Oncology Navigators:Oncology Navigators:The Tipping PointThe Tipping Point

Brenda Nevidjon, MSN, RN, FAANBrenda Nevidjon, MSN, RN, FAAN

Clinical Professor, Duke School of NursingClinical Professor, Duke School of Nursing

President, Oncology Nursing SocietyPresident, Oncology Nursing Society

Tipping PointTipping Point

The moment of critical mass, theThe moment of critical mass, thethreshold, the boiling point.threshold, the boiling point.

Characteristics:Characteristics:

1) Contagiousness,1) Contagiousness,

2) Little causes can have big effects,2) Little causes can have big effects,

3) Change happens at one dramatic moment3) Change happens at one dramatic moment

(Malcolm Gladwell, The Tipping Point, 2002)(Malcolm Gladwell, The Tipping Point, 2002)

The Harold P. Freeman PatientThe Harold P. Freeman PatientNavigator Institute (1990s)Navigator Institute (1990s)

Purpose:Purpose: eliminating barriers to timelyeliminating barriers to timelycancer screening, diagnosis, treatmentcancer screening, diagnosis, treatmentand supportive care.and supportive care. It has since evolvedIt has since evolvedto include the timely movement of anto include the timely movement of anindividual across the entire health careindividual across the entire health carecontinuum from prevention, detection.continuum from prevention, detection.diagnosis, treatment, supportive and enddiagnosis, treatment, supportive and end--ofof--life care.life care.

http://www.hpfreemanpni.orghttp://www.hpfreemanpni.org

Freeman Patient NavigationFreeman Patient NavigationModelModel

http://www.hpfreemanpni.org/patient-navigation/

Freeman Model: BarriersFreeman Model: Barriers

Financial barriers (including uninsured andFinancial barriers (including uninsured andunder insured)under insured)

Communication barriers (such as lack ofCommunication barriers (such as lack ofunderstanding, language/cultural)understanding, language/cultural)

Medical system barriers (fragmented medicalMedical system barriers (fragmented medicalsystem, missed appointments, lost results)system, missed appointments, lost results)

Psychological barriers (such as fear and distrust)Psychological barriers (such as fear and distrust)

Other barriers (such as transportation and needOther barriers (such as transportation and needfor child care)for child care)

Voices for a Broken SystemVoices for a Broken System(2001)(2001)

PresidentPresident’’s Cancer Panel reports Cancer Panel report

Identified barriers to cancer careIdentified barriers to cancer care

Did not specifically recommend patientDid not specifically recommend patientnavigation programsnavigation programs

http://deainfo.nci.nih.gov/Advisory/pcp/videohttp://deainfo.nci.nih.gov/Advisory/pcp/video--summary.htmsummary.htm

NCI's Patient NavigatorNCI's Patient NavigatorResearch Program (2004)Research Program (2004)

The purpose of the Patient Navigator Research ProgramThe purpose of the Patient Navigator Research Programis to develop interventions to reduce the time of deliveryis to develop interventions to reduce the time of deliveryof standardof standard cancercancer services, cancerservices, cancer diagnosisdiagnosis, and, andtreatment after identifying antreatment after identifying an abnormalabnormal finding.finding.

The patient navigator will assist patients and theirThe patient navigator will assist patients and theirfamilies through the cancer care continuum. Examples offamilies through the cancer care continuum. Examples ofnavigation services may include: arranging various formsnavigation services may include: arranging various formsof financial support; scheduling transportation toof financial support; scheduling transportation toappointments; and organizing childcare duringappointments; and organizing childcare duringappointments.appointments.

http://www.cancer.gov/cancertopics/factsheet/nci/patientnavigatohttp://www.cancer.gov/cancertopics/factsheet/nci/patientnavigatorr

NCI's Patient NavigatorNCI's Patient NavigatorResearch Program (2004)Research Program (2004)

A patient navigator can be a registeredA patient navigator can be a registerednursenurse or aor a social workersocial worker who functions aswho functions asa "guide." Navigators help their patientsa "guide." Navigators help their patientsmove through the complexities of themove through the complexities of thehealthcare system.healthcare system.

