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“Care coordination is a function that helps ensure that the patient’s needs and preferences for health services and information sharing across people, functions, and sites are met over time . . . Coordination maximizes the value of services delivered to patients by facilitating beneficial, efficient, safe, and high-quality patient experiences and improved healthcare outcomes.”

-National Quality Forum

How can we better coordinate the care of patients and families?

High-quality, patient-centered cancer care is greatly dependent upon the coordination of various specialties and services that a patient encounters. Complex care coordination is simplified through a formal patient navigation program aimed at improving the outcomes and efficiencies of a cancer program. C-Change defines navigation as “individualized assistance offered to patients, families, and caregivers to help overcome healthcare system barriers and facilitate timely access to quality medical and psychosocial care from pre-diagnosis through all phases of the cancer experience.” The goals of a patient navigation program focus on educating the patient, family, and caregivers on all aspects of care, removing barriers to care, providing timely access to support, assessing the need for additional services, and providing overall emotional support.

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What are the roles and responsibilities of a patient navigator?

A core element of the navigator’s responsibilities is patient care coordination. The navigator guides patients through the continuum of care, improving outcomes through education, support, and performance-improvement monitoring. It is also vital that the navigator educate patients and providers about any additional program and community resources available to them as well as open clinical trials. To effectively coordinate care among healthcare providers, the navigator participates in multidisciplinary clinics, clinical performance groups, tumor conferences, and/or cancer committees. A comprehensive navigation program offers patients the resources to navigate the challenges that come with a cancer diagnosis, whether they are clinical, financial, psychosocial, or logistical.

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What are the benefits of a navigation program and how can they be measured?

Oncology navigators play a significant role in a value-based world through metrics and patient outcomes. As healthcare reimbursements increasingly trend toward the management of care episodes, it is vital for programs to improve efficiencies and maximize value. Navigators  achieve this through minimizing the number of patient emergency room visits and unnecessary hospitalizations, decreasing patients’ length of stay, and facilitating standardized care based on national guidelines.

In the report “Ensuring Quality Cancer Care,” published by the Institute of Medicine (IOM), the IOM recommends quality care be measured using a core set of metrics. Released in May 2017, the Academy of Oncology Nurse & Patient Navigators (AONN+) Standardized Metrics Task Force formalized metrics focusing on the impact of navigation programs by measuring patient experience, clinical outcomes, and return on investment. The thirty-five metrics developed by the group “are a baseline that all navigation programs, regardless of their structure, should be evaluating and monitoring.” The implementation and tracking of these metrics enables cancer programs to accurately assess the value and effectiveness of their navigation programs.

How can navigators support physicians through value-based care initiatives?

By creating partnerships with and providing increased support for providers, the navigator  assists the program in its transition to value-based care. The navigator  increases efficiencies by creating standing order sets, physician profiles, pathways, and guidelines. As mentioned previously, the navigator  also reduces unnecessary costs through increased contact with patients who frequently utilize the emergency room—“frequent flyers”—to minimize these visits and avoidable admissions. Through comprehensive assessments and referrals to the appropriate disciplines, the navigator helps the program streamline its processes and provides the patient timely access to services and discussions, such as palliative care, goals of care, advanced care planning, and pre-habilitation.

If you were to evaluate your navigation program, would you consider it efficient? What metrics are being used to quantify the benefits of your navigation program? Oncology Solutions is a trusted advisor and operational partner providing strategic and business planning, operational enhancements, and program development spanning 40+ years and 1,900 projects. We work for small and large community hospitals and health systems as well as academic medical centers and NCI centers. Let us work with you to develop or improve your patient navigation program.

Call us today at 404.836.2000 or email us at [email protected] to inquire about our oncology consulting capabilities. At Oncology Solutions, we are reimagining cancer care—one program at a time.

Author Oncology Solutions

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