Patient Navigation Across the Continuum

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Linda Fleisher, PhD, MPH
Bonnie J. Miller, RN, BSN, OCN, FAAMA

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  • Corporate 65%Community =
  • Patient Navigation Across the Continuum

    1. 1. Patient Navigation Across the Continuum<br />Linda Fleisher, PhD, MPH<br />Assistant Vice President<br />Office of Health & Communications Disparities<br />Bonnie J. Miller, RN, BSN, OCN, FAAMA<br />Administrative Director, Women’s Cancer Center<br />Fox Chase Cancer Center<br />
    2. 2. Objectives<br />Discuss the roles of various types of navigators and our approach integrating both community and nurse navigators<br />Describe the strategies to identify and address barriers across the continuum of care<br />Describe the institutional structures and resources that support our model that support the implementation and sustainability<br />
    3. 3. 2<br />
    4. 4. Distinguished Honors & Accomplishments <br />Extraordinary Contributions to Basic Science-Philadelphia Chromosome, Hepatitis-B, “Two Hit Theory,” SCID mouse, and Protein Trafficking<br />International Recognition- 2 Nobel Prizes, 7-NAS, Pontifical Society, 3-ACS Gold Medals, 4-BMS Prizes, Kyoto Award<br />Discovery of Hepatitis B and Vaccine Development by Baruch Blumberg, Nobel Prize, 1976<br />Knudson’s “Two Hit” Theory by Alfred Knudson, Kyoto Prize for Basic Science, 2004, and the Lasker Award 1998<br />
    5. 5. Distinguished Honors & Accomplishments <br />The First Multidisciplinary Cancer Prevention Research Facility in the World- March, 2000<br />Clinical Recognition for Excellence-Esophageal Cancer, Ovarian Cancer, and Innovative Radiation- (3-D Conformal and IMRT)<br />32 out of 80 Physicians were selected as Top Doctors-Philadelphia Magazine (April 2007)<br />Magnet Award for Nursing Excellence-ANA- 2000, 2004, 2009<br />Fox Chase Cancer Center Ranked Top as “America’s Best Hospitals” in the Tri-state area, and 11th in the Nation- U.S. News & World Report’s (July 2007)<br />
    6. 6. Bonnie J. Miller, RN, BSN, OCN, FAAMA<br />Administrative Director Women’s Cancer Center at FCCC with oversight of Clinical Navigation<br />Chair Navigation Steering Committee for FCCC<br />Point Person: Strategic Plan FCCC: Patient Navigation<br />Co-author Orientation Manual for Navigation<br />Education Coordinator Navigator Orientation/Training <br />Consultant for FCCC: Program Development, Strategic Planning, Disease Management, Quality and Education<br />Experienced GYN ONC Nurse Navigator<br />
    7. 7. Linda Fleisher, PhD, MPH<br /><ul><li>Implemented the NCI’s Cancer Information Service for 15 years – telephone navigation
    8. 8. Founded and directs the FCCC’s Resource and Education Center
    9. 9. Conducted a qualitative study at Temple University in 2005 which lead to the development of the PA Navigator Demonstration Project
    10. 10. Co-lead (S. Miller & Fleisher) the PA Navigator Demonstration Project – a three year project with funds from PA DOH
    11. 11. Developed the Patient Navigation Resource Guide
    12. 12. Co-founded the PA Navigator Network
    13. 13. Steering Committee for the Academy of Oncology Nurse Navigators
    14. 14. Developed patient navigation for our community screening program
    15. 15. FCCC’s Navigation Steering Committee</li></li></ul><li>Navigation is… a noun and … a verb<br />
    16. 16. One Size Does Not Fit All<br />
    17. 17. Vision of an Integrated Model of Patient Navigation<br />
    18. 18. Internal Barriers to Successful Implementation<br />Lack of knowledge<br />Lack of clarity and need for navigation<br />Poor role development<br />Lack of physician champion<br />Lack of Administration/leadership support<br />Claiming navigator “ownership”<br />System “change”<br />“Blurry lines” /“plugging holes”<br />No outcome measures defined<br />Data management systems<br />Evaluation<br />
    19. 19. Strategies for Successful Implementation<br />Buy-in<br /><ul><li>Education to staff/service line
    20. 20. Show gaps openly: Demonstrate need
    21. 21. Secure a physician/leadership champion (s)
    22. 22. Change=Progress=“it’s ok”</li></ul>Structure and Roles<br /><ul><li>Clearly define roles
