The Current Landscape of Nurse Navigators: Oncology and the Impact on Outcomes

Transcription

1 The Current Landscape of Nurse Navigators: Oncology and the Impact on Outcomes SHERYL RILEY RN, OCN, CMCN DIRECTOR OF CLINICAL SERVICES SAI SYSTEMS 2015 SAI SYSTEMS INTERNATIONAL INC. Objectives Define Nurse Navigation and role they play in oncology care Discuss the changes and growth of Nurse Navigation over the last 20 years Outline the benefits of Nurse Navigation Explain the value of Nurse Navigation, financial and clinical outcomes 2015 SAI SYSTEMS INTERNATIONAL INC. 2 1

2 History of Nurse Navigation 1990 Harold Freeman, first program in Harlem Hospital, NY Focus underserved women with breast cancer Major goals: Expand access to cancer screening Clinical follow up among medically underserved women through community outreach Elimination of health access barriers Remove lack of insurance Remove distrust Deal with cultural and communication barriers Decreasing the time for abnormal dx to diagnosis and or treatment Improve 5 year survival rates An increase of patient survival for breast cancer increase 31% from 1995 to 2000 Role of the navigator in Freeman scenario was a lay person 2015 SAI SYSTEMS INTERNATIONAL INC. 3 Cancer Care is Multidisciplinary The amount of time required and the types of services cancer patients are using are expanding across prevention, screening, diagnosis and treatment. In general, the length of time a patient is engaged with the health care system is increasing as more cancer patients live with chronic illness. Utilization Intensity Routine imaging Genetic disease markers Patient education Outreach Prevention and Detection Patient education Family education 1 st line treatment Active Treatment Follow up imaging Molecular markers of recurrence or disease progression Progression of disease and time 2 nd, 3 rd line treatments with increased acuity End of Life Care Social work Palliative care Smooth transition To hospice 2015 SAI SYSTEMS INTERNATIONAL INC. 4 2

3 Definition of Navigation and Role of Navigators The original intent of navigation to facilitate timely access to quality cancer care that meets cultural needs and standards of care for all patients. NCI's CRHCD definition: Patient navigation refers to the support and guidance offered to persons with abnormal cancer screening or a new cancer diagnosis in accessing the cancer care system; overcoming barriers; and facilitating timely, quality care provided in a culturally sensitive manner. Target those who are most at risk for delays in care, including racial and ethnic minorities and those from low income populations. Targets specific time points in the cancer care continuum; Reducing the complexity to the patient of the multidisciplinary approach to care SAI SYSTEMS INTERNATIONAL INC. 5 The Evolution of Nurse Navigation Navigation programs were developed to reduce gaps in care by improving access to, and timeliness of, cancer services Navigation added the provision of support and guidance for timely access to the cancer care system, addressing barriers, and facilitating quality care Usual timeframe was from screening to treatment decision and start of treatment Studies demonstrating that navigation programs increase participation in cancer screening and adherence to diagnostic follow up as well as resolution of treatment decision New studies revel the expansion of Nurse Navigator role to include care management and coordination produce better economic outcomes Improved outcomes 2015 SAI SYSTEMS INTERNATIONAL INC. 6 3

4 Four Key Touch Points to Address Patient Needs Interval between diagnosis and first visit to surgeon or oncologist Pre surgery or pre chemotherapy/radiation 2 3 days post surgery or treatment, ongoing Follow up, provider support and coordination of services 2015 SAI SYSTEMS INTERNATIONAL INC. 7 Different types of Navigators Oncology Nurse Navigator: An Oncology Nurse Navigator (ONN) is a professional registered nurse with oncology specific clinical knowledge who offers individualized assistance to patients, families, and caregivers to help overcome healthcare system barriers and facilitate informed decision Gives timely access to quality health and psychosocial care throughout all phases of the cancer continuum. Lay Navigator: A trained nonprofessional or volunteer who provides individualized assistance to patients, families and caregivers to help overcome healthcare system barriers and facilitate timely access to quality health Psychosocial care from pre diagnosis through all phases of the cancer experience Novice: A nurse who has worked two years or less as an ONN and is building upon his or her academic preparation nursing knowledge, and oncology experience to develop expertise in the ONN role. (Oncology Nursing Society [ONS], 2010b) SAI SYSTEMS INTERNATIONAL INC. 8 4

