneal

Myeloma

Ovarian/Primary

Pancreatic

Prostate

Renal

Sarcoma

Testicular

Uterine

Other: _______

_____________

Male Female

< 35

35-44

45-54

55-64

65-74

> 75

Patient Name:

Gender:

Age:

____________________________

Navigator Name:

Cancer Type:

____________________________

Care Navigator Feedback Section

Directions: In the section below, Care Navigators will enter scores based on their perceptions

of the service quality offered during this treatment plan.

Yes No N/A

Patient had quick, seamless access to cancer services.

I was allowed an appropriate level of involvement in patient care.

The identified clinical plan of care (clinical guidelines) was initiated and followed.

Special Notes:

Patient Feedback Section

Directions: In the section below, scores will be reported

by patients during telephone follow-up.

Phone number: ___________________________

My cancer care was provided in a timely fashion.

My care navigator helped me develop my unique treatment plan.

My care navigator was important in ensuring seamless care between different

areas of the clinic.

My care navigator coordinated my care to meet my unique needs.

My care navigator answered my questions in a manner I could easily

understand.

Hello. My name is ______ with Billings Clinic. Is ____________available? I am calling on behalf of the Cancer Center and would

like to ask a few brief questions with regard to the care you received. Is this a good time for you? I have 5 statements and

I would like you to respond to each statement with a number indicating your agreement. A low number would indicate you

disagree with the statement I have read, whereas a high number indicates your agreement. I will begin if you are ready.

Date/Time of All Attempts Staff Signature

Thank you for taking the time to respond to these questions. Your input is very important so that we can offer

the best possible care. Have a nice day!

Was there any additional information or education that would have been beneficial for your care

navigator to give you?

Do you have any comments you would like to make?

____________________________ _________________________________________________________________________

1 2 3 4 5 6 7 8 9 10

Figure 5: Billings Clinic Cancer Center Care Navigation Survey

©Billings Clinic

S24 ACCC’s CanCer Care Patient navigation: A CAll to ACtion

hematological, and gynecologic can-

cers. The navigators will monitor and

report on the measures quarterly by

using a clinical quality dashboard. Lastly,

given the success of patient navigation

within the Cancer Center at Billings

Clinic and the recent interest expressed

by other service lines, it would not be

surprising if patient navigation programs

for other chronic diseases emerged

over the next year.

In summary, patient navigation

is integral to the interdisciplinary team

approach to cancer treatment that

Billings Clinic proudly endorses. It has

become the link that integrates every

aspect of patient care through the facili-

tation of timely communication, seam-

less patient ﬂow, and optimal clinical

outcomes.

Karyl Blaseg, RN, MSN, OCN, BC, is

manager of cancer programs at the

Billings Clinic in Billings, Montana.

[Patient navigation] has become the link that

integrates every aspect of patient care…

Acuity Scale Description

0 No navigation

0.5 Meet patient if referral received;

Initial guidance/education/coordination as needed;

Typically no follow-up required

1 Meet patients upon diagnosis;

Initial guidance/education/coordination;

Typically no follow-up required

1.5 Meet patient upon diagnosis;

Coordination of multi-modality treatment;

Typically ongoing guidance/education for 3-4 months;

2 Meet patients upon diagnosis;

Coordination of multi-modality treatment;

Moderate intensity of needs;

Typically ongoing guidance/education for 5-6 months or more

2.5 Meet patients upon diagnosis;

Coordination of multi-modality treatment;

High intensity of needs, often inpatient hospitalizations associated with care

Typically ongoing guidance/education for 6-12 months or more

4 Meets patient upon diagnosis;

Coordination of multi-modality treatment;

High intensity of needs, often associated with care coordination outside of facility;

Typically ongoing guidance/education for 6-12 months or more

Figure 6: Patient Navigation Acuity Scale

©Billings Clinic

ACCC’s CanCer Care Patient navigation: A CAll to ACtion S25

Good Samaritan Hospital is a

232-bed community hospital

serving a 15-county area in

both Indiana and Illinois. We

opened our new Cancer

Pavilion in April 2008.

state-of-the-art

facility designed

to bring all of our

cancer patient services under one roof,

the completion of the Cancer Pavilion

fulﬁlled the “bricks and mortar” portion

of our strategic plan. Next we focused

on expanding our existing patient sup-

port services. These included social

services, dietary counseling, patient

support groups, ﬁnancial counseling,

rehabilitation, pastoral care, and two

certiﬁed RN breast health navigators.

Our plan to increase patient support ser-

vices included growth on several fronts:

■ Hiring a patient support specialist to

assist with insurance authorizations.

This staff member will also help

patients apply to drug replacement

programs as well as organizations

that assist with co-pays.

■ Adding a dedicated social worker in

the outpatient setting to help grow

our offering of support groups and

build a survivorship program.

■ Expanding the use of patient naviga-

tors across the service line.

If you are a community hospital similar

in size to our facility, you may face the

same challenges that we do. You have

a dedicated, well-educated staff, as

well as varied support services, but you

lack a formal program to ensure that all

patients are getting the information and

support that they deserve.

Patient navigation has been a

growing force in cancer care since the

ground-breaking work by Harold P.

Freeman, MD. Patient navigators

can serve as compassionate, effec-

tive “guides” to

help patients move

through the complexi-

ties of the healthcare

system. While that

is exactly what

we wanted for our

patients, we did not

have the luxury of a

hospital-funded FTE

to devote to the proj-

ect. Our ﬁrst thought

was to write a grant,

but our experience

has shown us that

you have better suc-

cess being funded

when you have a

well-deﬁned program

prior to submitting

a grant. Our solu-

tion was to implement a scaled-down

patient navigation program within our

existing structure. This smaller program

would be just the ﬁrst step toward

establishing a fully developed, com-

prehensive Patient Navigator Program

in our facility. Below is a description of

the eight-step process we devised as a

road map to navigate toward success.

Step 1: Analyze the Role of the

Patient Navigator

Analyzing the patient navigator role

allowed us to identify key functions

we could realistically take on with our

existing staff. Our goal: to successfully

incorporate as much of the navigator

role into our program as possible, while

documenting its effectiveness. We

believed these actions would best pre-

pare us for submitting grant applications

in the future. And procuring grant funds

for a full-time patient navigator would

serve to fully expand the role and be a

bridge to eventually having a hospital-

funded FTE navigator position.

Patient navigator key time points

are:

■ Connecting individuals to screening

■ Following patients post-screening

■ Assisting patients through treatment

■ Providing support to survivors.

