Tricia Strusowski, MS, RN
At the recent 2017 annual CANCERSCAPE meeting of the Association of Community Cancer Centers, Strusowski, sat down with Oncology Nursing News to discuss the role of oncology nurse navigators, the important differences these professionals can make, and how their responsibilities tie seamlessly into the value-based care at the heart of Center for Medicare & Medicaid Services’ Oncology Care Model (OCM).
Oncology Nursing News: What are the essential tasks of an oncology nurse navigator?
Strusowski: Navigation has really been refined over the last 20 years, and that's how long I've been involved with oncology. We didn't have core competencies back then, but now we do. There are position statements from national organizations and we also have the Commission on Cancer (CoC) standards. A lot has happened.
The roles and responsibilities are mainly about the patient: coordinating the care for the patient and the family across the entire continuum. Providing education and support and performance-improvement monitoring is a big piece, including letting the patients know about the resources at the cancer centers as well as in the community. We also want to make sure we're educating the patient about clinical trials and providing access to the clinical trials department. We also want to make sure our navigators are involved with tumor conferences, with multidisciplinary centers within the cancer community. And the navigator’s role is very much a patient-centered mission.
The formal definition is “individualized assistance provided to the patient and family, to reduce barriers, and to increase access to medical and psychosocial care across the entire continuum.”
Do those responsibilities differ between a big academic center and a smaller, community setting?
They shouldn't. There are more challenges sometimes for the navigator who is working with 100 new cancer cases per year all by herself. She might have limited resources. However, we all have the same roles and responsibilities and core competencies. There shouldn't be a tremendous amount of difference between locations.
I tend to always want to help the navigators who are out there on their own, who are trying to figure things out. They were probably hired—maybe not even oriented—and just told, "Go out and navigate." Well, what does that mean, when you don't have a navigation background? You may have been a bedside nurse, or a chemotherapy nurse, and you may not understand the whole history and responsibilities of navigation.
Is it more important to have a navigator in the community setting?
Community cancer centers are where 80% of patients get their care. They cannot afford to travel to comprehensive cancer centers. Plus, they want to get care in their own backyard. They want to have those services. From my perspective, it's very important that we help navigators and everybody involved with support services to help the patients, because it's such a scary time for anybody diagnosed with cancer, let alone having to travel for 3 hours for treatment, having additional concerns, and lacking resources, such as the money required for expenses.
I support all navigators in their role because it's a challenge no matter where they are, with the number of patients and the caseload and the responsibilities. We try to focus on providing the right care at the right place at the right time. And having that navigator stay 1 step ahead of that patient is a constant challenge.
What is an example of how a nurse navigator can make a difference in the care a patient with cancer receives?
For a patient with head-and-neck cancer, things have to happen in a particular order. If they don't get dental clearance before they start to receive their treatment, it can be catastrophic. One performance improvement initiative that 1 of the programs I work with started was to make things happen on schedule. For patients with head-and-neck cancer, the dental clearance, on average, was taking about 2-3 weeks. That's a significant delay. It's a worrisome time for the patient, knowing that their treatment hasn't started. Dental clearance must be taken care of before multiple other appointments can occur, before patients can even start their chemotherapy or radiation.
We put a new process in place for that group. We worked with the tumor site team and we looked at the national guidelines and we did a process mapping exercise, to look at barriers and where their opportunities were for improvement. We knew immediately the dental clearance was a concern. So, we created a dental clearance process. The navigator took the lead and asked each patient, "Do you have a dentist? Can I contact your dentist so we can expedite the visit?" A problem that went from 2-3 weeks went down to 2 days almost immediately.
And we provided expert support for the community dentists so they could understand why the patients needed to have the dental clearance through our tumor site team. We also created standing order sets. The navigator—no matter who was covering those head-and-neck patients—provided the same high level of care, which is fantastic.
We also created appointment checklists. The patient could potentially leave with 7-10 referrals, and we provided definitions of the specialists the patient would be seeing. What is a medical oncologist? What is a radiation oncologist? What is a speech and swallowing therapist? What we did is we outlined and defined those terms and explained them so the patient would understand. We also created lists of frequent questions and answers to those questions, to serve as decision aids for patients. Sometimes, they don't even know what to ask their doctors. It could be as simple as, "What is my cancer?” “Where is it?” “What are my treatment options?” “What clinical trials are available?" We empower the patient, which is a huge piece part of helping.
