Gastrointestinal Cancer Navigation
Upcoming SlideShare
Loading in...5
×
 

Like this? Share it with your network

Share

Gastrointestinal Cancer Navigation

on

  • 1,502 views

Coralyn Martinez, MSN, RN, OCN

Coralyn Martinez, MSN, RN, OCN
Nicole Messier, BSN, RN

Statistics

Views

Total Views
1,502
Views on SlideShare
1,389
Embed Views
113

Actions

Likes
0
Downloads
22
Comments
0

3 Embeds 113

http://www.aonnonline.org 91
http://aonnonline.org 11
http://aonnonline.org 11

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • Simple introduction of ourselves – Basically why we deserve and are credible to be speaking Nursing background, schooling, years of oncology, ect.
  • Simple introduction of ourselves – Basically why we deserve and are credible to be speaking Nursing background, schooling, years of oncology, ect.
  • Nicole speaks about her hospital and location
  • Nicole speaks about her UGI Program
  • Coralyn speaks about her hospital and community
  • 1 of 30 NCCCP sites, only one in West Michigan. 42 hospitals, 4 th largest catholic health system. Two divinci robots
  • Coralyn Speaks about her GI MDC program
  • Maybe towards the very beginning, after we introduce ourselves, so we can define who are audience is and where they are coming from (we can use the colored cards for this) We should have each question with possible answers/responses come onto the slide separately Any other good to know info questions? It’s important to get an understanding of who our audience truly is, we need to understand where they are coming from so that we can help them to improve their programs. Oncology Nurse Navigator (ONN) The Oncology Nurse Navigator is a professional whose clinical nursing expertise guides patients, families and their caregivers to informed decision-making; collaborating with a multi-disciplinary team to allow for timely cancer screening, diagnosis, treatment, and increased supportive care across the cancer continuum. Patient Navigator (PN) The Patient Navigator can be a layperson, a social worker or nurse who is dedicated to the individualized assistance 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. NCONN.org definations
  • Look for articles to support this…. Freeman identified barriers that affected timely diagnosis - lack of insurance, poor social support, poor coping styles and poor health literacy.
  • A clear understanding of role, duties and how the navigator improves care Marketing – Community, organization, self!! Majority of referrals from GI, PCP, and Patient themselves. Clear consistent communication between patient, support staff, referring, PCP, all departments NCCN guidelines – Learn how to read them, use and refer to them often Tracking – Database, navigation software, documentation (by tracking this info can help validate the need for the navigator, and perhaps the need for additional navigators, as well as the MDC itself) Who to present, when to present, How to present Assuring the patient is never lost, providing support, education and continued consistency for patients
  • Visualization of nurse navigator
  • It’s important to get an understanding of who our audience truly is, we need to understand where they are coming from so that we can help them to improve their programs. Oncology Nurse Navigator (ONN) The Oncology Nurse Navigator is a professional whose clinical nursing expertise guides patients, families and their caregivers to informed decision-making; collaborating with a multi-disciplinary team to allow for timely cancer screening, diagnosis, treatment, and increased supportive care across the cancer continuum. Patient Navigator (PN) The Patient Navigator can be a layperson, a social worker or nurse who is dedicated to the individualized assistance 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. NCONN.org definations
  • Is there anyone different that they work with or have present on their team?
  • So what we really hoped to achieve is patient centered multidisciplinary care, one stop shopping, designed to increase communication between the specialists and to ensure fewer visits to the facility
  • If we improve the efficiency, we hopefully increase pt satisfaction Clear communication with pcp/referring MD, and the treating team re: the plan very important
  • Radiology, Pathology
  • Maybe these questions after slide 15, tying in with the question posed-”where do you get your referrals from?”
  • Role – What we do, why we do it, how it is a benefit for the patient By using an intake form you are consistent in “getting to know” your pts prior to their MDC appt, less apt to forget asking key questions Education – is an important part of our role as nurses, Pictures are GREAT! If you don’t have a lot of pamphlets or booklets, there are many available there the NCI, ACS, and independent organizations. Websites – In the beginning I tend to educate patients and families to try to stay away from the websites. It can be too overwhelming and there is a lot of BAD out there. AT the point of referral we often don’t have the whole picture put together yet and we are still looking for more pieces to the puzzles. Cancer. Org and cancer.gov are good places to start. Important to clarify what pt’s already know, what their biggest questions, fears, concerns are Appt-this is the most important part of the discussion, pt’s need the reassurance that they have an appt, therefore will have a plan, to reduce as much of their initial anxiety as possible Make sure to explain what they can expect the day of their appt-who, what, when, where, why
  • ACCC-cancer.org
  • Summary of appointment, calendar and next steps. Dates and times of future appointment.
  • As a nurse navigator what would you do next??
  • Maybe these questions, +/- any others you may think of, at the end, time allowing