    23. 23. Set framework, policies and timeliness for program development
    24. 24. Establish internal communication plan for policy and procedure</li></ul>Evaluation<br /><ul><li>Share outcomes
    25. 25. Center-wide data base
    26. 26. Develop evaluation including measures</li></ul>Sustainability<br /><ul><li>Integrate into Strategic Plan</li></li></ul><li>FCCC Navigation Steering Committee<br />Leadership: Clinical<br />Leadership Support: Academic<br />Representation:<br /><ul><li>Women’s Cancer Center
    27. 27. Office of Health Communications and Health Disparities
    28. 28. Patient Access
    29. 29. Hospital Administration
    30. 30. Nursing Administration
    31. 31. Social Work
    32. 32. Volunteers
    33. 33. Physician Champion
    34. 34. Clinical Research
    35. 35. Ambulatory Care
    36. 36. ALL Navigators</li></ul>Goals:<br /> Consistency<br /> Communication<br /> Collaboration<br />
    37. 37. Qualitative/Quantitative Navigation Measures<br />Implementation & Tracking<br />Patients accepting not <br />accepting navigation/ reasons<br />Education information <br />provided<br />Barriers/Resolution<br />Resources (internal/<br />external)<br />Clinical Trial <br />opportunities/accrual<br />Biosample repository <br />recruitment<br />Patient Satisfaction<br />Downstream revenue (Retention) <br />Clinical<br /><ul><li>Number of patients
    38. 38. Demographics
    39. 39. Diagnosis
    40. 40. Call to NPO
    41. 41. Call of NPO to Navigator to Patient
    42. 42. Appointments kept/missed/why
    43. 43. Appointment falling out of 7 day window (Strategic Goal)</li></ul>Community Screening<br /><ul><li>Demographics
    44. 44. Family History and Screening History
    45. 45. Abnormal
    46. 46. Time to follow-up
    47. 47. Outcome</li></li></ul><li>Clinical Navigation<br />
    48. 48. History<br />Started in Women’s Cancer Center <br /><ul><li>Breast
    49. 49. 3-month PILOT
    50. 50. 1.2-2.0 FTE Navigators
    51. 51. Launch GYN 7 months later</li></ul>Multiple Service Lines and Departments<br /><ul><li>Head & Neck
    52. 52. Thoracic
    53. 53. Infusion
    54. 54. GI</li></li></ul><li>Rationale for Nurse Navigator Role<br />Service Line Enhancement<br />Disease Specific Model of Care<br />Complexity of Health Care System<br />Access to FCCC and Retention Goals<br />Complexity of Cancer Care<br />Gaps/Barriers<br />Opportunity in WCC, Head and Neck Service Line, Thoracic and Infusion Room<br />Linkage to Clinical Research/Mission of FCCC<br />Response to Patients<br />
    55. 55. Key Institutional Factors<br />Champions<br />Senior Leadership support<br />ROI – proof of concept<br />Integration into strategic plan<br />Transitioning existing staff <br />Coordinated and consistent training and data collection<br />Screening Treatment Survivorship<br />Academic opportunities<br />
    56. 56. Service Line Concept Enhances Role of Disease Specific Nurse Navigation<br />Organ/Disease Specific focused teams<br />Program development in alignment with strategic priorities<br />Processes to improve patient satisfaction<br />Increase Clinical Research accrual from Prevention through Survivorship<br />Physicians, APCs, Navigators, Administration, Social Service, Protocol Office<br />
    57. 57. Service Line Goals/Governance/Accountability<br />Quality Improvement<br />Clinical Research, Performance and Priority Setting<br />Strategic Growth Planning<br />Clinical Practice Standards: Include algorithms for patient intake, scheduling, improve patient satisfaction, multidisciplinary/solo practice, use of Navigators and APCs<br />Regulatory - CoC<br />Coordinate processes for services delivered within Facility<br />Input in budget and fiscal oversight<br />
    58. 58. Navigation Process<br />Ideal Patient Navigation Model<br />
    59. 59. Differences in Navigation Services<br />Proportionate with acuity/needs of patients<br />Changes with disease specific navigation<br />Changes with specific sssignments of <br /> Navigation (Infusion Room)<br />Service level declines as volumes rise<br />Low volume/high acuity= ie: Head and Neck population<br />High volume/different needs=ie: Breast population<br />