NCI's Patient NavigatorNCI's Patient NavigatorResearch Program (2004)Research Program (2004)

NCI will assess the impact of patientNCI will assess the impact of patientnavigators on providing timely qualitynavigators on providing timely qualitystandard care and encouraging researchstandard care and encouraging researchcollaborations and partnerships acrosscollaborations and partnerships acrosscancer care delivery systems andcancer care delivery systems andorganizations (e.g., primary care facilities,organizations (e.g., primary care facilities,community health centers, hospitals, andcommunity health centers, hospitals, andacademic centers).academic centers).

Patient Navigator Outreach &Patient Navigator Outreach &Chronic Disease Prevention ActChronic Disease Prevention Act

Signed by President Bush in 2005Signed by President Bush in 2005

Provides funds for navigation programs inProvides funds for navigation programs incancer centerscancer centers

http://bhpr.hrsa.gov/patientnavigatorhttp://bhpr.hrsa.gov/patientnavigator

ACS Navigator (2005)ACS Navigator (2005)

American Cancer Society Navigators act on behalf of those affectAmerican Cancer Society Navigators act on behalf of those affectededby cancer in every community to identify and obtain beneficialby cancer in every community to identify and obtain beneficialresources. Navigators offer free, confidential assistance to canresources. Navigators offer free, confidential assistance to cancercerpatients and those who care for them. Navigators are trained topatients and those who care for them. Navigators are trained tolisten to you, learn your needs and put together a plan of actiolisten to you, learn your needs and put together a plan of action thatn thatis tailoris tailor--made just for youmade just for you…… What can a Navigator do for you?What can a Navigator do for you?

Provide extensive cancer informationProvide extensive cancer information Assist in locating local and national resourcesAssist in locating local and national resources Arrange for durable medical equipment such as wheelchairs,Arrange for durable medical equipment such as wheelchairs,

walkers and bedswalkers and beds Coordinate transportation and lodgingCoordinate transportation and lodging Connect you with wigs, hats and prostheses resourcesConnect you with wigs, hats and prostheses resources And so much moreAnd so much more……

http://www.cancer.org/docroot/COM/content/div_OH/COM_6_1x_Patienhttp://www.cancer.org/docroot/COM/content/div_OH/COM_6_1x_Patient_Navigator.aspt_Navigator.asp

Breast Patient Navigator Certification:Breast Patient Navigator Certification:National Consortium of Breast Centers (2008)National Consortium of Breast Centers (2008)

Certification EligibilityCertification Eligibility1) Be medically licensed as a physician, professional nurse, rad1) Be medically licensed as a physician, professional nurse, radiologyiologytechnologist, social worker (licensed medical professionals) andtechnologist, social worker (licensed medical professionals) and hold ahold avalid license ORvalid license OR2) Be medically certified as a physician's assistant, radiology2) Be medically certified as a physician's assistant, radiology practitionerpractitionerassistant, social worker, advanced practice nurse, (certified meassistant, social worker, advanced practice nurse, (certified medicaldicalprofessionals) and hold a valid certification ORprofessionals) and hold a valid certification OR3) Be master level prepared in a health related field3) Be master level prepared in a health related fieldPlease consider the following before deciding to sit for the CerPlease consider the following before deciding to sit for the CertificationtificationExam: Although experience is not a condition of certification elExam: Although experience is not a condition of certification eligibility,igibility,the beta testing results have revealed that experience has a dirthe beta testing results have revealed that experience has a directectcorrelation to the level of success in passing the certificationcorrelation to the level of success in passing the certification examination.examination.