Gastrointestinal Cancer Navigation Presentation Transcript

  • 1. Gastrointestinal Cancer Navigation Coralyn Martinez, MSN, RN, OCN The Lacks Cancer Center Nicole Messier, BSN, RN Vermont Cancer Center
  • 2. Gastrointestinal (GI) Cancer Navigation Coralyn Martinez MSN, RN, OCN The Lacks Cancer Center Saint Mary’s Health Care Grand Rapids, MI Nicole Messier BSN, RN Vermont Cancer Center Fletcher Allen Health Care Burlington, VT
  • 3. Objectives
    • Create strategies for the identification and removal of specific barriers to efficient and effective patient care in gastrointestinal (GI) cancer navigation
    • Discuss the roles of various types of GI navigators and the ways in which they improve patient care
    • Evaluate best practices regarding GI navigation and survivorship care
    • Understand the processes for implementing and sustaining a successful GI cancer navigation program
    • Assess methods for managing the psychosocial needs of patients and caregivers
  • 4. Fletcher Allen Overview
    • 6700+ employees
    • Regional referral center for 1 million; Vermont and northern New York
    • Academic medical center in affiliation with the University of Vermont
  • 5. Fletcher Allen Upper GI Multidisciplinary Cancer Clinic
    • Initiated in January 2007
    • Dedicated UGI Nurse Navigator
    • Patient navigator from American Cancer Society (2009)
    • Cancer Patient Support Program (nutritionist, clinical psychologists, social worker)
    • Surgeons, medical oncologists, radiation oncologists, gastroenterologists, pathologist, radiologist, nurses, fellows, residents, students
    • Second, fourth, and fifth Mondays with pre-clinic conference from 7:30 to 8:30 AM (films, path, and clinical presentation reviewed)
    • Patients then seen in clinic by all appropriate specialists
  • 6. The Lacks Cancer Center
    • Add picture here
  • 7. The Lacks Cancer Center
    • National Cancer Institute Community Cancer Centers Program (NCCCP) site
    • West Michigan’s only dedicated cancer center
    • Community teaching hospital
    • Member of Trinity Health
    • Focus on minimally invasive surgery
    • Multidisciplinary clinics available for all solid tumors
  • 8. Lacks Cancer Center GI Multidisciplinary Clinic
    • Initiated in 2009
    • Dedicated GI Nurse Navigator
    • Cancer Resource Specialist (CRS) (MSW)
    • Oncology Certified Dietitian
    • Surgical oncologist, medical oncologist, radiation oncologist, interventional radiologist, pathologist, financial consultant, CRS, palliative care, genetics counselor, nurses, residents, research coordinators
    • Meets weekly every Friday morning
    • Tumor Board/treatment planning conference prior to clinic
    • Patient seen by all “appropriate” disciplines
  • 9. Poll the Audience
    • What type of navigator are you?
      • Nurse
      • Social Worker
      • Lay Person
      • Other
    • What is the primary setting in which you work?
      • Hospital
      • Clinic
      • Other
    • Do you navigate additional cancer types?
  • 10. Nurse Navigation: Major Impacts on Patient Care
    • Efficiency of diagnostic evaluation
    • Expediency of treatment initiation
    • Increased access to clinical trials
    • Improved patient satisfaction
    • Enhanced communication with referring physicians
  • 11. Keys to Successful Navigation
    • Clarification of role
    • Strong referral base
    • Communication
    • Quality guidelines (National Comprehensive Cancer Network)
    • Tracking of metrics/QA projects
      • Database
    • Tumor Board/treatment planning conferences
    • Teamwork
      • Buy-in, commitment, and flexibility of key players
    • Survivorship programs
  • 12. Multidisciplinary Team Approach Survivor Network Pathology Clinical Research Familial Cancer Program Financial Counseling Prevention Program Cancer Education Specialty Physicians Nutrition Services Palliative Care and Integrative Medicine Social Services Radiology Nurse Navigator Medical Oncology Surgical Oncology Radiation Oncology Nurse Navigator
  • 13. Navigation Types
    • Diagnostic
    • Treatment
    • Survivorship
    • Patient versus nurse
    • All in one
    • Outpatient versus inpatient
  • 14. GI Navigators
    • What type of Navigator are you?
    • What types of GI cancers do you navigator?