    60. 60. Focused Areas of Data Capture<br />Improved coordination of high-quality care<br />Enhanced access to services for patients<br />Removal of barriers to care<br />Improved outcomes<br />Improved sharing of resources<br />Enhanced relationships with the community<br />Increased patient satisfaction<br />Increased referrals of patients to the system<br />
    61. 61. Impact of Navigation: Retention Rates with Disease Specific Navigation<br />
    62. 62. Impact of Navigation: Increase in Clinical Trial Accrual <br />
    63. 63. Navigation Database Evolution<br />Transition/Development<br /><ul><li>Excel Spreadsheet
    64. 64. ACCESS Database
    65. 65. Web Based Application
    66. 66. Links with current systems at FCCC
    67. 67. Scheduling, Chemo, Radiation, Coding/Billing
    68. 68. Less Time and Effort from Navigations
    69. 69. Reports Built in (Updated Daily)
    70. 70. Home Grown/Updated/Navigation Input
    71. 71. Integrated into current system: “We created something pretty good!”</li></li></ul><li>Navigation Database<br />
    72. 72. Internal/External Marketing/Education<br />Center wide Navigation Steering Committee<br />Presentation to Management Team<br />Service Line Meeting Format<br />Physician Champions<br />Community Advisory Committee<br />Presentation to Partner Organizations<br />Consistency in messaging….<br />External: Website, Print Materials, Commercial, Webisodes<br />
    73. 73. Marketing: WCC Brochure<br />
    74. 74. Communications: Web Page <br />
    75. 75. Women’s Cancer Center Commercial Featuring Navigators<br />
    76. 76. Next Steps<br />Expand navigators role in research<br /><ul><li>Biospecimen collection
    77. 77. Clinical trials (esp. underrepresented groups)</li></ul>Develop and conduct systematic patient <br />satisfaction and impact evaluation<br />Expand Navigator role in Service Line Design<br />Continued education about the role & scope of navigation<br />Grant/Research Opportunities<br />Ever Changing…Ever Evolving….Patient Focused<br />
    78. 78. Community Navigation<br />
    79. 79. Programs & Research<br /><ul><li>Community Outreach & Education
    80. 80. PA Cancer Education Network
    81. 81. Neighbors Program
    82. 82. General & Minority Outreach
    83. 83. State CCC
    84. 84. Dissemination of Body & Soul
    85. 85. New Partnerships
    86. 86. Targeted Media
    87. 87. Health Communications
    88. 88. Health Literacy
    89. 89. Resource and Education Center
    90. 90. Patient Education
    91. 91. Patient Navigation
    92. 92. Community Cancer Screening
    93. 93. Corporate and Community
    94. 94. Breast, Skin and Prostate</li></ul>Research & Evaluation<br /><ul><li>NCI’s Community Health Education Network
    95. 95. CIS Research Consortium
    96. 96. Prostate Cancer Decision Tool –Healing Choices
    97. 97. Research Studies: E-health, Community, Survivorship
    98. 98. P20 Lincoln Partnership
    99. 99. NCI’s Geographic Management Program
    100. 100. Health Disparities Research Work Group</li></ul>Office of Health Communications and Health Disparities, 2011<br />
    101. 101. Office of Health Communications & Health Disparities<br />Community Engagement & Partnerships, Fundraising & Grants, Evaluation, Communication, and Training <br />
    102. 102. Breast Cancer<br />Skin Cancer<br />Prostate Cancer<br />Breast Cancer<br />Relief Fund<br />Funding for <br />underserved<br />Philadelphia<br />Foundation<br />Pt. Navigator Pilot<br />Programs & <br />Research<br />potential<br />New Database<br />Linkage to FCCC<br />Community Screening<br />
    103. 103. In the News….<br />Mobile Mammography on 6ABC News<br />
    104. 104. Screenings July 2010 thru April 2011<br />Funding Sources (non-private insurance):<br />Breast Cancer Relief Fund – 20 Latina + 26 Asian women = $9,500<br />Wawa (coin box collection) - 91 uninsured @ $90,700 for screening and diagnostic services<br />HealthyWoman (CDC Breast and Cervical) = 221<br />Keystone Mercy Health Plan = 203<br />
    105. 105. Community Navigators<br />Seasoned health educators<br />Extensive community work<br />Collaborate with community <br />partners – co-navigate<br />Role<br /><ul><li>Ensure follow-up care
    106. 106. Emotional support
    107. 107. Appointments
