center for the advancement of cancer survivorship, navigation and policy creating a longitudinal...

Center for the Advancement of Cancer Survivorship, Navigation and Policy

Creating a Longitudinal Continuum of Access to Care

Anne Willis, MA

Director, Center for the Advancement of Cancer Survivorship, Navigation and Policy

Heather Kapp, LICSW, MPH

Director, Access and Quality

George Washington Cancer Institute


Objectives

• Discuss longitudinal navigation models• Describe the DC Citywide Patient

Navigation Network as a model of a longitudinal continuum of access to care

• Identify different navigation functions across types of navigators

• Discuss the role of quality improvement and patient navigation


GW Cancer Institute

• Mission– Ensure access to quality, patient-centered

care across the cancer continuum through community engagement, patient and family empowerment, health care professional education, policy advocacy and collaborative multi-disciplinary research.

• Center for the Advancement of Cancer Survivorship, Navigation and Policy


LONGITUDINAL MODELS


GWCI Longitudinal Model


Colorado Patient Navigation Model

Source: patientnavigatortraining.org


DC CITYWIDE PATIENT NAVIGATION NETWORK (CPNN)


Network Conception

• National Cancer Institute Patient Navigation Research Program (PNRP) funded nine (9) site demonstration projects & tested:• Effectiveness of patient navigation from

screening to time of diagnosis and treatment

• Impact on patient satisfaction• Cost-effectiveness of patient navigation

programs


Results from DC PNRP• 2,601 women

– 1,047 navigated– 1,554 records-based non-navigated

• 2006-2010 at nine hospitals/clinics in DC• Navigated women reached diagnostic resolution for

breast cancer 17 days sooner than non-navigated women• For those requiring biopsy, the difference between

navigated versus non-navigated women was nearly 31 days

Source: Hoffman HJ, LaVerda NL, Young HA, Levine PH, Alexander LM, Brem R, et al. Patient navigation significantly reduces delays in breast cancer diagnosis in the District of Columbia. Cancer Epidemiol Biomarkers Prev 2012.


Birth of DC Network

• Expand navigation beyond breast cancer• Expand beyond 9 sites of PNRP to 40

clinical and community sites• Focus on service delivery rather than

research• Utilize data to inform cancer control

planning


Citywide Patient Navigation Network (CPNN) Vision

• Ensure every patient in the DC region has access to cancer care across the continuum regardless of race, ethnicity, sexual preference, socioeconomic status or geographic residency

• Improve cancer outcomes among DC patients• Improve access to care across the cancer

continuum• Eliminate barriers to care


CPNN Goals

• Help patients overcome barriers to care, with special attention to vulnerable and minority populations.

• Navigators help patients obtain timely, coordinated cancer care, including screening and diagnostic services, treatment, survivorship and end‐of‐life care.


Site Selection• GWCI serves as the central coordinator of

CPNN which is currently comprised of 36 navigators stationed at primary care, tertiary care and community-based organizations.

• Several of these organizations have multiple clinics served.

• One navigator also navigates for the Department of Health's Project Wish, which provides qualified women with breast and cervical cancer screening at no cost.


Active Sites• Capital City Area Health Education Center• DC Primary Care Association• Howard University Cancer Center• Whitman Walker• Nueva Vida• The Smith Center for Healing and the Arts• MedStar Washington Hospital Center • Providence Hospital• Capital Breast Care Center• African Woman’s Cancer Awareness Association• Community of Hope


Role of CPNN Navigators

• Maintain communication with patients, survivors, families, and the health care providers

• Ensure appropriate records and referrals are available at scheduled appointments

• Arrange for language, financial, transportation, child/elder care, insurance, medication, home health care and other forms of support

• Connect patients to resources and support services• Help patients learn to navigate the health care system


CPNN Evaluation Plan

• Demographic data

• Barriers addressed

• Resources utilized

• Connectivity of network


Year One Accomplishments


Year 1 Success ExamplePatient Barrier Navigation Outcome

Transportation Tokens for assistance; insurance support

Care adherence Coordination among navigators across CPNN network

Communication Free cell phone

Food & Nutrition Food & Friends; Abbott Nutrition

Substance abuse / Housing Referral to Gift of Peace; Halfway House

Insurance Access to Medicaid


Year 2 Accomplishments

• CPNN grant extended to Year Two.• Goal: navigate at least 1,525 patients and

educate 4,301 individuals.• Total: 2,840 patients were navigated and

8,880 outreach contacts were made.


Year 2 Profile of Barriers


Year 2 Profile of Patients Served


Year 2 Profile of Insurance Status


Year 3• Focus on

– Sustainability– Quality improvements– Improved data systems

• To date, 1,800 individuals reached and 1,368 barriers to care have been removed.


