The document discusses patient navigation across the care continuum. It describes the roles of various types of navigators in integrating both community and nurse navigators. Strategies are presented to identify and address barriers across the entire care process. The institutional structures and resources that support the navigation model are described, including how implementation and sustainability are achieved.

1. Patient Navigation Across the Continuum Linda Fleisher, PhD, MPH Assistant Vice President Office of Health & Communications Disparities Bonnie J. Miller, RN, BSN, OCN, FAAMA Administrative Director, Women’s Cancer Center Fox Chase Cancer Center

2. Objectives Discuss the roles of various types of navigators and our approach integrating both community and nurse navigators Describe the strategies to identify and address barriers across the continuum of care Describe the institutional structures and resources that support our model that support the implementation and sustainability

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4. Distinguished Honors & Accomplishments Extraordinary Contributions to Basic Science-Philadelphia Chromosome, Hepatitis-B, “Two Hit Theory,” SCID mouse, and Protein Trafficking International Recognition- 2 Nobel Prizes, 7-NAS, Pontifical Society, 3-ACS Gold Medals, 4-BMS Prizes, Kyoto Award Discovery of Hepatitis B and Vaccine Development by Baruch Blumberg, Nobel Prize, 1976 Knudson’s “Two Hit” Theory by Alfred Knudson, Kyoto Prize for Basic Science, 2004, and the Lasker Award 1998

5. Distinguished Honors & Accomplishments The First Multidisciplinary Cancer Prevention Research Facility in the World- March, 2000 Clinical Recognition for Excellence-Esophageal Cancer, Ovarian Cancer, and Innovative Radiation- (3-D Conformal and IMRT) 32 out of 80 Physicians were selected as Top Doctors-Philadelphia Magazine (April 2007) Magnet Award for Nursing Excellence-ANA- 2000, 2004, 2009 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)

6. Bonnie J. Miller, RN, BSN, OCN, FAAMA Administrative Director Women’s Cancer Center at FCCC with oversight of Clinical Navigation Chair Navigation Steering Committee for FCCC Point Person: Strategic Plan FCCC: Patient Navigation Co-author Orientation Manual for Navigation Education Coordinator Navigator Orientation/Training Consultant for FCCC: Program Development, Strategic Planning, Disease Management, Quality and Education Experienced GYN ONC Nurse Navigator

8. Founded and directs the FCCC’s Resource and Education Center

9. Conducted a qualitative study at Temple University in 2005 which lead to the development of the PA Navigator Demonstration Project

10. Co-lead (S. Miller & Fleisher) the PA Navigator Demonstration Project – a three year project with funds from PA DOH

11. Developed the Patient Navigation Resource Guide

12. Co-founded the PA Navigator Network

13. Steering Committee for the Academy of Oncology Nurse Navigators

14. Developed patient navigation for our community screening program

16. One Size Does Not Fit All

17. Vision of an Integrated Model of Patient Navigation

18. Internal Barriers to Successful Implementation Lack of knowledge Lack of clarity and need for navigation Poor role development Lack of physician champion Lack of Administration/leadership support Claiming navigator “ownership” System “change” “Blurry lines” /“plugging holes” No outcome measures defined Data management systems Evaluation

20. Show gaps openly: Demonstrate need

21. Secure a physician/leadership champion (s)

23. Set framework, policies and timeliness for program development

25. Center-wide data base

27. Office of Health Communications and Health Disparities

28. Patient Access

29. Hospital Administration

30. Nursing Administration

31. Social Work

32. Volunteers

33. Physician Champion

34. Clinical Research

35. Ambulatory Care

36. ALL NavigatorsGoals: Consistency Communication Collaboration

38. Demographics

39. Diagnosis

40. Call to NPO

41. Call of NPO to Navigator to Patient

42. Appointments kept/missed/why

44. Family History and Screening History

45. Abnormal

46. Time to follow-up

49. 3-month PILOT

50. 1.2-2.0 FTE Navigators

52. Thoracic

53. Infusion

55. Key Institutional Factors Champions Senior Leadership support ROI – proof of concept Integration into strategic plan Transitioning existing staff Coordinated and consistent training and data collection Screening Treatment Survivorship Academic opportunities

56. Service Line Concept Enhances Role of Disease Specific Nurse Navigation Organ/Disease Specific focused teams Program development in alignment with strategic priorities Processes to improve patient satisfaction Increase Clinical Research accrual from Prevention through Survivorship Physicians, APCs, Navigators, Administration, Social Service, Protocol Office

57. Service Line Goals/Governance/Accountability Quality Improvement Clinical Research, Performance and Priority Setting Strategic Growth Planning Clinical Practice Standards: Include algorithms for patient intake, scheduling, improve patient satisfaction, multidisciplinary/solo practice, use of Navigators and APCs Regulatory - CoC Coordinate processes for services delivered within Facility Input in budget and fiscal oversight

