Promoting a model of navigation targeting one of the basic principles of health care: ACCESS

1. This presentation will probably involve audience discussion, which will create action items. Use PowerPoint to keep track of these action items during your presentation • In Slide Show, click on the right mouse button • Select “Meeting Minder” • Select the “Action Items” tab • Type in action items as they come up • Click OK to dismiss this box • This will automatically create an Action Item slide at the end of your presentation with your points entered. Promoting a model of navigation targeting one of the basic principles of health care: ACCESS Patti Marchand Dennis Webster February 2009 DRCC

2. Aligning with current initiatives • Improving access to better and more rapid cancer diagnosis has been identified as a priority for Cancer Care Ontario (CCO) and the Government of Ontario (2008) www.cancercare.on.ca

3. CCO Program in Evidence Care:Diagnostic Assessment Program • The mandate of a DAP is to coordinatepatient care from referral to definitive diagnosis. • The guiding principles for the DAP are: • To ensure that an environment of patient-centered care is established • Patients have equal access to high-quality diagnostic care regardless of where they live in the province • Patients are supportedthroughout the diagnostic process • Patients have a diagnosis of cancer made or ruled out in a timely fashion • To ensure that a coordinated referral and follow-up system is established • To ensure that indicators of quality are established and monitored to evaluate performance outcomes

4. Objectives of the Diagnostic Assessment Program (con’t) • will be enabled by the development and implementation of common evidence-based regional and/or provincial guidelines, which may include: • Disease-specific protocols regarding diagnostic work-ups • Service frameworks for primary care providers • Wait-time benchmarks

5. Why focus Diagnostic Phase of the Cancer Journey? Need for continuity is especially important in diagnostics context because there are many system handoffs and coordination challenges Feedback from patients focus groups* focused on concerns about the coordination of cancer care: Waiting is enormously stressful regardless of the length of the wait Patients often have to travel long distances for care, increasing the stress and further delay Physician to patient and physician to physician communications require improvement in the cancer sector Patients reported not knowing from whom to get information and that information was often unavailable or missing * Based on focus groups of patients and practitioners across Ontario in preparation for the Cancer Quality Council of Ontario signature event (2007)

6. Why focus Diagnostic Phase of the Cancer Journey?...con’t • Recommendations from the patients and practitioners focus groups include: • Every patient should have an advocate to help them navigate the cancer system • Test results and diagnoses should be communicated as quickly as possible, over the phone if necessary in order to shorten the stressful waiting period • Extra training should be provided to practitioners (e.g. family MDs) on how to communicate adverse information * Based on focus groups of patients and practitioners across Ontario in preparation for the Cancer Quality Council of Ontario signature event (2007)

7. How do we propose to address the concerns and meet the objectives of a diagnostic assessment program? Patient Navigation System

8. Navigation • Wikipedia • the art and science of determining one's position so as to safely travel to a desired destination • Meriam-Webster • the science of getting ships, aircraft, or spacecraft from place to place; the method of determining position, course, and distance traveled • Dictionary.com • the art or science of plotting, ascertaining, or directing the course of a ship, aircraft, or guided missile

9. Patient navigation…its origins • Dr Harold P. Freeman, founder and national champion of patient navigation, established the nation's first patient navigation program in 1990 at Harlem Hospital Center • Goal: to help improve access to cancer screening and address the delays in clinical follow-up and barriers to cancer care that poor people encounter. • The pilot program compared 5-year survival rates of breast cancer patients who were navigated and those who were not and found an improvement in the navigated patients. www.patientnavigation.com; Freeman, 2004, Oncology Issues

10. What is patient navigation? • Patient navigation is a process by which an individual—a patient navigator—guides patients with a suspicious finding (i.e.: test shows they may have cancer) through and around barriers in the complex cancer care system to help ensure timely diagnosis and treatment. (Freeman, 2004) • Patient navigation refers to a process whereby designated individuals proactively guide patients through the bureaucracy of the health care system to facilitate the successful completion of a specific diagnostic or therapeutic task.” (Psooy, 2004) • System or professional role primarily intended to expedite patient access to services and resources, and improve continuity and coordination of care throughout the cancer continuum (BC Cancer Agency)

11. Cancer Care Nova Scotia (CCNS) …evaluating the concept Findings outlined in the evaluation indicate: • Patients, families, physicians and health professionals are extremely satisfied • Patients are more knowledgeable about their disease and are better prepared for appointments with cancer specialists, which is resulting in better, more efficient care; • patients are often able to access more services in their home community; • increasing collaboration among health professionals; • Cancer Care Nova Scotia leadership, district commitment and good communication are critical to the success of Patient Navigation. www.cancercare.ns.ca