5 Is All Nurse Navigation the Same? Breast health nurse Patient advocate Nurse case manager Oncology Nurse Navigator Oncology patient navigator Pivot nurse in oncology Nurse Navigator Oncology nurse care manager 2015 SAI SYSTEMS INTERNATIONAL INC. 9 Oncology Nurse Navigation Training and Certification There are many different educational and certification programs regarding Navigation below are just a few organizations that are in the for front of this practice Oncology Nursing Organization Academy of Oncology Nurse & Patient Navigators The Breast Patient Navigator Certification Program (National consortium on Breast Cancer Centers) The Harold P Freemen, Patient Navigation Institute 2015 SAI SYSTEMS INTERNATIONAL INC. 10 5

6 The Last Twenty Years 2015 SAI SYSTEMS INTERNATIONAL INC. 11 Current Landscape and Research The American College of Surgeons Commission on Cancer (ACoS CoC) are working with ACS, ONS, AONN to create globally accepted measures of the navigation process or its clinical and economic outcomes. The development and dissemination of process and outcome measures allowing communities and researchers to evaluate the results of their programs. Creation and funding of more programs that study different types of navigation models, the original and expanded models Better definition of which model is best for evaluating navigation: Cost effective analysis Budget impact analysis Further development on the expanded role of the navigator SAI SYSTEMS INTERNATIONAL INC. 12 6

7 The Patient Navigation Research Program (PNRP) Sponsored by the National Cancer Institute's (NCI) Center to Reduce Cancer Health Disparities (CRHCD) is the first multicenter program to examine the role and benefits of patient navigation. Funded through the NCI with additional support from the American Cancer Society and the Avon Foundation. 5 year program with 9 community programs sites across the US. Focused on at least one of the four cancer types, breast, cervical, colorectal and prostate SAI SYSTEMS INTERNATIONAL INC SAI SYSTEMS INTERNATIONAL INC. 14 7

8 Patient Navigation Research Program (PNRP) study Enrolled in the Patient Navigation Research Program study from January 1, 2006 to March 31, 2010 Cost consequence analysis of navigation versus usual care 10,521 individuals Abnormal breast, cervical, colorectal, or prostate cancer screening Diagnostic resolution was higher for navigation versus usual care at 180 days (56.2% vs 53.8%; P =.008) and 270 days (70.0% vs 68.2%; P <.001). Probability of having diagnostic resolution was higher for the navigation group versus the usual care group (84.5% vs 79.6%; P <.001). Cost of Navigation $275 dollars per patient First published: 25 October SAI SYSTEMS INTERNATIONAL INC. 15 Impact of Patient Navigation on Timely Cancer Care Patient Navigation Research Program published 2014 PURPOSE: Assess timeliness of diagnostic resolution, we conducted a meta analysis of center and cancer specific adjusted hazard ratios (ahrs) comparing patient navigation vs usual care. Assess initiation of cancer therapy, we calculated a single ahr, pooling data across all centers and cancer types. RESULTS: 10,521 participants with abnormal screening tests 2,105 with a cancer or pre cancer diagnosis were predominantly from racial/ethnic minority groups (73%) and publically insured (40%) or uninsured (31%). There was no benefit during the first 90 days of care, but a benefit of navigation was seen from 91 to 365 days for both diagnostic resolution (ahr = 1.51; 95% confidence interval [CI] = 1.23 to 1.84; P <.001)) Treatment initiation (ahr = 1.43; 95% CI = 1.10 to 1.86; P <.007). Meta regression revealed that navigation had its greatest benefits within centers with the greatest delays in follow up under usual care. CONCLUSIONS: Patient navigation demonstrated a moderate benefit in improving timely cancer care. These results support adoption of patient navigation in settings that serve populations at risk of being lost to follow up. J Natl Cancer Inst Jun 17;106(6):dju115. doi: /jnci/dju115. Print 2014 Jun 2015 SAI SYSTEMS INTERNATIONAL INC. 16 8

