How are patients with cancer triaged at key points throughout their journeys? Who helps them understand their diagnoses or treatments and prioritizes what to do next? Who pulls in the resources needed to make sure patients get what they need as expeditiously as possible?
Oncology nurse practitioners (ONPs) who work as patient navigators are uniquely equipped to assist in transitional moments throughout the cancer continuum—for instance, dealing with a diagnosis, moving from chemotherapy to radiation therapy, beginning the survivorship follow-up process, and making end-of-life decisions. ONPs are doing this work at a variety of facilities, from private practices to large hospitals, many focused on patients affected by breast or colon cancer.
As part of a doctoral thesis, one nurse practitioner investigated how her fellow professionals fit into the navigation landscape across those medical settings. Frances Johnson, PhD, MSN, AOCN, ANP-BC, of the Carl R. Darnell Army Medical Center in Fort Hood, Texas, used an open-ended telephone questionnaire to poll 20 ONPs from across the country about their navigation work.
She concluded that diagnosing, prescribing, prioritizing and expediting care are among the areas where ONP patient navigators can make their most valuable contributions. For many, she noted, this involves finding and relieving obstacles in the health care system.
“Determine where bottlenecks are in your navigation system—patient, facility or community—and then build triage systems to speed up the process for more timely care,” Johnson suggested while sharing her findings in a presentation at the Oncology Nursing Society 43rd Annual Congress, held May 17 to 20 in Washington, DC.
For ONPs working as navigators, the overarching goals are expediting cancer care while staying connected to both patients and the health care system, Johnson said. Studies have shown that, when care is not streamlined, patients are diagnosed later, visit emergency rooms more, and struggle with unmet survivorship needs or uncoordinated end-of-life care, she said.
The job of an ONP navigator can start at diagnosis, which often occurs in the emergency room. Typically, triage there involves collecting information, assessing the severity of the health problem, prioritizing needs and predicting a condition’s trajectory. But oncology nurse practitioner patient navigators can add another dimension to these assessments, Johnson said, by coordinating care. That can involve pulling in needed resources while removing any barriers that could stand in the way of expedited care.
What does this look like in practice?
At diagnosis, a navigator might explain a patient’s condition, provide reassurance that cancer is not always terminal, explore the patient’s feelings about various potential treatments, prioritize and explain next steps, set up appointments and referrals, and later follow up to see how the patient is doing. In a setting where many patients are uninsured, it can be useful for nurse practitioners to focus their efforts on patients who have no family support, financial or transportation problems, dementia or other barriers to care, one study participant told Johnson.
A day for an ONP navigator can involve a flurry of phone calls to patients and hospital departments, or creating a multidisciplinary clinic experience—a day of visits to a variety of specialists—for a patient who needs an immediate diagnosis and treatment plan.
In the survivorship phase, a navigator might approach the patient at check-in, accompany him to his blood draws and doctor visits and then provide a written treatment summary, a distress screening, a discussion about potential long-term side effects and an invitation to check in if problems arise.
At the end-of-life stage, one oncology nurse practitioner navigator helped a family set up hospice care for a patient and get needed equipment, and then, after the patient had died, helped surviving family members quickly get rid of some of those items.
To be successful as navigators, nurse practitioners can rely on a variety of tools, and while many already exist, more are needed that are oncology-specific, Johnson said.
She suggested that nurses research potential new tools for navigators in the oncology setting, which would ideally help nurses track a cancer’s development, treat according to protocol for both physical and psychosocial issues, proactively screen for emergencies, rate treatment side effects, rank any barriers to cancer treatment according to their importance, and assess survivorship and end-of-life needs.
Tools already on hand that can directly help with patient care include risk-assessment models that predict for previvors their lifetime risk of developing specific cancer types. There are also tools to help nurses perform triage, help with advanced care planning or symptom management, and assess patient satisfaction with health care.
For work that involves creating and administering programs and systems, there are all kinds of charting and tracking assists, from forms, software, and spreadsheets to flowcharts and schedules, using either industry-wide formats or those created by individual facilities. Nurse practitioners also rely on computer programs for system analysis and goal formation, as well as software such as Journey Forward to help formulate survivorship plans. Additionally, they may use chart-review templates in conducting research.
Finally, oncology nurse practitioner patient navigators may reach out to the community through formats including group meetings, smoking cessation programs, and coordination of state and county cancer control programs or registries.
In response to questions from several audience members, Johnson noted that some ONP navigators bill for their services directly, while others are reimbursed through hospital bundled-payment systems that bill insurers at once for all the services used by a patient during a single cancer or treatment episode.
Johnson closed her presentation with a quote from Theodore Roosevelt, which she called “a very good example of triage: Do what you can, with what you have, where you are.”
Johnson F. The process of oncology nurse practitioner patient navigation: triage an essential process. Presented at: Oncology Nursing Society 43rd Annual Congress; May 17-20, 2018; Washington, DC. https://ons.confex.com/ons/2018/meetingapp.cgi/Paper/3367