Even in a limited capacity, if applied to

speciﬁc key time points, our patient

navigators could achieve the most basic

functions which are:

■ To eliminate barriers to care

■ To ensure timely delivery of

services

■ To save lives from cancer

■ To improve patient satisfaction.

Step 2: Identify Our Existing

Strengths

Our program already had in place a

number of components that would

support a navigation program including

an established breast health navigator,

a physician champion, certiﬁed staff,

existing support services, and

accreditations.

Established breast health

navigators. Our Breast Care Center

has a well-established patient naviga-

tion program, a huge advantage to

our facility. Approximately 80 analytic

breast cancer cases are accessioned

by our registry each year. In 2006

Good Samaritan Hospital established

the Breast Care Center to provide

comprehensive care to those patients

who present with a positive diagnosis

as a result of screening. As part of this

program, Traci Hill, RN, received training

Growing Your Patient

Navigation Program

A step-by-step guide for community cancer centers

by Joann Zeller, MBA, RTT, CTR

Traci Hill, RN, (left) is one of two certiﬁed breast health

navigators at Good Samaritan Hospital’s Breast Care

Center.

PHOTOGRAPH COURTESY OF GOOD SAMARITAN HOSPITAL, VINCENNES, IND.

S26 ACCC’s CanCer Care Patient navigation: A CAll to ACtion

to become a Certiﬁed Breast Health

Navigator (CBHN). She completed a

40-hour comprehensive training pro-

gram on all aspects of patient naviga-

tion for breast cancer patients through

EduCare, Inc., and received certiﬁca-

tion. A second nurse, Cindy Mouzin,

RN, was also sent for breast health

navigator training and certiﬁcation. She

now assists on all biopsies in the mam-

mography portion of the Breast Care

Center. Together these two nurses pro-

vide complete navigation services for all

of our breast cancer patients.

Physician champion. We have a

strong physician champion for patient

navigation at our facility. Even better,

we did not have to look for a cham-

pion—he came to us. Kurt Maddock,

MD, is a breast surgeon and medical

director of our Cancer Program. He

championed the CBHN training for the

nurses in the Breast Care Center. As a

strong advocate for patient navigation,

we have his full support as we expand

patient navigation across the cancer

service line.

Certiﬁed staff. The majority of

our nurses are ONS certiﬁed. As stated

above, our Breast Health Navigators are

also certiﬁed. Our nurses have com-

pleted the Certiﬁed Breast Care Nurse

(CBCN) courses offered by the Oncol-

ogy Nursing Society (ONS) and will be

sitting for the exam in the spring. To

date, we have not pursued any general

patient navigation certiﬁcations.

Existing support services. Our

cancer center already provides the fol-

lowing supportive care services to our

cancer patients: social services, dietary

counseling, patient support groups,

ﬁnancial counseling, rehabilitation, and

pastoral care.

Facility accreditations. Our

cancer program has received several

accreditations including: JCAHO;

ACoS, American College of Surgeons

CHCP; Magnet status (this speaks to

the dedication of our nurses and our

hospital’s support of the continuum of

care for the patient); and designation as

a Breast Imaging Center of Excellence

(BICOE) through the American College

of Radiology (ACR).

Step 3: Identify Our Challenges

as a Community Hospital

Our cancer center faced several

challenges to implementing patient

navigation. For example, our screening

programs take place across the com-

munity and are not centralized through

our hospital.

Another challenge: all of the patient

services listed under our strengths are

shared services within the hospital. In

other words, they are not immediately

available to outpatients without sched-

uling an appointment.

We also faced stafﬁng issues.

Speciﬁcally, our current RN FTEs have

limited hours to ﬁll the role of Patient

Navigator.

We saw a lack of an ofﬁcial sur-

vivorship program as another barrier.

(Developing a survivorship program is a

cancer program goal for 2009.)

Step 4: Develop the Bones of Our

Navigation Program

Now it was time to develop policies and

procedures to formalize our navigation

process. We started by looking at the

number of patients who were going to

use our navigation services each year.

Our literature search revealed an

effective navigation ratio of 1 FTE for 25

to 30 patients under treatment and 75

to 80 post-treatment. Our cancer center

treats approximately 50 patients a day

and has 450 analytic cases per year.

We have 7 oncology nurses and 2 certi-

ﬁed breast health navigators. Of our

analytic cases per year, 80 are breast

cancer patients. The remaining cases

divide into approximately 50 cases per

nurse. These cases are a combination

of patients undergoing treatment and

those in follow-up. The simple rule of

thumb at our facility is the ﬁrst nurse to

communicate with the patient becomes

that patient’s navigator. This approach

works for us because all of our nurses

are scheduled in the same work areas

with the same rotating duties. No one is

speciﬁcally assigned to education or to

patients experiencing chemotherapy or

radiation therapy for the ﬁrst time.

Prior to initiating the navigator role

(beyond the breast care center) we

met several times with our nurses to

discuss what the change would mean

to our patients, how best to manage

the process, and what documents they

thought would be worthwhile. We

wanted to give patients an easy way to

organize their papers and keep track of

smaller forms as they moved through

the healthcare system. Everyone

agreed to use an expandable ﬁle folder

with a fold-over top to hold the forms.

The folder had a place for the patient

navigator’s card, as well as a card

for the managing physician. We also

included an insert for other business

cards that patients invariably receive

during ofﬁce visits. After selecting a ﬁle

folder with 12 expandable pockets, we

organized the educational information

under ﬁve headings:

1. Intake Forms. This section includes

forms for the initial entry into the pro-

gram: Intake Form, Identiﬁcation of

Barriers to Care, and a Weekly Con-

tact Record. Our tools were based

on templates provided through

EduCare, Inc., and the Pﬁzer patient

navigation toolkit, which is available

online at www.patientnavigation.

com. Using the information from the

intake form, navigators can make

appointments for patients based on

their self-identiﬁed needs. These

can include dietary, rehabilitation,

nutrition, ﬁnancial, and assistance

from our Patient Support Specialist.

2. Medication Record. This record

is fully reconciled with the patient’s

hospital medication record.

3. Patient Support Services. We

include ﬂyers for our American

Cancer Society (ACS) support

groups, as well as information on

our Resource Library and Boutique,

which offers free wigs, hats, and

mastectomy bras.

4. Insurance. This information is gen-

erated at patient registration, but we

ACCC’s CanCer Care Patient navigation: A CAll to ACtion S27

found that having a copy in the folder

has been helpful to patients as they

make their various ofﬁce visits.

5. Demographics. This information is

also generated at patient registra-

tion. And again, patients have found

it helpful to have a copy in their

folder as they make their ofﬁce

visits. Our demographic form

contains basic information such

as address, next of kin, insurance

information, etc.