9 Patient Navigation Improves Cancer Diagnostic Resolution An individually randomized clinical trial in an underserved population. Purpose: Assess barriers to timely resolution of abnormal cancer screening tests add to cancer health disparities among low income, uninsured, and minority populations Of 993 eligible subjects with abnormal screening tests randomized to navigation and no navigation (control) arms and analyzed (all have varying test results). Results Time to resolution was significantly shorter in the navigated group On average for breast, colon/rectal and prostate the complete resolution was 20% higher for the patient with navigation vs those without. Cancer Epidemiol Biomarkers Prev Oct;21(10): doi: / EPI SAI SYSTEMS INTERNATIONAL INC. 17 Implementing and Measuring the Impact of Patient Navigation (At a comprehensive community cancer center 2010) Comprehensive community cancer center accredited by the American College of Surgeons, southeastern United States 1,037 analytic cases of cancer in patients (28 navigator and 20 non navigator) and 26 employees, including physicians, nurses, and other support staff. 10 item survey with Likert scale was sent to a stratified sample of 100 newly diagnosed patients with cancer. Five item survey with the same format was sent to 40 staff working with the patients. Patients who received navigation services responded more positively to survey statements. Statistical significance (p > 0.05) was identified in 7 of 10 statements when patient groups were compared Patients with cancer and oncology staff reported that patient navigation is effective in increasing patient satisfaction and decreasing barriers to care SAI SYSTEMS INTERNATIONAL INC. 18 9

10 The Ralph Lauren Cancer Center Supported by Pfizer Foundation one of three programs. Purpose Patient navigation targets medically underserved with the objective of reducing the time interval between an abnormal cancer finding, diagnostic resolution, and treatment initiation Results After 1 year, compared with standard care alone 78 of 959 individuals with an abnormal breast cancer screening 21 of 411 individuals with abnormal colonoscopies Reach timely diagnostic resolution Breast cancer 1 month Colorectal 2.5 months Cost effectiveness ratio ranged from $511 to $2080 per breast cancer diagnostic resolution achieved $1192 to $9708 per colorectal cancer diagnostic resolution achieved These numbers do not including medical treatment costs saved 2015 SAI SYSTEMS INTERNATIONAL INC. 19 Modeling a Better Way (Navigating the healthcare system for patients with lung cancer. Oncology Nursing 2007) The coordination of services for patients with suspected or newly diagnosed lung cancer produces improved patient outcomes, particularly in their quality of life. Evidence based practice demonstrates improved outcomes from the multimodality therapies offered today, especially for patients with lung cancer; however, navigating through the healthcare system is especially challenging for patients. In developing the Multidisciplinary Lung Cancer Clinic at Frederick Memorial Hospital, navigating through the system and services was difficult for the patient and could delay treatment Patients are receptive and pleased with the approach, in which a nurse practitioner coordinates services and provides guidance and support for patients SAI SYSTEMS INTERNATIONAL INC

11 Study of Three Community Based Programs Purpose: Improved diagnosis resolution Cost savings over patient treated without PN With navigation Results 959 breast cancer patients; 98% reached diagnosis resolution on average 20 days 411 colorectal cancer patients; 95% reached diagnosis resolution on average 7 days CDC national average resolution 60 day for both breast and colorectal Without navigation Results 863 breast cancer patients 90% reached diagnosis resolution 370 colorectal cancer patient, 90% reached diagnosis resolution 10% of patient without navigation on average were lost to follow up after abnormal screening 2015 SAI SYSTEMS INTERNATIONAL INC. 21 Expanding the Role of Patient Navigation 2015 SAI SYSTEMS INTERNATIONAL INC

