How to Build a System-Wide Ambulatory Navigation Program

Cancer Network had the opportunity to speak with Alisa Domb, RN, BSN, CBCN, oncology navigation supervisor at the Honor Health Virginia G. Piper Cancer Care Network, Phoenix, Arizona, during the 2018 ONS Congress, held in Washington, DC, May 17–20. Ms. Domb discussed her poster, “Building a System-Wide Navigation Program,” which explains how a comprehensive ambulatory patient navigation program was developed at her cancer center. In her presentation during Congress, she emphasized the importance of integrating oncology navigation programs to improve patient care, satisfaction, and overall experience.

-Interviewed by Lori Smith, BSN, MSN, CRNP

Cancer Network:Can you briefly explain to us your poster, “Building a System-Wide Navigation Program,” and its importance in the oncology setting?

Alisa Domb: In today’s health systems, the metrics under evaluation are not just related to financial performance and accountability of care, but are moreso about patient outcomes and experience. As hospitals develop their oncology service lines, they need to incorporate highly coordinated care with enhanced value propositions that improve the clinical outcomes and-equally important-patient satisfaction. We have learned that satisfaction is a key indicator of service quality, and our patients are very savvy consumers.

This new generation of healthcare consumers is not only looking for a set of services, but they are also linking care coordination and efficiency with quality, so patient satisfaction with care is not only reflected in the patient’s beliefs regarding care; satisfaction itself is a value proposition.

One component of a quality cancer service line is providing navigation. There is a body of robust data and strong evidence supporting the benefits of navigation in the oncology setting. We find navigation becoming an integral component of cancer care, and it is embraced in many high-quality programs, including the Oncology Care Model (OCM) from the Centers for Medicare and Medicaid Services.

Developing a system-wide navigation program requires an organizational commitment to the process of navigation, along with an investment in the workforce. This can be challenging, since navigation is not normally a revenue-generating area; we tend to see the return in the downstream revenue increased through referred services.

The purpose of building a system-wide navigation program was to create a sustainable navigation program that would improve the patient experience, as well as patient clinical outcomes and overall return on investment.

Cancer Network:Your poster mentions the need for a multidisciplinary team approach between nurses, physicians, social workers, and other caregivers. What is the training process and what competencies are necessary for those involved in oncology navigation?

Alisa Domb: This is a great question! Cancer care is complicated, and there are so many considerations around how to address our patients’ needs. It isn’t just about the diagnosis. In fact, if we only looked at the biology of the diseases we’re treating, we would miss one of the greatest care considerations-namely, identifying what is important to the patient. This includes evaluating the roles of cancer professionals in a patient’s extended care group. Building a dynamic navigation program requires us to embrace all members of our care team, because just as our patients’ courses of treatments can be complex, so are their psychosocial needs.

Training our team took time, because we wanted to provide navigation training to the patient and nurse navigators that is within their scope of practice. The patient navigators received their training online by registering and completing all training modules through the George Washington University Institute of Patient-Centered Initiatives and Health Equity (GW). The nurse navigators received online training from the Oncology Nursing Society (ONS), and all are certified oncology nurses. Competencies are based on position and the training modules completed through GW and ONS.

In addition to training, navigators work with physicians in the practice to build consensus, and to design and operationalize workflows around navigation that fit within the ambulatory clinical setting. These workflows include navigation entry points, navigation flow from patient navigator to nurse navigator, referrals to supportive and ancillary staff, and preferred routes of communication and documentation.

Cancer Network:Can you provide an overview of your findings and discuss their impact on oncology care and patient satisfaction?

Alisa Domb: What we found with our program was high levels of patient satisfaction. We measured this using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) drug treatment satisfaction survey.  We focused on evaluation of how the “drug therapy team” met the needs of our patients. We found very high ratings in areas of communication regarding maintaining health, dealing with emotional problems, coping with reduced energy levels, and addressing pain. In addition, tasks almost “always” undertaken by our team included talking with patients about their medications; spending time with them, while listening to them and showing respect for their needs and concerns; and explaining various aspects of their treatment and care in a way that they and their loved ones could understand. These are all areas in which the navigation team can have an important impact.

Other areas where we saw impressive changes included distress screening and referrals to specialists in nutrition and social work. Referrals generated included 48% to the oncology nurse navigator, mainly for chemotherapy education (about intravenous as well as oral treatment). There were also referrals for symptom management: 21% for nutritional support and 20% for social work support.

Screening for distress and depression is performed on every newly diagnosed patient, and we found an 85% increase in screening rates following implementation of our navigation program. That is especially impressive because our navigation program spans 10 ambulatory hematology/oncology clinics, a breast center, and a cancer center.

Cancer Network:Can you explain the nursing implications of a navigation system in terms of both patient care and the overall nursing experience?

Alisa Domb: As nurses, we look beyond our patients’ diagnoses to provide a holistic approach to care. We want to find out what is important to them, their families, and their communities. We want to learn what barriers each patient is facing, and to know whether these obstacles are practical, economic, social, and/or emotional. The essence of being a navigator isn’t about how we treat the disease, but instead how we offer patient-centered care. I always say that we can’t always make a difference in terms of the ultimate outcomes, but we can make a difference in the overall patient experience.