CPNN Summary Since 2010• Provided assistance to 6,556 individuals and

impacted 19,087 through education and outreach.

• Removed 24,846 barriers to care. • Nearly 25.79% patients were uninsured.• Top barriers were social/practical support

(16.02%), financial barriers (15.74%), system problems with scheduling care (13.78%) and language barriers (11.16%).


CPNN Summary Since 2010

• Approximately 85% of individuals served are racial or ethnic minorities, including over 50% African American and nearly 32% Latino.

• Patients served include the following top cancer diagnoses: breast (68%), cervical (7%), prostate (5.52%), and colorectal (4.55%) and lung (2.58%).

• Patients were 83% female, 14% male, and 0.1% transgender with 48% heterosexual and 1.5% LGBT (50.5% did not report sexual orientation).


CPNN Summary Since 2010

• About a third of individuals were age 50-64, with approximately 20% age 40-49 and about 13% over the age of 65. Approximately a quarter of individuals did not report age.

• Almost half of individuals served live in the District of Columbia, with 29% from Maryland and 18% from Virginia.

• Over 1,000 were from Wards 7 and 8, the most poverty-stricken Wards in DC.


Greatest Successes: Feedback from Site Visits

• Improved patient access to services across cancer continuum• Greater number of patients served and with more comprehensive

services• Network serves as forum for discussion of challenges and problem-

solving• Social and practical barriers resolved to improve adherence to

treatment• Network addressed system fragmentation to avoid loss to follow up.• Information and resource sharing• Relationships developed with other navigators make process of

referrals to other services seamless


Greatest Opportunities: Feedback from Site Visits

• Promote engagement/networking among the navigators• Programs need to be flexible and able to expand or

contract given the variability of grant funding• Training is critical to enable navigators to successfully

work with patients• Continue to provide updates to resources and support

groups• Dedicate funds to support patient transportation to and

from treatment• Most of the community organizations that navigators

referred to were not in the network


Lessons Learned:Feedback from Site Visits

• Breadth of network• Promoting the program to raise awareness in the community

about patient navigation and CPNN• Developing standards for patient navigators to ensure a high

quality service• Collecting data and information to support sustainability from

the beginning• Simplifying paperwork • Addressing patient language issues


Challenges and Solutions• Multiple changes to evaluation methods• Staff turnover• Program coordinator is a core coordination node,

providing monthly networking/training meetings and process improvements responsive to partner feedback. Keeps the network engaged!

• Funding and sustainability, patient navigation is not a billable service

• Ensuring a quality standard for navigation across the network


Future Directions• Pilot database to improve outcomes tracking

• Involve navigators in the metrics selection• Collect ROI data to show program value• Collect health equity data

• Provide weekly resource newsletter to help sites better organize updates and resources, create blog?

• Conduct focus groups with navigators• Revisit training preferences:

• Live? Webinar? • Invite community organizations to participate

• Provide individualized technical assistance to help sites show value


Summary• Navigation continues to show value as an important

strategy for patient‐centered care.

• CPNN provides a critical safety net for cancer patients in the DC area that can be replicated in other urban areas and for other diseases.

• CPNN has many accomplishments and successes to carry forward.


NAVIGATION ROLE DELINEATION PROJECT


Role Delineation Project Overview

• Distinguish roles across CHWs, patient navigators and nurse and social worker patient navigators

• Methods– Review of literature, training curricula, grey

literature– Development of a framework– Expert consensus– National survey


Existing Competencies

• CHW Competencies– MA, MN, NM, NY, OH, TX

• Oncology Nursing Society• Patient navigator training programs at

GWCI, University of Colorado, PNRP, Freeman


Preliminary Findings: DomainsProfessional Roles and Responsibilities

Community Resources

Patient Empowerment

Communication

Barriers to Care/Health Disparities

Education/Prevention and Health Promotion

Ethics and Professional Conduct

Cultural Competency

Outreach

Care Coordination

Psychosocial Support Services/Assessment

Advocacy


Preliminary Findings: Similarities and Differences

Domain CHW Patient Navigator Nurse/Social Worker Patient Navigator

Patient Empowerment: Identifying problems and resources to help patients solve problems and be part of decision-making process.

Motivating individual and community to positively change health behaviors.

Assisting patient with identifying administrative, structural, social and practical issues to participate in decision making and solutions.

Assisting patients in decision making regarding diagnostic testing and treatment options. Assisting patients by providing them with coping strategies to deal with disease, treatment and manage stress.

Ethics and Professional Conduct:Understanding scope of practice, professional boundaries, assuring confidentiality and following legal requirements. Maintains and adheres to the professional standards. It brings about accountability, responsibility and trust to the individuals the profession services.

Abiding by state defined scope of practice.

Understanding difference in scope of practice between licensed professionals and non-licensed professionals.