    • Who makes up your GI MDC team?
    • What are the goals or objectives of the MDC in your hospital?
    • Where do you get your referrals from?
    • What is your case load? What defines your case load?
    • What are the goals or objectives of the MDC in your hospital?
    • How do you document? (EMR/Navigation Software)
    • What are your favorite resources for patients/ yourself?
    • Keys to success?
    • How are you measuring your accomplishments?
    • Do you measure the quality of the care delivered?
  • 15. The GI MDC Team
    • Surgical Oncologists
    • Radiation Oncologists
    • Medical Oncologists
    • Gastroenterologists
    • Radiologist
    • Interventional Radiologist
    • Pathologist
    • Nurse Navigator
    • Patient Navigator
    • Clinical Psychologist
    • Nutritionist
    • Social Worker
    • Financial Consultant
    • Research Coordinators
    • Palliative Care
    • Genetic Counselor
  • 16. Goals of GI MDC
        • Provide high-quality multidisciplinary patient care:
          • Patients see a radiation oncologist, surgical oncologist, medical oncologist, nurse navigator, nutritionist, and cancer patient support specialists in a single visit
          • Staging and treatment according to best practice standards (NCCN guidelines)
  • 17. Goals of GI MDC
      • Deliver efficient patient care and increase patient satisfaction:
        • Every effort to complete all necessary diagnostic testing made prior to the patient’s first MDC clinic visit
        • Provide both patients and their physicians with a clear treatment plan at the conclusion of their clinic visit
        • Patients will be seen in days, instead of weeks of being referred to the clinic
  • 18. Getting into the System…
    • GI referral
        • Abnormal finding on imaging and/or EGD/EUS
    • Primary care physician (PCP) referral
        • Abnormal finding on imaging
    • Self-referral
    • Medical Oncology
    • Radiologists
    • Pathology
  • 19.
    • Where do you get referrals from?
      • PCP
      • GI
      • Oncology
      • Radiology
      • Pathology
  • 20. Poll the Audience
    • When do you start navigating patients?
      • Abnormal finding
      • Confirmed cancer diagnosis
      • With treatment initiation
    • How long do you navigate your patients?
      • Through workup and diagnosis
      • Through treatment
      • Into survivorship
    • What is your case load?
  • 21. Initial Interview
    • Introduction of Nurse Navigator
    • Thorough intake
    • Education – clarification of diagnosis
      • Pamphlets/booklets
      • Websites
      • Answer their questions
    • Appointment!!
      • Explain MDC
  • 22.  
  • 23. MDC Appointment
    • Patient and support person(s):
      • Meet with each specialist individually
      • Information about diagnosis and treatment
      • Reinforcement of education/current knowledge
      • Questions
      • Plan: Next steps
  • 24. Case Discussion
    • 73-year-old man, P.L.
      • Medical history: diabetes, hypertension, chronic obstructive pulmonary disease, asthma
      • Social history: borderline mental retardation (independent with exception of management of his medications and finances), lives alone, no family in area, attends the VNA Adult Day Program Monday-Friday 8 AM to 5 PM, transportation provided by the Special Services Transportation Agency (SSTA)
        • Primary contact/support person is Heather, the RN at the Adult Day Program
  • 25. Continued…
    • Heather sets up an appointment for P.L. to see his PCP on 6/9/11 after noticing that he is “choking” and “coughing” when eating solids, once requiring the Heimlich maneuver
    • 50-lb weight loss noted over past year, although most loss is attributed to hospitalization for dehydration and hypoglycemia secondary to infection with the norovirus in late 2010. Was admitted to rehab for several months due to significant weakness and inability to perform activities of daily living
  • 26. Continued…
    • PCP refers P.L. to GI for EGD, done on 6/13/11
      • Mass in middle third of esophagus identified
      • Path c/w poorly differentiated squamous cell cancer
    • Referral to GI MDC by GI
      • Met with patient in endoscopy
      • GI unwilling to discharge patient home due to