6. Education. We do not pre-load this

portion of the ﬁle folder. Instead, the

information is speciﬁc to the patient

and his or her disease process. The

navigators believe it is important to

ﬁrst review the information with the

patient prior to putting it into the ﬁle

folder.

Our hope is that patients view the ﬁle

folder and all of its documents as their

own “tool box.”

Step 5: Initiate the Navigator

Role

Once the formal processes and tools

were in place, it was time to educate

the community about our new naviga-

tion program. Our patient navigation

service is featured on hospital and

cancer center brochures, on the hos-

pital’s website, and on ﬂyers available

in the cancer center’s resource area.

The most effective communication,

however, is from our navigators them-

selves when they ﬁrst see the patient.

When we have fully expanded our

program and incorporated navigation

services at the most basic screening

level, we anticipate a full marketing

campaign to include our regional

physicians.

Step 6: Measure Program

Effectiveness

Our Cancer Program has an ongoing

process improvement initiative that

tracks our current compliance rate with

the American College of Surgeons

R NCDB studies. Beginning in

2009, ACoS requires accredited facili-

ties to not only report compliance rates

to their own Cancer Committee but

also to set benchmarks and establish

plans to address low performance

rates. Our facility went one step further

and is now reporting current data four

to six months out. We felt this was

important because the online NCDB

data reﬂect 2006 data with 2007 soon

to follow.

The navigators are all well-versed

on the CP

R studies and the qualiﬁ-

cations for the patient subsets. We

felt this was an ideal way to use and

measure the patient navigator skill set.

If navigators know up front that the

patients’ disease and stage qualiﬁes

them to be included in a study, they

can be proactive in watching for the

appropriate appointments for specialty

consultations. More importantly, the

navigators can make sure that the

patient follows through on these

appointments.

The resulting data on performance

rates are tracked by our quality depart-

ment and reported to the Cancer Com-

mittee six times a year.

Step 7: Apply for Grant Funding

The Patient Navigator Outreach and

Chronic Disease Prevention Act of

2005 (The Patient Navigator Act) was

signed into law on June 29, 2005.

This Act authorized $2 million in FY

2006, $5 million for FY 2007, $7 mil-

lion for FY 2008, $6.5 million for FY

2009, and $3.5 million for FY 2010 to

the Health Resources and Services

Administration (HRSA) to provide

grants to eligible entities. The grants

are to recruit, assign, train, and employ

patient navigators who have direct

knowledge of the communities they

serve to facilitate the care and improve

healthcare outcomes for individuals

with cancer or chronic disease. This

legislation has increased both aware-

ness of patient navigation and the

number of available grants. Your local

libraries may be an additional resource

if they have user passwords to speciﬁc

grant writing websites such as www.

foundationcenter.org.

Step 8: Transition to

Hospital-funded FTE Employee

Our goal is to have a hospital-funded

FTE patient navigator by 2012. Once

our current, abbreviated navigated

program has been in place for one

year, we will submit grant applica-

tions. A grant-funded FTE will allow

us to expand the navigation services

to capture all patients receiving initial

suspicious ﬁndings of what may be

cancer. Establishing these expanded

services will take some time as it will

require structuring a system to gather

community-wide screenings. If we

are lucky enough to receive a grant to

establish a comprehensive navigation

program over a two-year period, we

anticipate having well-established cost

and effectiveness outcomes on the

patient navigation program ready to

submit for FTE approval in our hospital

budget.

For our community cancer center,

incorporating the patient navigator role,

even in a limited fashion, has been well

received and extremely valuable to our

patients. Like many projects that seem

overwhelming at ﬁrst glance, growing

a patient navigation program is achiev-

able if you break it down into manage-

able sections. As Theodore Roosevelt

said, “Do what you can, with what you

have, where you are.”

Joann Zeller, MBA, RTT, CTR, is

director of Oncology Services at Good

Samaritan Hospital in Vincennes, Ind.

References

Katz Mira L. Patient Navigation Measure-

ment Tools. Overcoming Disparities through

Patient Navigation. Detroit, Michigan.

September 20, 2007.

Good Samaritan

Hospital’s new

Cancer Pavilion

opened in April

2008.

PHOTO COURTESY OF GOOD SAMARITAN HOSPITAL, VINCENNES, IND.

S28 ACCC’s CanCer Care Patient navigation: A CAll to ACtion

I am a breast health

specialist and breast cancer

patient navigator at Alexian

Brothers Health System.

I am also a breast cancer

survivor. One important

aspect of my role as a breast

health specialist and breast

cancer patient navigator is

to be available for all and

not limit the possibilities.

I am fortunate and proud to

work at a community cancer

center that has valued the

navigator role for more

than nine years and has a

well-established navigator

program.

ne of my favorite

quotes and one that

I use today when I

talk with my own breast cancer patients

is—To know the road ahead, ask those

coming back. These words sum up per-

fectly the value of our regional Network

of Navigators in the Chicago area. Our

Network has been meeting for a year

now, and we often ﬁnd it difﬁcult to end

our meetings on time because of the

networking opportunities available. We

have forged a bond between us based

on the new trails we are blazing!

Many patient navigators at facili-

ties in our region are still working to

break down barriers and establish their

programs. They face many challenges

including gaining approval and accep-

tance from their colleagues and care-

givers. At the outset of navigation ser-

vices, physicians may be uncertain of

the navigator’s role in patient care and

may feel threatened. When working

with new physicians who are unfamiliar

with my patient navigator role, I explain

that I serve as an extension of their

ofﬁce and can work alongside them to

provide patients with the resources and

information they need in order to feel in

control and supported throughout their

cancer journey. It can take years to earn

the trust and support needed to be able

to reach and help those who would

beneﬁt the most. Sometimes even the

patients themselves are cautious about

letting us slip into their lives at a time

when they feel the most vulnerable and

lost. However, patients soon recognize

the navigator’s value and that our ofﬁce

is a safe and secure place.

In the same way that a new patient

learns to navigate the healthcare sys-

tem when diagnosed, we navigators

are learning where and how to help

patients in need so that our services will

have the greatest impact. Our Network

of Navigators is unique because our

group is open to all navigators—those

who are hoping to start a program as

well as experienced navigators in an

established program. Among our group

are nurse navigators—the largest seg-

ment—and community-based naviga-

tors who provide education on detec-

tion and prevention and how to access

the healthcare system for screenings

and care. The need for navigation in

our region is great, especially with our

underserved populations.