Abiding by the ethical principles in the profession’s scope of practice and code of conduct according to licensure.

Care Coordination:Deliberate organization of patient care activities to facility the appropriate delivery of health care services.

Case management, service coordination and system navigation.

Assessing and facilitating social and practical coordination of care along the care continuum.

Assessing and facilitating coordination of psychosocial and medical/clinical care along the care continuum.


PATIENT NAVIGATION AND QUALITY IMPROVEMENT


Q/PI Tools

• Understanding the problem:– Patient Flow/Process Map– Fishbone Diagram– Pareto Chart

• Planning for change:– PDCA (PDSA)– Six Sigma DMAIC


Q/PI Tools: Patient Flow

• How many times is the patient passed from one person to another (hand-off)?• Where are delays, queues and waiting built into the process?• Where are the bottlenecks?• What are the longest delays?• What is the approximate time taken for each step (task time)?• What is the approximate time between each step (wait time)?• What is the approximate time between the first and last step?• Wow many steps are there for the patient?• How many steps add no value for the patient?• Are there things that are done more than once?• Look for “re-work loops” where activities are taken to correct situations that could be

avoided is work being batched?• Where are the problems for the patients?• At each step is the action being undertaken by the most appropriate staff member?• Where are the problems for staff?

Understanding the Patient Journey-Process Mappinghttp://www.scotland.gov.uk/Resource/Doc/141079/0036023.pdf



1. Screening

2. Diagnosis

3. Treatment

4. Post-treatment

How/where are patients screened? What happens when

there is an abnormal finding? How are patients notified? How do

they get to your institution?

What happens after treatment begins? Are psychosocial needs assessed and resources made

available? How are medical, psychosocial and practical needs

managed and by whom?

What happens during the diagnosis meeting? How are

treatment decisions made? What do patients do when and after

treatment options are discussed?

What happens when treatment ends? Is there communication with the primary care provider? How are medical, psychosocial,

and practical needs managed and by whom?



Blasberg. ACCC Cancer Care Patient Navigation: A Call to Action http://accc-cancer.org/education/pdf/PN2009/s15.pdf



Sandoval et al. 2013. J of the Society for Healthcare Improvement Professionals.


Q/PI Tools: Fishbone Diagram

• Problem • Categories of problems• Causes of problems

Why? Why? Why? Why? Why?



Blasberg. ACCC Cancer Care Patient Navigation: A Call to Action http://accc-cancer.org/education/pdf/PN2009/s15.pdf


Q/PI Tools: Pareto Chart

• When analyzing data about the frequency of problems or causes in a process.

• When there are many problems or causes and you want to focus on the most significant.

• When analyzing broad causes by looking at their specific components.

• When communicating with others about your data.


Q/PI Tools: Pareto Chart

Lang

uage

Bar

riers

Sched

uling

Other

Social

/Pra

ctica

l

Liter

acy

Fear

Trans

porta

tion

Loca

tion

Anxiet

y

Comm

unica

tions

Con

cern

s0

100

200

300

400

500

600

700

800

900

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

26%

50%

70%

77%

83%88%

91%94%

97%100%

PN Barriers Pareto Chart

Frequency

Percentage


Q/PI Tools: PDCA

• Plan– Plan a change

• Do– Test/pilot change

• Check/Study– Analyze results

• Act– Make a decision: expand, alter, abandon

• CAP-Do

Plan

Do

Check/Study

Act


Q/PI Tools: Six Sigma DMAIC

• Define– Define problem

• Measure– What is happening

• Analyze– Analyze results

• Improve– Make change

• Control– Continually monitor

Define

Measure

Analyze

Improve

Control


KEY POINTS


Strategies for Community Engagement

• Involve navigators in the data; move from outputs to outcomes to truly show the public health impact/value of the intervention

• Come together to decide the vision• Instead of competing over funds, find ways

to work collaboratively


Questions for Florida CHW Network

• What do you want to see your network accomplish?• What is your baseline for health disparities? Where

do you want to be? How will you measure change?• What resources do you need to accomplish your

goal?• How will you sustain your network?• Who are your stakeholders?• What do your stakeholders value and how will you

demonstrate that value?


Contact Information

Heather Kapp

CPNN Program Manager

Director, Access and Quality

George Washington University Cancer Institute

[email protected]

202-994-2062

Mandi Pratt-Chapman

CPNN Principal Investigator

Associate Director, George Washington University Cancer Institute

[email protected]

202-994-5502

mailto:[email protected]

mailto:[email protected]

center for the advancement of cancer survivorship, navigation and policy creating a longitudinal...

Documents

patient navigation slide

cancer care

cancer continuum

cancer outcomes

policy slide

longitudinal navigation

breast cancer diagnosis

cancer control planning