Certification TypesCertification TypesPart I is the Breast Imaging Navigator Certification Exam> CBPNPart I is the Breast Imaging Navigator Certification Exam> CBPN--II(Imaging) for the Certified Breast Imaging Patient Navigator(Imaging) for the Certified Breast Imaging Patient NavigatorPart II is the Breast Cancer Navigator Certification> CBPNPart II is the Breast Cancer Navigator Certification> CBPN--C (Cancer) forC (Cancer) forthe Certified Breast Cancer Patient Navigatorthe Certified Breast Cancer Patient Navigator

http://www.bpnc.org/abouthttp://www.bpnc.org/about--bpnc.cfmbpnc.cfm

National Coalition of OncologyNational Coalition of OncologyNurse Navigators (2008)Nurse Navigators (2008)

Conceived by five nurses who met whileConceived by five nurses who met whileattending meetings of the MD/DC/VAattending meetings of the MD/DC/VACoalition of Breast Care Coordinators aCoalition of Breast Care Coordinators aregional group of breast care nurseregional group of breast care nursenavigators (2003)navigators (2003)

www.www.nconnnconn.org.org

National Coalition of OncologyNational Coalition of OncologyNurse Navigators (2008)Nurse Navigators (2008)

MISSION:MISSION:

To promote excellence in oncology patient care byTo promote excellence in oncology patient care byfostering collaborative relationships and professionalfostering collaborative relationships and professionaldevelopment among oncology nurse navigators and alldevelopment among oncology nurse navigators and allhealthcare disciplines locally, regionally and nationally.healthcare disciplines locally, regionally and nationally.

VISION:VISION:

To be the national leader in establishing standards thatTo be the national leader in establishing standards thatdefine the oncology nurse navigator role by advocatingdefine the oncology nurse navigator role by advocatingfor the oncology nurse navigator within the communityfor the oncology nurse navigator within the communityand professional arenas.and professional arenas.

North Carolina OncologyNorth Carolina OncologyNavigator Association (2008)Navigator Association (2008)

Goals of the NCONA are to embrace thevision and mission of the NC State Cancerplan; increase awareness of the OncologyNavigator role; ensure that all newly-diagnosed patients and their caregiverswill be provided with patient navigationresources; and promote collegiality forbest practice.

Academy of Oncology NurseAcademy of Oncology NurseNavigators (2009)Navigators (2009)

Network for Oncology Nurse Navigators,Network for Oncology Nurse Navigators,Oncology Nurses, Practice Managers,Oncology Nurses, Practice Managers,Patient Care Coordinators, and NursingPatient Care Coordinators, and NursingAdministrators to better manage theAdministrators to better manage thecomplexities of the cancer care treatmentcomplexities of the cancer care treatmentcontinuum.continuum.

www.aonnonline.orgwww.aonnonline.org

Academy of Oncology NurseAcademy of Oncology NurseNavigators (2009)Navigators (2009)

AONN MissionAONN MissionThe mission of AONN is to provide a network forThe mission of AONN is to provide a network forOncology Nurses, Nurse Navigators, Practice Managers,Oncology Nurses, Nurse Navigators, Practice Managers,Patient Care Coordinators, and Nursing AdministratorsPatient Care Coordinators, and Nursing Administratorsto better manage the complexities of the cancer careto better manage the complexities of the cancer carecontinuum focused improving the treatment and qualitycontinuum focused improving the treatment and qualityof life of patients.of life of patients.

AONN VisionAONN VisionThe vision of AONN is to increase the role of and accessThe vision of AONN is to increase the role of and accessto oncology nurse navigators, so that all cancer patientsto oncology nurse navigators, so that all cancer patientsmay benefit from their guidance, insight, and personallymay benefit from their guidance, insight, and personallyadvocacy.advocacy.

Have we tipped?Have we tipped?

Examples that say we have.Examples that say we have.

&&

In 2007, Institute for Alternative FuturesIn 2007, Institute for Alternative Futuresreported over 200 programs in the US.reported over 200 programs in the US.