Our community has excellent

resources available for patients, and

our regional navigators’ network is an

opportunity for us to share information

about these local resources. We also

help support each other and network

about ways in which we’ve succeeded

in overcoming barriers to patient naviga-

tion. Our regional navigators’ network

is also a support group, providing an

opportunity to share how difﬁcult it can

be to cope with the loss of a patient.

We meet quarterly, with each

meeting held at a different facility in the

region. We tour each others centers

and work places and see ﬁrsthand what

others have been able to accomplish.

Our meetings start with an educational

presentation, followed by networking

and information sharing. We discuss

the community we serve and the chal-

lenges we face. I encourage all commu-

nities to try and establish such a group.

The networking possibilities and part-

nership opportunities are invaluable.

Debbie Williams, RN, is breast health

specialist and breast cancer patient

navigator at Alexian Brothers Health

System in Elk Grove Village, Ill.

A Regional Navigators’ Network

A First-person perspective

by Debbie Williams, RN

ACCC’s CanCer Care Patient navigation: A CAll to ACtion S29

When you are diagnosed with lung cancer, there are many

procedures you need to have to establish a comprehensive

diagnosis. The patient navigator takes the burden off the patient

to get those tests and procedures scheduled. They are an

important link between the doctor, the patient, and all other

adjunct services. Perhaps most importantly, patient navigators

are the ‘constant’ in the continuum of care to return the patient to

wellness. They offer patients a personal contact to help alleviate

their fears and concerns.

—Patti Jamieson-Baker, MBA

Vice President

The Cancer Institute at

Alexian Brothers Hospital Network

he evaluation and manage-

ment of lung cancer can

be complex. The majority

of lung cancer cases are diagnosed

at an advanced stage, with treatment

often involving intensive multi-modality

therapies. So in 2006, Alexian Broth-

ers Hospital Network, which includes

a 400-bed community hospital com-

prehensive cancer program and a

nearby 331-bed community hospital

cancer program in northwest suburban

Chicago, began offering lung cancer

patient navigation services. Here’s

how the site-speciﬁc program was

developed and implemented.

Thoracic Oncology Coordinator

Under the direction of a newly hired

dedicated thoracic surgeon, Alexian

Brothers initiated a formal thoracic

oncology program in 2006. The thoracic

oncology program included a newly

created FTE patient navigator position.

Because the navigator would provide

care to all thoracic oncology patients—

not just lung cancer patients—the job

title for the new position was thoracic

oncology coordinator. The decision

was made to hire a mid-level provider

from outside the hospital system for

this newly created position. Because

the new coordinator had no prior rela-

tionships within the hospital network,

the individual could be perceived as an

ally non-billable. Therefore, adminis-

trative support and understanding of

the patient navigator’s role is crucial.

At Alexian Brothers, we believe that

patient navigation helps improve

patient outcomes and satisfaction,

which translates to more patients

choosing to remain within our hospital

system for care. This, in turn, increases

downstream revenue for our hospital.

Navigation services can also

be attractive to referring physicians.

Today, physicians are often on staff at

multiple hospitals. Ensuring that pri-

mary care physicians are aware of the

quality care that their thoracic oncol-

ogy patients receive from our thoracic

oncology coordinator can potentially

help grow patient volumes.

Culture Counts

The culture of the institution is a key

factor in developing a workable thorac-

ic oncology navigation program. Plan-

ning for our program included investi-

gating multiple navigation models and

a site visit to a well-established lung

cancer patient navigation program at

St. Joseph Hospital in Orange County,

California, to observe a best practice

model in operation. During our litera-

ture search we identiﬁed one naviga-

tion model that referred suspected or

newly diagnosed lung cancer patients

to a call center where a patient coordi-

nator or navigator scheduled tests and

specialty physician appointments. Giv-

en that both Alexian Brothers Medical

Center and St. Alexius Medical Center

are community hospitals with patients

coming into the system from multiple

on- and off-site private physician of-

ﬁces with well-established referral

patterns, the call center model was

not viewed as a good ﬁt.

Many primary care physicians

refer patients with suspected lung

cancers to a pulmonologist for further

evaluation, but a signiﬁcant number

will either send the patient to a sur-

geon or direct the diagnostic workup

themselves. Under our model, the

thoracic oncology coordinator is

Thoracic Oncology Patient Navigation

Creating a site-speciﬁc navigation program

by Susan Abbinanti, MS, PA-C

objective staff member who would be

an advocate for the patients and the

thoracic oncology program—rather

than any speciﬁc agenda or physician

group(s). An initial period during which

physicians would need to develop a

level of trust in the new coordinator’s

abilities was anticipated.

The thoracic oncology coordinator

is a hospital network employee based

at The Cancer Institute at Alexian

Brothers Hospital Network. Naviga-

tion services provided by the thoracic

oncology coordinator are loosely mod-

eled after Alexian Brothers’ breast

navigation program, which has been

in operation since 2000. In a similar

fashion, the thoracic oncology coordi-

nator provides support and education

for thoracic oncology patients and their

families at the time of diagnosis, during

treatment, and beyond. Speciﬁc duties

include:

■ Planning multidisciplinary

conferences

■ Acting as a liaison between

members of the care team

■ Tracking programmatic quality

indicators

■ Networking with community

organizations

■ Providing community education.

In the present healthcare system,

patient navigation services are gener-

S30 ACCC’s CanCer Care Patient navigation: A CAll to ACtion

available to all physi-

cians’ ofﬁces and

patients to assist with

scheduling diagnostic

tests; however, the

pattern that naturally

developed in our hospi-

tal network was for the

thoracic oncology co-

ordinator to meet most

patients after diagnosis.

That said, given the

multiple points of entry

into our healthcare system, meeting all

lung cancer patients can be challeng-

ing for our thoracic oncology coordina-

tor. Some third-party payers require

that the diagnostic workup be done as

an outpatient, and sometimes even at

multiple locations. If the patient has

metastatic disease, he or she may be

referred from the primary care physi-

cian’s ofﬁce directly to an off-campus

oncologist. When the oncologist’s

ofﬁce is off-site, the thoracic oncology

coordinator may initially contact the

patient by phone. The patient is then

met in person at a later time when he

or she is at the hospital for a scheduled

test.

Patient Beneﬁts

Our thoracic oncology navigation

program has beneﬁted patients in

several ways. Patient education,

psychosocial support, and advocacy

services are some of the key functions

of our thoracic oncology coordinator.

Education. We collect

educational and supportive materials

at no cost from multiple sources,

including national lung cancer

organizations and pharmaceutical

companies. The thoracic oncology

coordinator individualizes these

materials on a case-by-case basis.

