Patient Engagement: The Role of Navigators in Cancer Care
A suspected cancer is bewildering and frightening—and for some patients, that suspicion is the beginning of an arduous journey through the health system. Proactive providers are adding navigators empowered to guide cancer patients, coordinating and expediting their care (and providing exactly the support that patients need). In the process, they are generating enthusiastic comments on Press Ganey surveys, in addition to fierce loyalty and donations to their organizations from grateful patients. “Our approach to the cancer patient is multidisciplinary and comprehensive, not fragmented. You have the surgeon, the oncologist, the medical oncologist, the radiologist, and the pathologist—a lot of moving parts. The person who glues all of the disciplines together is that navigator," says Thomas Buse, MD, medical director of radiology, Riverside Methodist Hospital, Columbus, Ohio. Like Columbus, Ohio-based Riverside Radiology and Interventional Associates, of which Buse is a member, many of the 17 radiology practices in the Strategic Radiology (SR) consortium have implemented navigator programs for breast-cancer inpatients and outpatients, gaining valuable experience and refining care protocols. While lung-cancer navigators are less common, that is beginning to change as more providers add low-dose CT lung-cancer screening. As medical director of radiology at 796-bed Riverside Methodist Hospital (Columbus, Ohio), Buse oversees the outpatient centers owned by the multihospital OhioHealth system. While he can’t put a price tag on the program, he says that it includes salaries for the system’s nurse navigators, office space, patient-tracking software, and IT support. OhioHealth’s program began about a dozen years ago; it has grown to include 16 breast-cancer navigators with responsibility for diagnosis and treatment at both hospitals and breast centers. As a mammographer and medical director, Buse works closely with the navigators on clinical and administrative levels. “If I read a screening mammogram and see a spot or some calcifications that need to be worked up, they get involved at the call-back point,” he explains. Diagnosis navigators coordinate the diagnostic mammogram, biopsy (if necessary), and delivery of pathology results to the referring physician. Treatment navigators take patients through chemotherapy, surgery, radiation therapy, home care, palliation, and hospice care (as required)—providing education, friendly support, and a consistent presence.

Diagnosing Cancer: Vital Statistics

Strategic Radiology is a nationwide consortium of 17 radiology practices that share data to optimize quality and safety in medical imaging. In 2013, they performed the following diagnostic procedures.

Screening mammograms: 1,356,743

Diagnostic mammograms: 371,415

Cancers detected: 8,429

Stereotactic biopsies: 21,755

Breast ultrasound: 258,323

Lung cancer screening: 4,446

Coordination of Care

As health-care providers seek greater coordination of care, the navigator program at 625-bed Huntington Memorial Hospital (Pasadena, California) demonstrates how it is done. The hospital began its program nearly 20 years ago, according to Cathy Vesolowski, vice president of operations for The Hill Medical Corp (Pasadena, California), the radiology group contracted to read the hospital’s studies and to operate and manage its outpatient imaging centers. What began as an informal program of cooperation and communication among the hospital’s surgeons and radiologists evolved, over the years, into a vast support network that revolves around the Huntington-Hill Breast Center (Pasadena), accredited by the National Accreditation Program for Breast Centers. “You have to have this huge support group to be accredited,” Vesolowski notes. “It starts with the breast center where patients are diagnosed and must include the surgeons, social workers, hospital, oncologists, and pathologists.” She continues, “The nurse navigator is a very important piece of this program.” In addition, the network includes psychiatrists who help patients deal with emotional difficulties; a physician who performs acupuncture to alleviate the side effects of chemotherapy; and an appearance center, staffed by a hairstylist who works with patients experiencing hair loss.

Educating the Patient

Two nurse navigators track patients of the Huntington-Hill Breast Center and two imaging centers, in addition to patients whose cancers are diagnosed elsewhere, but who are referred to hospital-based surgeons. When the patient receives a breast-cancer diagnosis, she is told that a nurse navigator will contact her within 24 hours to answer questions. The nurse navigators become familiar with patients’ treatment plans and educate patients about what to expect. They also communicate with all providers, always closing the loop. “With the nurse navigators, nothing falls through the cracks,” Vesolowski says. A patient having a problem is likely to call the nurse navigator first. The navigator makes sure that the problem is addressed and follows up to verify that the patient is happy with the results. “Patients call nurse navigators instead of physicians to ask, ‘Am I supposed to be running a fever? Am I supposed to get sores my mouth?’” Vesolowski says. “Although there is a resource for these questions in the oncology department, there is more comfort with that nurse.” A number of SR practices employ navigators in their outpatient clinics—a service that is much appreciated by referring physicians. When Jessica Montgomery, MBA/HCM, COO of Scottsdale Medical Imaging Ltd (SMIL) in Arizona, pitched implementing a nurse-navigator program at the practice’s six breast centers of excellence, the board of directors agreed to a six-month trial. Almost immediately, referring physicians embraced the program. “We sent them back an educated patient, so they didn’t have to spend their office time doing that,” Montgomery says. “They loved that we provided support, throughout the process, for the patient.” The navigator program was turned into a permanent service line due to overwhelmingly positive response from the referral community—and because the service garnered even more referrals for the breast centers.