ExamplesExamples

At St. Anthony Hospital, we know that when youAt St. Anthony Hospital, we know that when youor your family member is diagnosed with canceror your family member is diagnosed with cancerthe feeling can be overwhelming. Wethe feeling can be overwhelming. Weunderstand the frustration and confusion youunderstand the frustration and confusion youmay have when it comes to medical tests,may have when it comes to medical tests,appointments, and insurance. Thatappointments, and insurance. That’’s why wes why wedeveloped our innovative Nurse Navigatordeveloped our innovative Nurse Navigatorprogram.program.

Working with breast and lung cancer patients,Working with breast and lung cancer patients,our Nurse Navigator expedites all aspects ofour Nurse Navigator expedites all aspects ofcare.care.

ExamplesExamples

"It's the bedside stuff they remember,""It's the bedside stuff they remember,"says (Jeanne) Poole, the breast cancersays (Jeanne) Poole, the breast cancernurse navigator at Rex Cancer Center innurse navigator at Rex Cancer Center inRaleigh, N.C. "When they're afraid andRaleigh, N.C. "When they're afraid andanxious, they appreciate having someoneanxious, they appreciate having someoneto hold their hand."to hold their hand."

Nurse.comNurse.com

ExamplesExamples

Nurse NavigatorsNurse Navigators are patient educatorsare patient educatorsand advocates, care coordinators, systemand advocates, care coordinators, systemnavigators, and community ambassadorsnavigators, and community ambassadorson a mission to improve the canceron a mission to improve the cancerexperience for each patient. The Nurseexperience for each patient. The NurseNavigators are aNavigators are a support system for thesupport system for thepatient and his/her family at a criticalpatient and his/her family at a criticaltimetime —— after diagnosis and throughafter diagnosis and throughtreatmenttreatment —— and serve as a "gateway" toand serve as a "gateway" toPalmetto Health services.Palmetto Health services.

ExamplesExamples

Patient Navigator, LLCPatient Navigator, LLCGuiding Your Journey Through Illness and AgingGuiding Your Journey Through Illness and Aging……

Patient Navigator, LLC is dedicated to workingPatient Navigator, LLC is dedicated to workingwith patients and families as they journeywith patients and families as they journeythrough illness and aging.through illness and aging. We provide you withWe provide you withinformation and researchinformation and research, we, we advocateadvocate ononyour behalf, weyour behalf, we solve problemssolve problems and we helpand we helpyou benefit from anyou benefit from an integrative careintegrative care approachapproachto your illness.to your illness.

ExampleExample

Nurse NavigatorNurse NavigatorssSMSM works with you toworks with you toidentify elder care needs, evaluateidentify elder care needs, evaluateoptions, put solutions in place and provideoptions, put solutions in place and providethe ongoing support needed to maintainthe ongoing support needed to maintainindependence and quality of life. Ourindependence and quality of life. Ouronline resources and telephoniconline resources and telephonicassistance with trained Eldercareassistance with trained EldercareSpecialists helps you plan and manageSpecialists helps you plan and managedecisions that arise as loved ones age.decisions that arise as loved ones age.

SM

ExampleExample

The Association of Community Cancer Centers' CenterThe Association of Community Cancer Centers' Centerfor Provider Education provides ACCC members withfor Provider Education provides ACCC members withthisthis Cancer Care Patient Navigation: A Call to ActionCancer Care Patient Navigation: A Call to Actiononline resource. ACCC launched this project to:online resource. ACCC launched this project to: Identify barriers to access to care that patient navigation canIdentify barriers to access to care that patient navigation can

addressaddress

Increase successful implementation of patient navigationIncrease successful implementation of patient navigationservicesservices

Refine staffing modelsRefine staffing models

Establish effective metrics for measuring patient navigationEstablish effective metrics for measuring patient navigationservices internally and for benchmarking patient navigationservices internally and for benchmarking patient navigationservices against other community cancer centers.services against other community cancer centers.

http://accchttp://accc--cancer.orgcancer.org

ExampleExample

CC--Change Cancer Patient Navigation Tool KitChange Cancer Patient Navigation Tool Kit Who provides cancer patient navigation?Who provides cancer patient navigation?