Educational and supportive materials

are then either mailed to the patient’s

home or delivered to the ofﬁce of a

physician on the patient’s treatment

team. Lung cancer patients typically

express dismay at the prognostic

statistics they read in books or on the

Internet, and often limit their exposure

to information afterward. In response

to patient feedback, our lung-

cancer-speciﬁc booklets are concise,

with more comprehensive printed

material provided upon request.

Families and signiﬁcant others

can beneﬁt from receiving written

information on strategies for being

supportive to someone with a cancer

diagnosis. At the same time, well-

meaning family and friends often

research multiple treatment options,

many which make claims that are

not evidence-based. The thoracic

oncology coordinator is available

to provide individualized emotional

and educational support for patients

and their families in an objective and

understandable fashion.

Psychosocial support and

advocacy. Receiving a diagnosis of

lung cancer can be a frightening and

confusing time for patients and their

families. The availability of information

on the Internet can be overwhelming.

If the patient is a current or former

smoker, an added component of

guilt can affect not only the patient’s

willingness to be treated, but family

support as well.

Frequently, patients ask our

thoracic oncology coordinator to

simply provide hope. Both hospitals

within the Alexian Network offer

lung cancer support groups, and the

thoracic oncology coordinator plans

and attends all of these meetings.

The groups meet monthly and often

feature speakers on various topics

of interest. Two of the most popular

topics are complementary medicine

and physician question-and-answer

sessions. For patients who are not

comfortable in a group setting, the

thoracic oncology coordinator can

connect them with another patient in a

similar situation who has already gone

through treatment and volunteered to

be available for one-on-one support.

During Lung Cancer Awareness month

in November, all lung cancer patients

are invited to a lung cancer survivors’

luncheon. Some of the same patients

have returned for several years,

providing hope and encouragement

to others.

When appropriate, the thoracic

oncology coordinator refers patients

and family members to other support

services, such as nutrition or social

work.

Scheduling assistance. For

lung cancer patients, traveling long

distances to a tertiary care center

for chemotherapy or daily radiation

therapy treatments can be a hardship.

The median age at diagnosis for lung

cancer patients is 71 years.

Many

patients have signiﬁcant co-morbidities

and transportation issues. Most

patients express a desire to receive

treatment for lung cancer close to

home, where their primary care

physician can remain involved.

At the urging of family, newly

diagnosed lung cancer patients often

seek a second opinion at an academic

institution. A thoracic oncology

coordinator can support the patient

Multidisciplinary lung cancer conferences are an integral component of the thoracic

oncology program at Alexian Brothers Hospital Network.

PHOTO COURTESY OF ALEXIAN BROTHERS HOSPITAL NETWORK

ACCC’s CanCer Care Patient navigation: A CAll to ACtion S31

and family in their desire to be seen at

another medical facility and can help

gather the necessary medical records.

If the recommended treatments are

the same at both institutions, the

majority of lung cancer patients opt

to receive their treatment locally. The

thoracic oncology coordinator is often

involved in supporting the patient

through this decision.

Programmatic Beneﬁts

Thoracic oncology navigation ser-

vices also offer a number of program-

matic beneﬁts: 1) expediting the

diagnostic workup and start of treat-

ment; 2) improving patient participa-

tion in clinical trials; and 3) increasing

patient volumes. Other programmatic

beneﬁts include:

Multidisciplinary lung cancer

conferences. These conferences are

an integral component of our thoracic

oncology program. The thoracic oncol-

ogy coordinator participates in case

selection, helping prioritize cases if the

agenda is full. The thoracic oncology

coordinator prepares a concise, com-

prehensive case summary to assure

that the physicians attending the

multidisciplinary conferences have all

the necessary information to discuss

the case. As physicians become more

aware of lung cancer patient treatment

options, nihilism does not appear as

prevalent. One of the goals of the tho-

racic oncology program is to increase

the number of cases discussed pro-

spectively.

Accurate staging is key to optimal

lung cancer management. To date,

our outcomes measurements have

focused on increasing physician aware-

ness and compliance with national

guidelines so as to standardize the

evaluation and management of tho-

racic malignancies. We evaluate each

patient case for adherence to national

guidelines in diagnostic evaluation and

treatment planning. Referring physi-

cians can now expect that their lung

cancer patients are managed accord-

ing to a uniform set of guidelines.

When areas for improvement have

been identiﬁed, physician support has

been excellent because our quality

improvement activities are evidence-

based and supported by the hospital’s

Cancer Committee.

State-of-the-art technology

and treatment. Another priority of the

thoracic oncology program is being

able to offer lung cancer patients the

latest technology. Our thoracic oncol-

ogy coordinator is knowledgeable

about cutting-edge treatments and

able to provide the most accurate and

up-to-date information to patients and

families. For example, the thoracic

oncology coordinator often attends

product demonstrations and/or

observes the delivery of new technolo-

gies to stay abreast of new technologic

and treatment advances. Our thoracic

oncology coordinator also communi-

cates with staff physicians regarding

new technology-based treatments

gleaned from peer-reviewed literature

or at professional conferences.

Spreading the Word

There was an early focus on internal

and external marketing of our lung

cancer navigation services. Internal

marketing included articles in physician

newsletters, lunch-and-learn presenta-

tion in physicians’ ofﬁces, and partici-

pation in hospital CME activities, such

as grand rounds. External marketing

included exposure in local publications,

speaking to community groups, and

involvement with community respira-

tory organizations. Patient and family

word of mouth and comments on the

Internet are under-recognized but pow-

erful motivators.

Lung cancer is not a “sexy” topic

by any means. A lot of stigma is still

associated with lung cancer. Raising

community awareness is important

both from the standpoint of educating

the public about signs and symptoms

of lung cancer as well as programs

that support lung cancer patients and

research funding. The thoracic oncology

coordinator helps increase community

awareness about lung cancer in general

and the hospital network’s thoracic

oncology program speciﬁcally by:

■ Participating in local walks or hikes

■ Planning performances and ben-

eﬁts by artists who desire to help

raise awareness and funds

■ Accepting speaking engagements

at local civic organizations

■ Networking with other thoracic

oncology coordinators to foster the

exchange of information and strate-

gies used by other programs.

In 2007 about 20 navigators and nurse

coordinators attended the ﬁrst regional

thoracic oncology conference for

navigators and coordinators. Spear-

headed by Michele O’Brien, a thoracic

oncology CNS, the meeting focused

on developing the nurse coordinator

role in thoracic oncology. It has now

become an annual event.