        • No caregiver at home to monitor patient post-anesthesia
        • SSTA to transport patient home
      • Phone call to Heather to see if VNA could provide a home visit to assess patient that evening
  • 27. Continued…
    • Due to social situation/patient anxiety, staging CT was bypassed in favor of a PET/CT to reduce number of tests/visits
      • H&P, CBC, and chemistry profile
      • EGD
      • CT chest/abdomen with IV and oral contrast
      • PET scan if no evidence of M1 disease
      • EUS if no evidence of M1 disease, with FNA if indicated
    • PET/CT performed on 6/21/11
      • Avid FDG uptake in the esophageal mass and in an 8-mm para-esophageal LN
  • 28. Continued…
    • EUS 6/24/11
      • 7-cm esophageal mass, invading the adventitia (T3)
      • Lymph nodes around the mass seemed to be involved, with 1 to 2 nodes greater than 1 cm (N1)
      • Clinically staged as T3 N1 M0 (stage III)
  • 29. Continued…
    • GI MDC 6/27/11
      • Evaluated by medical, radiation, and surgical oncology
      • Role of chemo versus chemoradiation versus palliation of symptoms discussed
        • Not an ideal candidate for surgery, role of surgery to be determined
      • Treatment with chemoradiation recommended
      • Initiated weekly paclitaxel/carboplatin with radiation on 7/18/11
  • 30. Continued…
    • P.L. also meets with…
      • Jessica, ACS Patient Navigator
      • Jennifer, Nutritionist
      • Julia, Psychologist
  • 31. Lower GI-Colon Cancer Work-Up
    • Case Study E.H.
      • 53-year-old male
      • Presented with anemia
      • Abdominal CT scan reveled umbilical hernia and multiple liver lesions
      • Liver lesions were thought to be cysts and cavernous hemangioma
      • Ultrasound reading didn’t agree
      • Colonoscopy revealed mass at hepatic flexure
  • 32. Colon Cancer Work-Up (cont.)
    • You are the Nurse Navigator referred to work with the patient
    • What would you recommend the physicians order next?
    • NCCN guidelines
    • CEA
    • CT of Pelvis and Chest
    • PET
    • Why??
    • To assess liver lesions
  • 33. Colon Cancer Work-Up (cont.)
    • Sent to surgery without further evaluation of liver lesions
    • Liver was palpated in surgery and described as normal
    • Patient unhappy with his care, came to The Lacks Cancer Center
    • Proper work-up completed
    • Liver lesions positive on PET
    • Chemotherapy followed by liver resection
  • 34. Colon Cancer Follow-Up Care Case Study
    • Case Study P.I.
      • 65-year-old male
      • Screening colonoscopy found colon cancer
      • Right hemicolectomy
      • T2, N0, M0 – Stage I
  • 35. Colon Cancer Follow-Up (cont.)
      • What should his surveillance consist of?
      • Surveillance with CEA and CT scans
      • Rise in CEA and liver lesion seen on CT scan
      • Liver biopsy order
      • Biopsy canceled by radiologist, because it was a “hemagioma”
  • 36. Colon Cancer Follow-Up (cont.)
    • Repeat scan ordered by oncologist
    • Liver lesion seen once again
    • Biopsied – + adenocarcinoma
    • PET scan – 2 lesions in liver
    • Referred to Nurse Navigator
    • Referred to surgical oncology
    • Liver resection followed by chemotherapy
  • 37. Long-Term Colon Cancer Surveillance
    • What should it include?
      • CEA
      • CT
        • C/A/P or A/P
  • 38. Resources
    • National Comprehensive Cancer Network (NCCN) guidelines (for work-up, diagnosis, staging, and treatment) – NCCN.org
    • American Cancer Society – Cancer.org
    • National Cancer Institute (NCI) – Cancer.gov
    • Pancreatic Cancer Action Network (PanCAN)
    • The Lustgarten Foundation for Pancreatic Cancer
    • Mycoloncancercaoch.org
    • AJCC staging manual
    • AONN.org
    • What are your favorite resources?
  • 39. Take-Home Points/Conclusion
    • Develop a consistent process
    • Provide clear communication to patients and providers
    • Be alert to red flags
      • Eliminate barriers
      • Improve timely service
    • Use quality standards and guidelines
    • Measure your success!
  • 40. Questions to Ponder
    • What do you like best about being a navigator?
    • What do you like least about being a navigator?
    • Is there anything you would change about your current navigation role or program?