So You’re a New

Navigator: Now What?

Deborah Christensen, MSN, APRN, AOCNS, OCN

Objectives

• Describe key navigator competencies and patient touch points

• Apply methods/tools for patient intake, tracking, education, and documentation

• Identify internal and external staff needed to accomplish patient navigation

What Knowledge and Skills do I need?

2017 Oncology Nurse Navigator Core Competencies

• Coordination of Care

• Communication

• Education

• Professional Role

Coordination of Care

Skills

• Assess, identify, & address

patient needs

• Facilitate timely care

• Provide resources

Knowledge

• Barriers to care and resources

• Internal and external network

• Local, community and national

resources

Communication

Skills

• Build effective relationships

• Advocate & empower

• Cultural & social sensitivity

Knowledge

• Active listening

• Effective communication

• Health literacy

• Cultural competence

Education

Skills

• Translate medical terms

• Educate to plan of care

• Promote healthy lifestyle

Knowledge

• Health literacy

• Disease specific information

• Screening guidelines & health

information

Professional Role

Skills

• Effective communicator

• Participates in program

growth

• Lifelong learner

Knowledge

• Communication strategies

• Use of metrics

• New medications, guidelines,

indications

Communication Strategies

• Motivational

Interviewing

• Crucial

Conversations

• Active listening

Scenario I

Scenario II

Scenario III

When do Navigators interact with Patients?

What Methods/Tools are Available for:

• Patient Intake?

• Standards of Work?

• Patient Tracking?

• Nursing Note?

New Patient Intake Nurse Navigation Assessment and Tracking Tool

Date of Service ____________

Patient name______________________________________________________________________________

EM PI # _________________ DOB __________________ Diagnosis ____________________________Navigator__________________________________________

ASSESSMENT Location of visit: ☐Diagnostics ☐Med Onc ☐Rad Onc ☐Hospital ☐Nursing Home

☐Community ☐Telephone ☐Email ☐Home

☐Other

Reason for Call/Visit: ☐Initial Assessment (NEW) ☐Intervention (REPEAT)

☐Other

HIGH RISK: ☐URGENT ☐ 24 hr f/u ☐72 hr f/u

ECOG Status: ____________________________

NCCN Distress Score:______________________

HIGH RISK IDENTIFIERS/COMORBIDITIES

BARRIERS TO CARE ☐Care coordination ☐Travel/lodging ☐Financial ☐Psychosocial ☐Communication ☐Other_______________________________________

ACCESS TO SUPPORT SERVICES/REFERRALS ☐Advanced Directive ☐Lymphedema Cancer Prevention/Screening ☐Cancer Rehab/Wellness ☐Ostomy ☐Clergy/ Spiritual Support ☐PT/OT/Speech ☐Clinical Trials ☐ Primary Care Provider ☐Community Care Clinic ☐ Psycho-Social Support Dietician ☐Diagnostic Test; Labs; Transfusions ☐ Second Opinion ☐Fertility/Sexuality ☐ Smoking Cessation ☐Financial Counselors ☐ Social Services/Public Health ☐Genetic Counselor ☐ Social Worker ☐Home Care ☐ Specialist ☐Hospice/Palliative Care ☐ Survivorship/Support Program ☐Integrative Medicine ☐ Transportation ☐Lodging ☐ Other

DATE FOR FOLLOW UP_________________ ☐ PCP ☐ Surgeon ☐ Medical Oncologist ☐ Radiation Oncologist ☐ Nurse Navigator .

☐familiar history of cancer (breast, colon) ☐>70 yrs old ☐low health literacy

☐>4 medications ☐> 2 co-morbidities ☐multiple ED visits ☐lack of social support/distance to travel ☐language barrier ☐uninsured ☐history of tobacco products ☐primary caregiver ☐recent d/c from hospital

Standards of

Work

Standard Work |Treatment Education: Systemic Therapy Key Process: TREATMENT EDUCATION Systemic Therapy

Peformed By: Oncology Nurse Navigator Next Review

01/2020 Trigger: Patient receiving systemic therapy from an Intermountain employed medical oncologist

Owner: Navigation Executive Council

V: 1.1

Timing Major Steps Key Points Reasons Why

a) Introduce yourself and explain the purpose for the call/meeting

b) Provide patient with the expected

duration of the visit (10-20 minutes) c) Ask patient if now is a good time to

talk d) Thank patient for choosing

Interemountain cancer services

Guide patient in understanding treatment recommendations Discuss potential side effects of treatment Provide supportive care strategies Familiarize patient with cancer center policies and resources and community/ national resources

AIDET (Patient Engagement/Healing Commitments). Sets expectations and respects patient’s time.

a) Assess patients understanding of prescribed therapy.

b) Ask patient to describe their

greatest concern about therapy.

Use open ended questions like: What is your understanding of _______? Share with me what you understand so far? What is your greatest concern about_____? Describe your ususal (diet, exercise, stress management, etc.).