12. Is navigation possible by any person? • Whose role is it to provide navigation? • What are the requirements?

13. Navigator Models • One author suggests there are 3 navigator models identified in the literature * • Active Coordination Model • Largely done by nurses; proactive role; direct contact with MDs and patients; navigator directs patients and physicians; coordinates appointments and makes decisions • Facilitating Navigator Model • Navigator acts more as a consultant to the patient; responsibility lies mostly with the recipient to take action such as contact recommended agency; high education role but little coordination by navigator • Shared Navigation Model • Functions are distributed among several people or professions; implicit in each person’s role or responsibility • An active coordination model would likely have the greatest impact on system process improvement and reduction in wait times.

14. What are patients telling us… • a universal desire of the women who participated in the Up Front project to have had a care coordinator or navigator dedicated to providing information, supportand guidance throughout the course of treatment from the time of their diagnosis. • All informants believed that coordination, continuity and supportive care would be strengthened by the existence of a patient navigator role. • Ability to get information from a knowledgeable professional and have time to get your head around it, that would be an incredible asset Trussler (2007)Toward Kinder Care

15. They (the patients) described the navigator role as… • Coordinating care • Advocating for the patient • Providing information, direction and emotional support, adapted to individual needs. • Not only did women want chart information to be transferred more efficiently between practitioners and facilities, but they wanted access to it themselves. • They recognized treatment as a staged process and their need to know “what’s happening next” as having a significant impact on their levels of anxiety and stress.

16. Nurses as patient navigators Appropriate role for nurses since it requires knowledge, skill and professional judgment and is within nurses scope of practice Nurses can encourage patient self care Nurses provide information which assists patients to better understand their condition Nurses communicate on a regular basis to members of the health team on the patient’s behalf Nurses have the knowledge and skill to interpret assessment data and provide direction The Canadian Association of Nurses in Oncology includes navigation as one of their standards of care * Investigation and Assessment of the Navigator Role, Canadian Breast Cancer Initiative, 2002

17. The Nurse as navigator… • Oncology nurse is: • Knowledgeable of the continuum of oncology care • Understanding the importance of a complete work up and accurate staging • Aware of the risks and side effects of procedures/ treatment modalities • Expert in nursing interventions for side effect management and complication recognition • An advocate for patients/families • A Promoter of patient empowerment/decision making • Skilled in collaboration/communication among physicians and support services • Accessible to the patient for questions/concerns (treatment plan and individual clinical questions) vs MD • Able to provide test results and interpretation of same Seek & Hogle, 2007

18. A nursing background with a strong oncology component strengthens the role of the navigator in providing the educational, physical, and psychosocial dimensions of care that patients with cancer require. Seek & Hogle, 2007;

19. A growing model of care… • Elizabeth Anderson Cancer Institute, Savannah • APN as breast cancer and gynecologic cancer nurse navigator • Palo Alto Medical Foundation: Integrated Prostate Cancer Centre • CNS as Prostate Cancer Nurse Navigator • Pennsylvania Life Insurance Company, USA • Nurse Navigator • Red Deer Regional Hospital, Alberta • Cardiac Nurse Navigator Program • Tom Baker Cancer Center, Calgary Alberta • Nurse navigation in breast cancer • MaryLand, Ohio • Multidisciplinary lung cancer clinic: Nurse navigator

20. What are the objectives of a diagnostic program that embraces a system of patient navigation? • Patients without significant problems should be reassured as quickly as possible, and those with cancer should be diagnosed without delay • allow for consistent, reliable and straightforward access for family physicians • facilitate timely surgical consultation • provide and promote community awareness of existing local expertise

21. Responding to the initiative: Active Coordination Navigation Model Patient presents with imaging, laboratory, or clinical abnormality: NP/Family MD initiates referral • Nurse Navigator as entry to system: • Resource to patient • Resource to referring MD Triage Priority coding Medical directives Clerk Support • Education/teaching • procedures • diagnosis: benign or malignant • plan of care • cancer system Assessment: Knowledge base psychosocial Referral to community support services Additional tests Surgical consult Medical/Radiation Oncology

22. Critical components • Care map • Standards of care • Multidisciplinary input • Where explicit standards do not exist: consensus