Those are just a few examples of how a navigator can really enhance the care for the patients, as well as the entire cancer program.
Can you tell me about the effort to gather metrics in navigation and how that contributes to the value of navigators to the Oncology Care Model?
We had experts from across the country. We did a tremendous amount of research. We ended up with over 300 source documents that supported our 35 metrics, based on patient experience, clinical outcomes, and return on investment.
When you cross-reference these metrics with the value-based cancer care of the OCM, they're beautiful. It's a perfect fit. For the first time, we can truly partner and all be on the same page with the same mission and vision, to enhance the care for our patients and families. It's extremely exciting.
Over the last 3 years, administrators have been turning to me and saying, "I've had my navigation program for about 10 years, what's the return on investment?" How can we measure success or sustainability?
We have to support our programs. We know navigation is good, but we have to have our metrics to demonstrate success. The wonderful thing is, there's a tremendous amount of buy-in. Physicians and administrators realize that the navigator helps them reach their goal of patient- and family-centered care. It's just really good care. My own program used to get involved with the patients as soon as possible, at diagnosis. By the time we have a pathology report, we were involved immediately. That's what the doctors wanted, too. I had one doctor tell me, "I just want to push the 'go' button. I want you involved as soon as possible, automatically, to help these patients and their families." The buy-in is there.
They're also starting to see how well the care is coordinated. What we need to look at next is these benchmarks—navigation benchmarks—nationally. Then we can really move navigation forward. We need some solid research in regards to navigation. That's the next goal. We want to create a repository to actually house all this information and help all of the navigators with their information, reporting, and best practices, and then start research.
How can a center that has a limited budget afford a navigator?
One very important metric is return on investment. We created 8 metrics just on return on investment. A navigator can make a difference. For example, a patient that is frequently in the emergency department, or frequently readmitted, for avoidable reasons—constipation for 3 weeks, nausea and vomiting for a week. By navigators intervening, they can keep those patients out of the ED and inpatient setting. That's huge, also referrals to revenue-generating services, monitoring no-show-rates, early intervention to decrease “out-migration.” You're keeping that patient there through the entire continuum. Those are the metrics we've actually created to demonstrate to administrators the return on investment of a navigator.
Are navigation services reimbursable?
It's not reimbursable at this time. That would be wonderful. Hopefully in the future they'll look at that. The good thing is, there's no cost to the patient. Every patient deserves this and there is no navigator who is actually charging a patient for their services.
How are tumor site–specific teams organized in navigation?
I was very fortunate, I had a group of 7 navigators who were disease-site specific. We had about 3200 new analytic cases per year. What we actually did was process-map:
- What's going to happen to these patients?
- What is the navigator going to do during different pieces across the continuum?
- When are they going to introduce the dietician, or the social worker, or financial counseling, based on that specific disease site?
- What other support services need to be involved?
I also had each of my navigators create disease-site toolkits and they cross-trained each other, so they could easily step in for each other, when they're either on vacation or if an emergency came up.
What does the handoff from treatment to survivorship look like?
Survivorship still tends to be a challenge for a lot of cancer programs. The standards have been revised to be for patients of curative intent to receive a survivorship care plan. What I envision as a best practice is that we start to educate our patients during every episode of care, to get them ready and we're not just waiting for the end of care to share what they need to do with regards to their late and long-term effects, or their long-term surveillance. Things that they need to be aware of and need to share with their primary care physician. That's very important.
With the survivorship care plan in itself, there are still challenges. It takes a navigator or a survivorship team a lot of time to put it together. We still don't have a tremendous amount of interoperability between electronic medical records (EMRs). They still may be getting some information from a chart form, or multiple EMRs to collect the information. There's not a lot of research out right now that says that it's helpful. We need to do some research with that, too.
In the future, if we want to do survivorship well, it's not meant to just be at the end of treatment. It's meant to be throughout the entire continuum and then we can constantly reinforce the same information, and that's the best way anybody learns.
What is your advice to navigators?
Value-based cancer care is here. Navigators need to be business-savvy. They need to utilize metrics and they need to partner with their physicians and their administrators to really put these puzzle pieces together not only for patients and their families, but for their cancer programs.