Patient navigation is provided by culturally competent professioPatient navigation is provided by culturally competent professionals or peers innals or peers ina variety of settings, depending on the complexity of the situata variety of settings, depending on the complexity of the situation.ion.

The navigator can work within the health care system, or outsideThe navigator can work within the health care system, or outside the healththe healthcare system, but in close collaboration with providers and the ccare system, but in close collaboration with providers and the community.ommunity.

The design of the cancer patient navigation system is engineeredThe design of the cancer patient navigation system is engineered to be directedto be directedby, and to meet the needs of, the patient and their family in thby, and to meet the needs of, the patient and their family in the context of thee context of thecommunity and the health care environment.community and the health care environment.

What are the key benefits to cancer patient navigation?What are the key benefits to cancer patient navigation? Cancer patient navigation can help save livesCancer patient navigation can help save lives Cancer patient navigation can help overcome barriers to access tCancer patient navigation can help overcome barriers to access to careo care Cancer patient navigation can be tailored to meet the needs of tCancer patient navigation can be tailored to meet the needs of thehe

community and the institutioncommunity and the institutionwww.www.cc--changechangetogether.orgtogether.org

ONS & Nurse NavigationONS & Nurse Navigation

Focus Group ~ 2 yearsFocus Group ~ 2 years

2009 Think Tank with Association of2009 Think Tank with Association ofOncology Social Work (AOSW)Oncology Social Work (AOSW) ““Patient navigation in cancer care refers toPatient navigation in cancer care refers to

individualized assistance offered to patients,individualized assistance offered to patients,families, and caregivers to help overcomefamilies, and caregivers to help overcomehealth care system barriers and facilitatehealth care system barriers and facilitatetimely access to quality health andtimely access to quality health andpsychosocial care from prepsychosocial care from pre--diagnosis throughdiagnosis throughall phases of the cancer experience.all phases of the cancer experience.””

ONS, AOSW, NASW JointONS, AOSW, NASW JointPosition StatementPosition Statement

HighlightsHighlights Navigation is an essential component of cancer careNavigation is an essential component of cancer care

Nurse, social worker, lay navigators function as aNurse, social worker, lay navigators function as ateamteam

Education and Knowledge in: communityEducation and Knowledge in: communityassessment, cancer program assessment, resolutionassessment, cancer program assessment, resolutionof system barriers, cancer continuum, cancer healthof system barriers, cancer continuum, cancer healthdisparities, cultural competence, and individualizeddisparities, cultural competence, and individualizedprovision of assistanceprovision of assistance

Navigation services can be delegated toNavigation services can be delegated tononprofessional and/or volunteers who arenonprofessional and/or volunteers who aresupervised by a professional navigator.supervised by a professional navigator.

ConsiderationsConsiderations

StandardsStandards

Educational preparationEducational preparation

CertificationCertification

Is the Navigator a New Title orIs the Navigator a New Title orNew Job?New Job?

Social workerSocial worker

Nurse coordinatorNurse coordinator

Nurse clinicianNurse clinician

Case managerCase manager

Care coordinatorCare coordinator

Closing ThoughtsClosing Thoughts

Stay unitedStay united –– dondon’’t confuse the public with toot confuse the public with toomany definitions and job descriptions.many definitions and job descriptions.

Evaluate the effectiveness of your workEvaluate the effectiveness of your work –– notnotjust patient satisfaction with your role. Developjust patient satisfaction with your role. Developmetrics that you will measure.metrics that you will measure.

Communicate the value you bring to yourCommunicate the value you bring to yourorganization so when the budget gets tight, yourorganization so when the budget gets tight, yourposition is not eliminated.position is not eliminated.

Publish, presentPublish, present –– not just in your organizations,not just in your organizations,but strategically choose meetings and journals.but strategically choose meetings and journals.

Do not follow where the path mayDo not follow where the path maylead. Go, instead, where there islead. Go, instead, where there isno path and leave a trail.no path and leave a trail.

Ralph Waldo EmersonRalph Waldo Emerson