25. Criteriafor referral • Physician referrals to the Prostate Program will be accepted for the following reasons: • ·PSA above age adjusted average (see Table 1) • ·Abnormal DRE (suspicious for malignancy) • ·Free/Total PSA < 0.1 • ·Rapid PSA rise (see Table 2) Table 1: Age adjusted PSA ranges: AgePSA (ng/mL) < 50< 2.5 51 – 60< 3.5 61 – 70< 4.5 or < 4.0 71 – 75< 6.5 Table2: Rapid PSA rise thresholds (based on at least 3values 6 months apart) PSA (ng /mL) PSA velocity cut-off (ng/mL/y) < 4> 0.4 > 4> 0.75

26. Appendix A: Priority Coding for new referrals • Priority 1: (wait time: 5 business days) • ·PSA above age adjusted average (see Table 1) • ·Abnormal DRE (suspicious for malignancy) • ·Free/Total PSA < 0.1 • ·Rapid PSA rise (see Table 2) • Priority 2: (wait time: next available) • Previous negative biopsy but HGPIN • Previous negative biopsy but rising PSA • Family history of prostate cancer • Patient or Physician request for evaluation but not meeting Priority 1 criteria • NOTE: All Priority 2’s may be bumped to accommodate a Priority 1 as needed.

27. Case study…the navigator as the point of triage http://www.stacommunications.com/journals/cme/2006/CME_Jan_06/PSA%20Article.pdf

28. …merging of the navigator role into the domains of practice of a Clinical Nurse Specialist… • Clinician • Educator • Researcher • Consultant • Leader Canadian Nurses Association, 2008;Educare Inc., 2006

29. Clinical Practice • Receive and triage referrals to program • Access and provide information • Refer to community resources • Provide emotional support • Assess symptoms; provide symptom management and practical guidance • Communicate across specialties • Communicate with primary care physician • Facilitate availability of testing results • Resource to DI clerk regarding patients requiring extra views/ultrasound • Facilitate multidisciplinary evaluations

30. Educator • Patient • Content review and update • One on one • Telephone • Face-to-face • Written • Websites • Staff • Multidisciplinary across the continuum • DI • Pre-op • Oncology • Public • Community Forums • Professional • Cross appointment to local university

31. Researcher • Knowledge transfer • dissemination of the latest clinical knowledge and application of evidence-based practices in the clinical setting and ensuring excellence in breast health and cancer care • Identify, conduct and support research • Primary Investigator: Abnormal Breast screening results: The psychological consequences experienced by women and the social supports they access • Inform multidisciplinary practice • Influence patient care

32. Consultant & Collaborator • Staff Nurses • Family MDs • Surgeons • Oncologists • Pathologists • Radiologists • Public Health • Supportive care agencies • Hearth Place

33. Leader • Program development • Process and Evaluation • Development/review of policies/procedures • Creation of clinical pathways to guide care • Quality assurance • Identification and communication of indicators • Actively developing and participating in audit and other reviews to monitor and improve clinical care • monitoring access to care • tracking timelines from presentation through diagnosis/resolution, • evaluating wait times for provider appointments • monitoring and evaluating patient satisfaction • Establish and maintain a regional network of contacts • Committee Chair • Clinical advisory group for breast assessment • Administrative/business team for breast assessment

34. The Nurse Navigator • seeks to improve healthcare delivery through • the assessment of patient care systems • questioning of traditional approaches of care • identifying areas of needed change

35. We must never forget… • …patients today evaluate the success of a procedure/ intervention based on their experience surrounding the procedure, not the intervention itself ...the nurse navigator brings advanced knowledge, skills and ability to positively impact this ‘surrounding’ (Kerfoot, 2000)

36. Summary Using a navigator: patient gets from point A to Point B with information support and access to a knowledgeable professional; the navigator assumes ownership for the process and embraces a systems approach to change with the knowledge, skill and ability to implement and evaluate processes at a leadership level

37. http://www.articlearchives.com/health-care/health-care-professionals-nurses-nursing/878581-1.htmlhttp://www.articlearchives.com/health-care/health-care-professionals-nurses-nursing/878581-1.html • http://onsopcontent.ons.org/Publications/SIGNewsletters/cns/cns18.2.html#story3 • http://onsopcontent.ons.org/Publications/SigNewsletters/bc/bc3.2.html#story6 • http://www.ons.org/publications/journals/Connect/pdf/2203.pdf • http://www.ons.org/Meetings/Congress07/summaries/navigators.shtml