While navigation services are con-

sidered an important aspect of com-

prehensive cancer care, programmatic

beneﬁts need to be measurable. To

that end, Alexian Brothers purchased

and implemented a thoracic oncology

database. It is anticipated that the

information gleaned from this database

will help us identify strengths and

weaknesses that will help in develop-

ing program goals, without duplication

of statistics generated by the cancer

registry.

Susan Abbinanti, MS, PA-C, is thoracic

oncology coordinator at The Cancer

Institute at Alexian Brothers Hospital

Network in Elk Grove Village and

Hoffman Estates, Ill.

References

Dvorak P. Lung cancer’s double

burden. Washington Post. January 20,

2009. Available online at: http://www.

washingtonpost.com/wp-dyn/content/

article/2008/12/12/AR2008121203425_

pf.html. Last accessed March 10, 2009.

National Cancer Institute. SEER Stat

Fact Sheets, Cancer: Lung and Bronchus.

Available online at: http://seer.cancer.gov/

statfacts/html/lungb.html. Last accessed

March 10, 2009.

S32 ACCC’s CanCer Care Patient navigation: A CAll to ACtion

In 2008 Broward Health provided

29,380 mammograms, nearly 3,000 to

women who were uninsured and could

not afford to pay.

In 2006 Broward Health applied

for a patient navigation grant through

the American Cancer Society

(ACS). We received a grant of nearly

$150,000 from the Florida Division

of the American Cancer Society,

allowing us to establish our Breast

Navigation Program and to hire one

full-time RN patient navigator.

This

effort was spearheaded by Nicholas

Tranakas, MD; Lori Kessler, manager,

disease state, and the author. The

grant was speciﬁcally used to fund the

RN patient navigator position. The RN

navigator is located in the Case Man-

agement Department, and she travels

to the different Breast/Cancer Centers

throughout the Broward Health Sys-

tem. Initially, the navigator was self-

taught, using the Navigator Pathways

and the Patient Navigator Training

Manual from the HANYS Breast

Cancer Demonstration Project and

Pﬁzer Oncology. She later attended

the Harold P. Freeman Patient Naviga-

tion Institute certiﬁcation course in

Harlem, N.Y.

Our Breast Cancer Patient Naviga-

tion program was designed to navigate

medically underserved women of all

ages, living below 200 percent of the

Federal Poverty Level, who received

an abnormal mammogram.

Our Team At-a-Glance

Our ﬁrst step was to establish a

navigation planning team composed of

Nicholas Tranakas, MD; Pia Delvaille,

ARNP, MSN; and Paulet Reyes, RN,

BSN. The team was responsible for

establishing criteria and guidelines

for referral to the Breast Navigation

Program. The next step was to intro-

duce the navigation program to all

Broward Health departments, clinics,

and community afﬁliates who would

be involved in referral and care of the

patient. To accomplish this, the plan-

ning team scheduled appointments to

meet with these groups during their

staff meetings.

Next, the navigation planning

team developed forms for patient

referrals, patient intake, program evalu-

ation, patient progress notes, and

a referral log (see pages S34–S38).

With tremendous growth in the

ﬁrst year, our navigation program soon

outgrew the capabilities of our single

nurse navigator. In 2007 we received

a $150,000 AVON Foundation grant,

which allowed us to expand our navi-

gation services by adding a bilingual

social worker who is also a trained

mental health professional.

Today our breast cancer naviga-

tors are a part of the Comprehensive

Cancer Center and Breast Center

Team. The navigators’ ofﬁces are

located in the Disease State Manage-

ment Department, and they report

to the Manager of Disease State

Management and the Breast/Cancer

Center ARNP.

An abnormal ﬁnding on a mam-

mogram triggers a patient referral to

the breast cancer navigator who does

a detailed intake to assess the patient’s

needs. The patient is then in the

navigation program through comple-

tion of care. If the patient’s work up is

negative for cancer, the patient is put

back on the schedule for follow-up as

recommended by the physician, and

the patient is educated and told to call

for any changes or concerns. Once

patients are diagnosed with cancer,

Broward Health’s Breast Cancer

Navigation Program

Meeting the needs of underserved patients

by Pia Delvaille, ARNP, MSN

roward Health is a

community healthcare

system serving 1.7

million residents in the northern part of

Broward County in southeastern Flor-

ida. Our healthcare system is respon-

sible for the care and treatment of

uninsured patients in this geographic

area. According to 2007 data from the

U.S. Census Bureau, approximately

340,000 residents within Broward

County fall into this patient population.

The Breast Cancer Navigation Program

at Broward Health began in Septem-

ber 2006 when we realized that our

healthcare system was becoming

more and more difﬁcult for patients to

navigate. Multiple obstacles hampered

our patients from diagnosis through

treatment—ranging from uninsured

patients without funds to pay for care

to patients without transportation to

come in to receive care. Accordingly,

our Breast Cancer Navigation program

was designed to serve this under-

served population.

Reaching Out to the Underserved

We educate our community on the

screening guidelines for good breast

health through outreach programs

conducted by our physicians, nurses,

and outreach staff. Broward Health

also offers several options for free

mammograms and clinical breast

exams through our healthcare system

and afﬁliated community resources.

Broward Health, a nonproﬁt community health system, is

one of the ten largest public health systems in the United

States. Broward Health has more than 30 healthcare

facilities including Broward General Medical Center, North

Broward Medical Center, Imperial Point Medical Center,

Coral Springs Medical Center, Broward Health Weston, and

Chris Evert Children’s Hospital at Broward General. Broward

Health is a medical safety net for Broward County residents.

For more information, go to www.browardhealth.org.

ACCC’s CanCer Care Patient navigation: A CAll to ACtion S33

they are followed by the breast naviga-

tors from diagnosis through treatment

and for ﬁve years after the completion

of treatment.

Outcome Measures

Starting in 2007, we began evaluating

our navigation program using outcome

measures developed by the American

Cancer Society (see Table 1 on this

page). At Broward Health, we devel-

oped the following outcome measures

for our navigation program:

■ Patient will be contacted by a naviga-

tor within 72 hours of referral (after

an abnormal ﬁnding)

■ Follow-up procedure will be sched-

uled within 48 hours of patient being

contacted by the navigator

■ Patient will receive follow-up proce-

dure (biopsy, ultrasound, etc.) within

5–10 days (after initial call from

navigator)

■ Patient will be notiﬁed of procedure

results within 72 hours (after the

procedure has been carried out)

■ All biopsies will be scheduled within

48 hours (after abnormal ﬁnding)

■ All biopsy procedures will be

completed within 7 days (after the

patient is notiﬁed of an abnormal

result of the diagnostic mammo-

gram or ultrasound)

■ Pathology results will be commu-

nicated to patient within 72 hours

(after biopsy has been performed)

■ Patients with a positive cancer ﬁnd-

ing will be referred to Broward’s

Comprehensive Cancer Center

within 7 days

■ Patients will receive ﬁrst cancer

treatment within 14 days after refer-

ral to the patient navigator.