Saving Time

In addition to providing a link between the outpatient and inpatient settings, the navigator can save time for primary-care physicians and patients. Another SR practice, Charlotte Radiology in North Carolina, has 12 breast centers that perform screening and diagnostic mammography. One of those centers, on the Carolinas Medical Center campus in Charlotte, is where the practice’s navigator is based. Jerome Carter, assistant director of outpatient clinical services, says, “Prior to having a navigator, we often saw a delay from diagnosis to surgical referral. A navigator is able to more quickly relay the report of diagnosis from our radiologist to the patient, her referring physician, and surgeon of choice because it is her sole focus.” Charlotte Radiology expedited the process further by setting up an agreement to share biopsy results with the patient, and (if needed), connect the patient with the referrer’s preferred surgeon. “It saves a lot of time for patients,” Carter says. “They are already anxious and scared, and they want their results yesterday.” In guiding patients, navigators are freeing time for everyone from surgeons to nurses to referring physicians. “It allows the offices to be more efficient,” Carter says. SMIL maintains a list of preferred surgeons for each referring physician, and with the referrer’s authorization, patients with a cancer diagnosis are set up directly with the surgeon. This eliminates a step for the referring physician and shortens patients’ waits. “In essence, it shortens the time from diagnosis to treatment,” Montgomery notes.

The Navigator Profile

While all navigators have prescribed clinical duties, the extra things that they do distinguish them—and generate loyalty. One patient’s letter reads, “She was everything in a nurse that I needed, when I needed it,” Montgomery says. “Navigators strengthen our brand—to the point that their patients say they will never go anywhere else.” At Huntington Memorial Hospital, patients clearly appreciate the service. “[Navigators] get unbelievably huge ratings on the Press Ganey surveys we do,” Vesolowski says. “There is a volunteer group at the hospital that recognizes them, and the nurse navigators actually cause a lot of donations for the cancer center. Basically, they are just doing their jobs, but patients will donate in the names of their nurse navigators, to honor them.” OhioHealth’s criterion for nurses used as navigators is clinical experience. “They’ve been on the floors, they’ve seen a breast-cancer patient after surgery, and they’ve seen what the breast looks like after radiation treatment,” Buse says. Charlotte Radiology, which implemented its program less than two years go, transitioned a diagnostic technologist to the navigator’s position. She understood the exams, the processes, the biopsies, and the language used, but also had a great understanding of pathology, Carter notes. “We are helping to define the standard of care,” he says. “Our navigator tells patients, ‘Call me any time, night or day, if you have a problem—even if you just want to talk.’ Sometimes, they just need someone to talk to them. We are here to do whatever we can to help the patient through a very difficult time.”

Extending the Program

Shortly after OhioHealth established its breast-cancer navigator program, 12 years ago, it added navigators for lung-cancer treatment. Last July, the program was expanded to the diagnostic side, when the system instituted lung-cancer screening using low-dose CT. Buse chairs OhioHealth’s lung-cancer Advisory group and is the radiology liaison for the lung-cancer screening program. While CMS and many third-party payors do not reimburse for screening lung CT, OhioHealth instituted subsidized screening for eligible patients in July 2013, in a decision based on the results of the National Lung Screening Trial.¹ “Now that we have data, we knew we had to have a program, and if we did a program, we wanted a comprehensive program,” Buse explains. “We knew it couldn’t be successful without nurse navigators.” OhioHealth already had three lung-cancer navigators in place on the treatment side, so their responsibilities were broadened to include diagnosis. The navigators screen patients for eligibility and also coordinate imaging, biopsy, follow-up care, and smoking cessation. “We basically mirrored what we had in breast care,” Buse says. “The glue that holds the program together is the nurse navigator.” OhioHealth hopes that within the next year, CMS will begin to cover screening. The US Preventive Services Task Force2 has given lung-cancer screening a category B recommendation.

Preventing Leakage

While other factors—such as offering the advanced imaging, treatment, and chemotherapy trials important to cancer patients—are involved in patient retention, nurse navigators also play a role in keeping patients within the system. “What we don’t want is for patients to go home and not know what the next step is because they were operated on and treated in a silo fashion,” Buse says. Uninformed patients get frightened and frustrated. “Then you get leakage, because they don’t know where to go next, and they wind up going outside the network,” Buse explains. “We want our patients to have the continuity of care within our system that offers them everything they need, when it comes to breast- and lung-cancer diagnosis, treatment, and management. The nurse navigator really helps to get the patient through that,” Buse adds. It might be difficult to justify supporting additional programs, in the current economy, but hospital executives would be wise to consider the consequences of leakage (particularly if they are assuming risk), as well as the downstream revenue associated with cancer patients. Cheryl Proval is editor of HealthCXO. References 1. National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409. 2. Screening for lung cancer. US Preventive Services Task Force. Published December 2013. Accessed February 17, 2014.