12 Concept of Patient Navigation is Based on the Care Management or Case Management Model The Four Components: 1. The first is case identification, which is a systematic approach to the identification of those individuals with abnormal cancer screening in need of follow up care or incident cancers. 2. The second is identifying individual barriers to receiving care. Navigators contact patients and elicit information regarding the barriers to completion of recommended care. 3. The third is developing an individualized plan to address the barriers that are identified. 4. The fourth is tracking, which is a systematic method of following each case through resolution of the problem. In the case of cancer navigation, this is to resolution of a diagnostic evaluation when a benign condition is diagnosed or follow up to the completion of primary therapy when a cancer or premalignant condition is diagnosed. The navigator will focus on assisting patients and coordinating care of the patients among providers, community, and the patients and their families. Many or most of current patient navigator programs are focused primarily with racial/ethnic minority and low income patients, cultural competence is a key feature SAI SYSTEMS INTERNATIONAL INC. 23 Gaps in Care May Lead to Missed Opportunities Lack of coordination during the complex phases of cancer care can create serious consequences. Care Phase Gaps Consequences Prevention Ineffective identification of eligible patients Inability to reach underserved populations Screening Appointment wait times too long Patients not contacted with abnormal test results Diagnosis Referrals not made Patients not understanding diagnosis Treatment Lack of patient compliance Missed clinical trial accruals Fracture care experience More patients develop preventable cancer Patients seek screening elsewhere Cancer is detected at a later stage Patients seek care elsewhere Treatment is delayed Patients miss neo adjuvant opportunities Outcomes are inferior IP and ED utilization are higher Surveillance Lack of coordinated follow up services Patients seek care elsewhere End of Life Care End of life issues not proactively addressed IP utilization is high Palliative care is insufficient Patients miss palliation opportunities IP = inpatient; ED = emergency department Source: Sq2 Analysis SAI SYSTEMS INTERNATIONAL INC

13 The Benefits of Coordinated Services 2015 SAI SYSTEMS INTERNATIONAL INC. 25 Changes Based on 12 Months of: Navigation + Coordination = Cancer Disease Management Kentucky Managed care plan 2015 SAI SYSTEMS INTERNATIONAL INC

14 Cost Savings from Navigation and Coordination Coordination and integration make a nurse navigator program an effective aspect of a cancer disease management strategy SAI SYSTEMS INTERNATIONAL INC. 27 Key Roles and Areas of Importance Contact patients at high stress points Offer psychosocial support and access to resources Educate to enable patient led treatment decisions Liaise between clinical specialists and family physicians Streamline care path transitions and logistical issues 2015 SAI SYSTEMS INTERNATIONAL INC

15 How Patient s View Nurse Navigation Improved overall patient and care giver satisfaction Improved patient communication and willingness to participate in their care Better understanding of treatment and treatment options Improved quality of life Improved communication with the health care team Improvements seen in depression, anxiety and fatigue Improved side effect management 2015 SAI SYSTEMS INTERNATIONAL INC. 29 Where are We Going? In recent decades, advances in screening and treatment have resulted in improved cancer outcomes. Disparities in cancer outcomes according to race and income continue. A recent focus in cancer research has been to understand the social, economic, cultural, behavioral, and systems barriers to receiving comprehensive cancer care in a timely fashion and to eliminate these persistent disparities. Patient navigation represents one proposed remedy for disparities in cancer outcomes by intervening to address these barriers to care. Several uncontrolled studies and small single site trials have suggested that patient navigation may improve cancer outcomes. More studies are ongoing 2015 SAI SYSTEMS INTERNATIONAL INC

16 What is Happening? While advances in cancer treatment have helped save millions of lives over the last three decades, patients now often face far more complex treatment decisions and follow up options than they did in the past. Efforts by hospitals to make the system clearer and to increase coordination among doctors haven't always kept up with the changes, and patient navigation is seen as one possible solution to the problem. Hospitals around the country have been adding patient navigation services in recent years, helped by funding from governments and private groups. The Commission on Cancer, part of the American College of Surgeons, issued new standards this year that will require cancer centers to offer patient navigation services by 2015 to meet accreditation requirements SAI SYSTEMS INTERNATIONAL INC. 31 Summary and Future Patient navigation has proven: Its value in reducing health care disparities for the underserved population Cut the time from screening to diagnoses resolution Alter the economic cost of the natural history of the disease process through early detection and timely treatment But we need: Better ways to measure the cost effective value Universal set of measure Expanded role of the navigation process 2015 SAI SYSTEMS INTERNATIONAL INC