Outcomes from the breast navigation

program are excellent (see Table 1), and

the program helped keep the cost of

care down for patients who qualify for

navigation services. Broward Health’s

Administration is currently reviewing

the Breast Navigation Program with

the goal of continuing the program and

expanding navigation services to all

cancer patients.

Pia Delvaille is an Advanced Practice

Registered Nurse in the Comprehen-

sive Breast/Cancer Center at Broward

Health-Broward General Medical

Center. Pia has worked in oncology

for 25 years.

References

Broward Health. Breast Cancer Navigator

Program. Available online at: http://www.

browardhealth.org/?id=196&sid=2. Last

accessed 03.04.09.

Broward Health. Avon Foundation

Awards Grant to Broward Health Breast

Cancer Patient Navigator Program.

Available online at: http://www.broward-

health.org/news/?sid=1&nid=119. Last

accessed 03.04.09.

Services Offered by the Breast Navigation Program

■ Assessment of patients and identiﬁcation of barriers or possible barriers

to care.

■ Assistance with paperwork needed to access healthcare system for care.

■ Help scheduling appointments in a timely manner.

■ Identiﬁcation and help accessing national and community resources.

■ Weekly communication with patients while they are undergoing treatment.

■ Ongoing communication with the multidisciplinary team to ensure seamless

care of the patient.

■ Assistance to establish a medical home (i.e., a facility where patients can

receive healthcare).

■ Continued support of patient on a quarterly basis once treatment is

completed.

Table 1: ACS Benchmarks/Broward Health Outcomes

ACS Broward Health

American Cancer Society estimated 53 days 51 days

benchmark for navigation from

abnormal mammogram to care

Time from abnormal ﬁndings to 13 days 13 days

diagnosis

Time from positive diagnosis to 37 days 25 days

initiation of treatment

Contacted by navigator case manager within 3 days 1 day

Follow-up procedure scheduled within 4 days 1 or less

Receive follow-up procedure within 5-10 days 8 days

Woman notiﬁed of procedure results within 3 days 3 days

Biopsy scheduled within 4 days less than 4 days

Biopsy procedure within 7 days 7 days

Pathology results within 3 days 3 days

Referred to Cancer Center within 7 days 13 days*

Receive ﬁrst cancer treatment within 14 days 12 days

* Challenges and barriers affecting outcomes: Co-morbid conditions that needed to be

resolved prior to referral to cancer center and start of cancer treatment.

S34 ACCC’s CanCer Care Patient navigation: A CAll to ACtion

BREAST CANCER PATIENT NAVIGATION PROGRAM INDICATORS

1,2

PATIENT NAME_________________________________ MEDICAID/SOCIAL SECURITY NUMBER_______________________

DATE OF BIRTH________/___________/_____________ AGE_________ RACE/ETHNICITY______________________________

PRIMARY LANGUAGE___________________________ EMERGENCY CONTACT_______________________________________

BREAST CANCER PROVIDER: BCC CCC NBMC CC PCP __________________________________________ CM____________

DATE CASE OPENED________/___________/________ DATE CASE CLOSED________/___________/________

PREVENTATIVE CARE MONITORS: Continuity, Patient Participation, Efﬁcacy and Appropriateness of Care

01. FIRST VISIT

Date of last mammogram: Date of biopsy: Date of last ultrasound:

visit date: <Within 2 weeks: Yes No

Negative/positive biopsy: Breast cancer stage:

Provider seen at 1

visit:

02. BREAST CANCER CARE/SURGEON

Visits: Date:

03. PROVIDER OF TREATMENT

Hospital: Admit date:

Name: Discharge date:

04. TREATMENT DATA

Surgery: Yes No Date: Procedure:

Type of treatment: Chemo: Radiation: Other: Date of treatment:

05. FOLLOW-UP DATE FOR NEXT PRIMARY CARE PROVIDER

Name:

Date of appointment:

06. FOLLOW-UP DUE DATE FOR NEXT MAMMOGRAM

Provider: Results: Date: Seen: Yes No

07. PSYCHOSOCIAL STATUS

Certiﬁcation date: Approval date:

Federal poverty level: Date: Seen: Yes No

Type of transportation: Private car:_________ Public Transportation:_________ Friend/Family:__________

Distance to treatment center: Family support:

08. COMMENTS:

09. CHECKLIST: (Case manager to initial or mark N/A)

Gilda’s Club Educational materials

American Cancer Society Medicaid transportation

Childcare Smoke cessation classes

Social Worker Counseling: Smoking Genetic Nutrition

Educate on breast self exam

Substance abuse/Mental health

Physical therapy Case closed letter

Breast Cancer Patient Navigator Program Indicators worksheet/tool to be placed in internal DSM case ﬁle upon opening

of each case. Tool to be retained in the patient’s internal DSM case ﬁle. This tool should not be placed in enrollee’s medical

record.

Completion of Breast Cancer Patient Navigation Program Indicator’s worksheet done from the following data sources:

documents faxed from provider’s ofﬁce, information obtained telephonically from provider’s ofﬁce, PCP provider ofﬁce or primary

care center, and Breast Cancer Center medical record.

ACCC’s CanCer Care Patient navigation: A CAll to ACtion S35

BREAST CANCER PATIENT NAVIGATOR PROGRAM

REFERRAL FORM/INTAKE SUMMARY

FAX TO: _____________________________

DATE: _____________________________

TO:

Breast Cancer RN Nurse Manager: ___________________________________________________________________

Breast Cancer Social Worker:_________________________________________________________________________

REFERRED BY: _________________________________________ PHONE: _______________________________________

FAX: __________________________________________

CRITERIA FOR REFERRAL:

■ Uncompensated care patient with a minimum of a positive mammogram or newly diagnosed with

breast cancer

 ■ Patient must be aware of her most current diagnostic results and/or mammogram status

CHECK BOX IF PATIENT IS AWARE OR HER POSITIVE (+) MAMMOGRAM, BIOPSY, DIAGNOSIS, ETC.