    108. 108. Transportation
    109. 109. Insurance/financial support
    110. 110. Translation
    111. 111. Referrals to support services</li></li></ul><li>Mobile Mammography Navigation<br />Pilot program focused on underserved<br />All women with an abnormal finding are contacted by navigator<br />Navigator assesses & addresses barriers to follow-up<br />Provide support to return to FCCC or other appropriate facility for follow-up <br />
    112. 112. Mammography Navigation PilotDecember 2010 – April 2011<br />Purpose: Navigate uninsured women with additional services as needed<br />Selection Criteria: Uninsured, Healthy Woman<br />29 uninsured women received diagnostic mammograms <br />Clinical Outcomes<br />17 had ultrasounds<br />3 had stereotactic biopsies<br />1 woman diagnosed<br />1 six-month follow-up<br />Challenges<br />Language – 19 women (Spanish, Chinese, Korean)<br />Transportation – 5 (we paid $125 for transport to FCCC)<br />Unable to reach participant<br />Obtain needed prescriptions for services<br />Successes<br />29 women navigated for continuity of care. Included assistance <br />with appointment scheduling and transportation. <br />Average of 12 days between initial screening and diagnostic testing<br />
    113. 113. Project REACHPilot for Community-Based Prostate Risk Assessment Program<br />Collaboration between OHCHD and Prostate Risk Assessment Program; funded by The Philadelphia Foundation<br />Community partners provide location for mobile van where screening takes place<br />Full PRAP services (DRE,PSA, research bloods and educ)<br />Navigation services and funds for uninsured men<br />12 men screened/1 biopsy<br /><ul><li>9 Black/ African American
    114. 114. 1 Caucasian
    115. 115. 1 Trinidadian </li></li></ul><li>Future Plans<br />Navigate all community screening participants as needed <br />HealthyWoman – expand agreement to include diagnostic testing and treatment <br />Health Partners – establish a comprehensive agreement to cover women with this Medicaid insurance<br />Seek IRB approval to conduct quality improvement and outcomes analyses<br />
    116. 116. Prostate REACH Navigation<br />Advertising through community partners<br />Men call into PRAP office, if no insurance they are referred to the navigator & scheduled for upcoming community program<br />Navigator assesses barriers, works with financial services and addresses other barriers<br />Navigator is present at screening<br />Navigator follows all men with an abnormal result and facilitates access to follow-up care at Fox Chase<br />Funding for navigator, screening and biospy through foundation funding<br />
    117. 117. Lessons Learned<br />
    118. 118. Lessons Learned<br />Infrastructure<br /><ul><li>Champions
    119. 119. Senior Leadership support
    120. 120. ROI – proof of concept
    121. 121. Integration into strategic plan
    122. 122. Steering Committee across all domains</li></ul>Staffing<br /><ul><li>Transitioning existing staff
    123. 123. Coordinated and consistent training and data collection
    124. 124. Coordination across all navigators</li></ul>Promotion & Marketing<br />Evaluation<br /><ul><li>Consistent data collection – with a goal to evaluation and research</li></li></ul><li>Lessons Learned: The Five Cs<br />Committee Oversight<br />Infrastructure across domains – Steering Committee<br />Center wide component of Strategic Plan<br />Alignment with Strategic Goals for Center (Enhancing Patient Experience)<br />Coordination across all navigators<br />All one “Team”<br />Comprehensive Education, Promotion & Marketing<br />Consistent data collection <br />All Navigators<br />Goal to evaluation and research<br />
    125. 125. Contact Info<br />Bonnie J. Miller, RN, BSN, OCN, FAAMA<br />Fox Chase Cancer Center<br />Women’s Cancer Center<br />333 Cottman Avenue<br />Philadelphia, Pa. 19111<br />Bonnie.Miller@fccc.edu<br />215-728-7036 (Office)<br />215-728-3100 (Adm Office)<br />Linda Fleisher, PhD, MPH<br />Fox Chase Cancer Center<br />Office of Health Communications <br />and Health Disparities<br />510 Township Line Road<br />Cheltenham, PA 19012<br />Linda.Fleisher@fccc.edu <br />215-728-3690 (Office)<br />

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