58. Navigation Process Ideal Patient Navigation Model

59. Differences in Navigation Services Proportionate with acuity/needs of patients Changes with disease specific navigation Changes with specific sssignments of Navigation (Infusion Room) Service level declines as volumes rise Low volume/high acuity= ie: Head and Neck population High volume/different needs=ie: Breast population

60. Focused Areas of Data Capture Improved coordination of high-quality care Enhanced access to services for patients Removal of barriers to care Improved outcomes Improved sharing of resources Enhanced relationships with the community Increased patient satisfaction Increased referrals of patients to the system

61. Impact of Navigation: Retention Rates with Disease Specific Navigation

62. Impact of Navigation: Increase in Clinical Trial Accrual

64. ACCESS Database

65. Web Based Application

66. Links with current systems at FCCC

67. Scheduling, Chemo, Radiation, Coding/Billing

68. Less Time and Effort from Navigations

69. Reports Built in (Updated Daily)

70. Home Grown/Updated/Navigation Input

72. Internal/External Marketing/Education Center wide Navigation Steering Committee Presentation to Management Team Service Line Meeting Format Physician Champions Community Advisory Committee Presentation to Partner Organizations Consistency in messaging…. External: Website, Print Materials, Commercial, Webisodes

73. Marketing: WCC Brochure

74. Communications: Web Page

75. Women’s Cancer Center Commercial Featuring Navigators

77. Clinical trials (esp. underrepresented groups)Develop and conduct systematic patient satisfaction and impact evaluation Expand Navigator role in Service Line Design Continued education about the role & scope of navigation Grant/Research Opportunities Ever Changing…Ever Evolving….Patient Focused

78. Community Navigation

80. PA Cancer Education Network

81. Neighbors Program

82. General & Minority Outreach

83. State CCC

84. Dissemination of Body & Soul

85. New Partnerships

86. Targeted Media

87. Health Communications

88. Health Literacy

89. Resource and Education Center

90. Patient Education

91. Patient Navigation

92. Community Cancer Screening

93. Corporate and Community

95. CIS Research Consortium

96. Prostate Cancer Decision Tool –Healing Choices

97. Research Studies: E-health, Community, Survivorship

98. P20 Lincoln Partnership

99. NCI’s Geographic Management Program

100. Health Disparities Research Work GroupOffice of Health Communications and Health Disparities, 2011

101. Office of Health Communications & Health Disparities Community Engagement & Partnerships, Fundraising & Grants, Evaluation, Communication, and Training

102. Breast Cancer Skin Cancer Prostate Cancer Breast Cancer Relief Fund Funding for underserved Philadelphia Foundation Pt. Navigator Pilot Programs & Research potential New Database Linkage to FCCC Community Screening

103. In the News…. Mobile Mammography on 6ABC News

104. Screenings July 2010 thru April 2011 Funding Sources (non-private insurance): Breast Cancer Relief Fund – 20 Latina + 26 Asian women = $9,500 Wawa (coin box collection) - 91 uninsured @ $90,700 for screening and diagnostic services HealthyWoman (CDC Breast and Cervical) = 221 Keystone Mercy Health Plan = 203

106. Emotional support

107. Appointments

108. Transportation

109. Insurance/financial support

110. Translation

112. Mammography Navigation PilotDecember 2010 – April 2011 Purpose: Navigate uninsured women with additional services as needed Selection Criteria: Uninsured, Healthy Woman 29 uninsured women received diagnostic mammograms Clinical Outcomes 17 had ultrasounds 3 had stereotactic biopsies 1 woman diagnosed 1 six-month follow-up Challenges Language – 19 women (Spanish, Chinese, Korean) Transportation – 5 (we paid $125 for transport to FCCC) Unable to reach participant Obtain needed prescriptions for services Successes 29 women navigated for continuity of care. Included assistance with appointment scheduling and transportation. Average of 12 days between initial screening and diagnostic testing

114. 1 Caucasian

116. Prostate REACH Navigation Advertising through community partners Men call into PRAP office, if no insurance they are referred to the navigator & scheduled for upcoming community program Navigator assesses barriers, works with financial services and addresses other barriers Navigator is present at screening Navigator follows all men with an abnormal result and facilitates access to follow-up care at Fox Chase Funding for navigator, screening and biospy through foundation funding

117. Lessons Learned

119. Senior Leadership support

120. ROI – proof of concept

121. Integration into strategic plan

123. Coordinated and consistent training and data collection

125. Contact Info Bonnie J. Miller, RN, BSN, OCN, FAAMA Fox Chase Cancer Center Women’s Cancer Center 333 Cottman Avenue Philadelphia, Pa. 19111 Bonnie.Miller@fccc.edu 215-728-7036 (Office) 215-728-3100 (Adm Office) Linda Fleisher, PhD, MPH Fox Chase Cancer Center Office of Health Communications and Health Disparities 510 Township Line Road Cheltenham, PA 19012 Linda.Fleisher@fccc.edu 215-728-3690 (Office)