Assess patients’ health literacy Clear up any misconceptions early in the visit Address patient’s individual needs and personalize care

c) Assess barriers to care • Financial

• Transportation/lodging

• Psychsocial needs

• Employment

• Lifestyle

Coordinate care and avoid unnecessary delays in patient care.

d) Discuss how oncologists personalize treatment recommedations

• TNM staging

• NCCN Guidelines, Clinical Practice Guidelines

• Patients overall health

• Tumor conferences

• Oncologist’s experience

Help patients understand how treatment decisions are made

Standards of

Work

e) Discuss cancer therapy in general f) Explain types and rational for

patient- specific systemic therapies

• Chemotherapy

• Biotherapy

• Immunotherapy

• Oral oncolytics

Assist patient in understanding why certain side effects can happen and how their specific treatment is designed to meet treatment goals

g) Review common side effects associated with patient’s regimen and appropriate supportive care cards

Use approved chemotherapy teaching sheets (TBD) and supportive care cards

Provide the patient with resources and written information to support the verbal education. Reduce patient anxiety by knowing what to expect before, during, and after systemic therapy

h) Review Chemo 101 packet and discuss each page in detail

• My Treatment Guide

• My Cancer Care Team

• Reporting Side Effects

• Be Prepared

i) Discuss antiemetics if needed and use teach back to demonstrate patient understanding

Use code words to help patient understand the rational for each medication.

Assist patient in using antiemetics effectively.

j) Empower patients to use self care methods throughout treatment and provide approved resources and referrals

Describe your ususal

• Diet

• Activity

• Stress management

Encourage patients to actively participate in their cancer care. Provide wellness strategies.

k) Discuss Intermountain, community, and national resources

Use Intermountain Cancer Resource Guide (to be developed) for reference and provide patient with copy via email or mail.

Provide resources for current and future needs. Refer to appropriate support service personnel:

• Resource coordinator

• Social worker

• Financial advocate

l) Review elements of informed consent

m) Ask patient to sign consent for treatment.

Use approved consent (TBD) Navigators understand that the attending physician documents informed consent in the patient record.

Acknowledge patients’ acceptance and desire to proceed with treatment.

n) Provide your contact information and remind patient of NN availability for any future general questions.

Encourage patient to use supportive care as available through their oncologist.

Provide point of contact for general questions and resource needs.

Immediately following appointment

a) Determine patient acuity b) Chart in iCentra

Establishes touchpoints based on acuity Enables team communication and collaboration in patient’s care Fulfills legal responsibility

Patient Tracking

• Navigation software

– OncoNav

– NurseNav

• EHR tracking option

– Patient lists

• Excel spreadsheet

• Outlook calendar

Documentation: Nursing NoteStandard SOAP Note

– Subjective

– Objective

– Assessment

– Plan

Modified SOAP Note

– Situation

– Observation

– Assessment

– Plan

Modified SOAP Note

• Situation: Why is the patient being seen? What is the diagnosis?

• Observation: How does the patient appear physically, emotionally,

cognitively?

• Assessment: What are the presenting symptoms? Barriers to care?

Special needs?

• Plan: What are next steps? For the patient? For the navigator?

How do I form a Navigation Network?

Navigation

Network

Consulting resources Names phone fax iCentra contact roles and responsibilities

Area/facility:

Social Work

Rehabilitation team

Financial Assistance Advocate

Pastoral Care

Genetic counseling

Cancer Registry

Rehabilitation team

Speech Therapy

Physical Therapy

Occupational Therapy

Lymphedema Specialists

Palliative Care Team

Hospice team

Fertility Preservation

AYA Adolescent/Young Adult

Coordinator

Navigation

Network

Consulting resources Names phone fax iCentra contact roles and responsibilities

Area/facility:

Social Work

Rehabilitation team

Financial Assistance Advocate

Pastoral Care

Genetic counseling

Cancer Registry

Rehabilitation team

Speech Therapy

Physical Therapy

Occupational Therapy

Lymphedema Specialists

Palliative Care Team

Hospice team

Fertility Preservation

AYA Adolescent/Young Adult

Coordinator

Consulting resources Names phone fax iCentra contact roles and responsibilities

Area/facility:

Social Work

Rehabilitation team

Financial Assistance Advocate

Pastoral Care

Genetic counseling

Cancer Registry

Rehabilitation team

Speech Therapy

Physical Therapy

Occupational Therapy

Lymphedema Specialists

Palliative Care Team

Hospice team

Fertility Preservation

AYA Adolescent/Young Adult

Coordinator

Putting it all together

Action Plan

References

Lew, V., & Ghassemzadeh, S. (2018). SOAP Notes. StatPearls, 1–5. Retrieved from

http://www.ncbi.nlm.nih.gov/pubmed/29489268

Oncology Nursing Society. (2017). 2017 Oncology Nurse Navigator Core Competencies. Pittsburg, PA. Retrieved from

https://www.ons.org/practice-resources/competencies

Spencer, J. C., & Wheeler, S. B. (2016). A systematic review of Motivational Interviewing interventions in cancer patients and survivors.

Patient Education and Counseling, 99(7), 1099–1105. http://doi.org/10.1016/j.pec.2016.02.003

Institute for Healthcare Improvement. 2019. Science of Improvement: Spreading Changes, retrieved from

http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementSpreadingChanges.aspx

Images by Robin Higgins from Pixabay