Patient Name: ____________________________________________________________________________________________

Primary Care Provider: _____________________________________________________________________________________

Social Security Number: ____________________________________________________________________________________

Phone Number: ____________________________________________________________________________________________

Address: __________________________________________________________________________________________________

Site of appointment: _______________________________________________________________________________________

Next appointment: ________________________________________________________________________________________

Date of Breast Cancer Diagnosis: __________________________ Intake Form Attached: Yes _______ No ________

Other Pertinent Information:

The information contained in this facsimile message is intended only for the personal and conﬁdential use of the designated

recipients named above. This message may be an attorney-client communication, and, as such, is privileged and conﬁdential. If the

reader of this message is not the intended recipient or an agent responsible for delivering it to the intended recipient, you are hereby

notiﬁed that you have received this document in error and that any review, disclosure, dissemination, distribution, or copying of this

message or the taking of any action in reliance of its contents, is strictly prohibited. If you have received this communication in error,

please notify us immediately by telephone and return the original message to us by mail. Thank you.

S36 ACCC’s CanCer Care Patient navigation: A CAll to ACtion

TRACKING TOOL—BREAST CANCER NAVIGATION

PATIENT NAME: _____________________________________________ ID NUMBER: ____________________________

DATE ENROLLED: ________/___________/___________ DATE DISENROLLED: ________/___________/________

MR# ___________________________________________________

Positive Mammogram Date Date Date Date Date Date Date Date Date

Enrollee contacted

Positive mammogram/provide

educational materials

Schedule follow-up appointment

Attend appointment with patient

(per patient request)

Medical records reviewed

(results within 72 hours)

Resolution

Positive Breast Cancer

Positive breast cancer diagnosis/

provide educational materials

Schedule breast cancer treatment

Nutritional education/referral

Monitor lab results

Family education and support

Refer to support groups

Cultural/language preferences in

educational materials

Interventions: Forms (F),

Childcare (C), Transportation (T)

Interventions: Eligibility (E),

Financial (F), Caregiver (CG)

Communicate with other disciplines

Case manage chronic health

conditions

Resolution

ACCC’s CanCer Care Patient navigation: A CAll to ACtion S37

BREAST CANCER NAVIGATOR PROGRAM

PATIENT SATISFACTION SURVEY

You are enrolled in the Breast Cancer Navigation Program at Broward Health. With your participation, we can help

you to manage your breast cancer diagnosis and treatment and help you to live a healthy lifestyle.

Please answer these questions for us. The results of the survey will be used to improve our services to you.

Does

Very Not

Excellent Good Good Fair Poor Apply

1. How well did the Breast Cancer RN Navigator

and/or Social Worker explain the purpose of the

Breast Cancer Program to you?

2. Did the program help you understand your breast

cancer diagnosis and treatment better?

3. Were the educational materials and/or community

resources provided to you helpful?

4. How well did the Breast Cancer RN Navigator

and/or Social Worker Program help you to better

understand Broward Health’s healthcare system?

5. How would you rate the care and concern

provided you by the Breast Cancer RN Navigator?

6. How would you rate the care and concern

provided you by the Breast Cancer Social Worker?

7. How would you rate the Breast Cancer Navigation

Program overall?

COMMENTS

What did you like best about the program?

Other comments:

S38 ACCC’s CanCer Care Patient navigation: A CAll to ACtion

BREAST CANCER NAVIGATION PROGRESS NOTES

Date of Initial Mammogram:

Results:

Identiﬁed Barriers/Concerns:

Plan of Care:

Resolution and Date:

Notes:

Breast Cancer Navigator Case Manager:

Date:

ADDRESSOGRAPH

Patient Name: _____________________________________________

MR# ________________________________________________________

Date of Birth ________________________________________________

BREAST CANCER NAVIGATOR CONTACT LOG

Type of

Date Patient Name Contact Action Follow-up

ACCC’s CanCer Care Patient navigation: A CAll to ACtion S39

Outcome Measures Tool

PATIENT SATISFACTION

1. Patient satisfaction score prior to implementation of navigation services (baseline score).

2. Patient satisfaction score 6-12 months after navigation program has unrolled. Continue to monitor scores on an ongoing basis.

3. Number of patients leaving the cancer center for treatment elsewhere prior to implementation of navigation services.

4. Number of patients leaving the cancer center for treatment elsewhere 6-12 months after navigation program has unrolled.

Continue to monitor scores on an ongoing basis.

5. Number of patient referrals prior to implementation of navigation services.

6. Number of patient referrals 6-12 months after navigation program has unrolled. Continue to monitor scores on an ongoing

basis.

7. Patient satisfaction with navigation program. Continue to monitor scores on an ongoing basis.

PATIENT ENCOUNTERS

1. Time to diagnostic mammogram BEFORE and AFTER implementation of navigation services.

2. Time to needle biopsy BEFORE and AFTER implementation of navigation services.

3. Time to diagnosis BEFORE and AFTER implementation of navigation services.

4. BEFORE and AFTER implementation of navigation services, the time to initial treatment from: a) Initial visit, b) diagnostic

mammogram, 3) diagnosis.

5. BEFORE and AFTER implementation of navigation services, the time from diagnosis to consult with: a) breast surgeon,

b) plastic surgeon, c) medical oncologist, d) radiation oncologist, e) genetic counselor.

6. Time from OR to chemo/radiation BEFORE and AFTER implementation of navigation services.

7. Number of referrals to: a) navigator, b) genetic counseling, c) nutrition, d) social work.

8. Number of underserved BEFORE and AFTER implementation of navigation services.

9. Number of unavoidable admissions/ER visits BEFORE and AFTER implementation of navigation services.

10. Length of hospital stay BEFORE and AFTER implementation of navigation services.

PROGRAMMATIC COMPONENTS AND PERFORMANCE IMPROVEMENT

1. Track tumor conference recommendations based on guidelines (e.g., NCCN, ASCO).

2. Create standing order sets by disease site and measure use of tools.

3. Track percentage of patients provided with educational materials/information, BEFORE and AFTER implementation of patient

navigation services.

4. Track percentage of patients given information on clinical trials and monitor percentage of patients put on clinical trials.

5. Create site-speciﬁc navigation programs.

6. Establish a Patient and Caregiver Advisory Committee.

7. Develop marketing materials and measure physician referrals BEFORE and AFTER implementation of navigation services.

8. Establish survivorship program and measure patient satisfaction.

9. Develop end-of-treatment celebration and measure satisfaction.

10. Create support groups and other educational programs and evaluate.

This tool can help your organization identify outcome measures for your patient navigation program. Keep in

mind, measures will be speciﬁc to individual programs.

Association of Community Cancer Centers

11600 Nebel Street, Suite 201

Rockville, MD 20852

301.984.9496

www.accc-cancer.org

Publication and distribution of this booklet

were made possible through a sponsorship

funded by sanoﬁ-aventis U.S.