Tag Archives: cancer patient navigation

Navigation Caseload Quandary?

Learn about 2017 ACCC Innovator Award winner USA Mitchell Cancer Institute’s homegrown Oncology Navigation Acuity Tool.

By Rev. Diane Baldwin, RN, OCN, CBCN, and Meredith Jones, MS, BSN, RN

FinalSealUnfortunately, nurse navigation services are typically non-revenue generating, necessitating a cost/benefit evaluation of these services for many programs. To justify nurse navigation in this new era of value-based care, we must define appropriate caseload volumes through risk stratification, and determine how best to allocate nurse navigation time and resources among those caseloads.

How Best to Measure & Define Acuity?
Acuity tools have been used in healthcare for decades and have proven successful as a means of determining staffing needs, improving patient care, and controlling costs.  Most acuity tools score patients on a scale of specific attributes. For nurse navigation programs, an acuity tool can be used to determine caseloads and aid in more efficient nurse navigator caseload management.

At USA Mitchell Cancer Institute, our nurse navigators, known as Clinical Care Coordinators, maintain a caseload of approximately 175 patients. However, as we identified more patients needing navigation services, we recognized the need for an acuity tool specifically for caseload management.

As we researched acuity tools, we found limited options related to oncology nurse navigation. Each of the tools we identified was specific to a facility, and was either used to determine overall staffing or focused specifically on the amount of time spent with patients.  We believed that a more generalized tool, including more patient factors, was needed to accurately determine patient acuity. Therefore, the USA Mitchell Cancer Institute began developing an Oncology Navigation Acuity Tool, universally designed to benefit our practice, while also allowing for use and adaptation by other cancer programs.

More Than Just a Number
USA Mitchell Cancer Institute’s goal was to develop a tool that measures a patient’s acuity through a holistic lens. As cancer care providers know, each patient’s navigation needs depend on a variety of factors. Our Oncology Navigation Acuity Tool considers 11 factors that we identified as directly correlating with patient resource utilization and, therefore, acuity level.  Each factor is reviewed individually to determine the acuity score, placing less emphasis on cancer type and stage, and more emphasis on overall patient context. For example, two patients with the same type and stage of cancer, receiving the same treatment, may present with different comorbidities and levels of family support, resulting in two very different acuity scores.

An inherit weakness in most acuity tools is that the “score” assigned to the patient determines overall acuity. However, we know that our patients are more than just a number.  Standardized tools often fail to identify important elements needed to address individual patient needs. Therefore, our Oncology Navigation Acuity Tool includes a 12th factor in determining a patient’s acuity: The clinical assessment of the nurse navigator.  This factor is essential to assessing the “whole patient” and our aim of providing holistic care.  Our nurse navigators use the 11 factors of Oncology Navigation Acuity Tool as a guide to assess the acuity of the patient and combine this with their overall clinical assessment, for a final acuity score.  Ultimately, our nurse navigators, may elect to change the acuity level based on their assessment of the individual patient.

Putting the Tool to Work
The Oncology Navigation Acuity Tool allows us to easily assess the needs of each navigated patient prior to caseload allocation and to quickly determine the level of navigation the patient will need. The tool has also guided managerial decisions to adjust caseloads based on acuity rather than patient count alone.  Further, we’ve utilized this tool for both quality and process improvement to study the varied needs of patients among the acuity levels, and to determine the effect of accurately navigated patients on system utilization and cost.

In our presentation at the ACCC 34th National Oncology Conference, October 18-20, in Nashville, TN, we’ll share more on how using this low-cost, simple to implement tool has resulted not only in a cost-effective, efficient means of refining navigation utilization, but also in the delivery of more personalized, comprehensive, improved quality of care for our navigated patients.

We look forward to seeing you in Nashville!


Rev. Diane Baldwin, RN, OCN, CBCN, is Manager, Quality Assurance, and Meredith Jones, MS, BSN, RN, is Director, Quality Management, at the USA Mitchell Cancer Institute.  

Navigators: Communicating Your Role

By Tricia Strusowski, RN, MS

Patient Navigation Healthcare CompassAlthough patient navigation services are becoming more common at cancer programs nationwide, physicians and administrators still frequently ask, “What are the responsibilities of the navigator?” Navigators coordinate care and remove barriers across the care continuum, which can potentially include many responsibilities. It is very important for navigators to be able to articulate their role concisely so that there is no room for misinterpretation. It is also important to share the Commission on Cancer Standards, Chapter 3: Continuum of Care Services, and navigator competencies/position statements from national organizations such as the Association of Oncology Social Work (AOSW), the Academy of Oncology Nurse & Patient Navigators (AONN+), and the Oncology Nursing Society (ONS), just to name a few.

Over the past year I’ve had several cancer programs request a tool to educate their physicians, office staff, and other departments on the role of the navigator and oncology support staff.  For programs looking for a similar tool, here are two sample questions and suggested answers. These can be customized to reflect your cancer program’s structure and its navigation and support staff responsibilities.

Example 1:

What is a navigator and what are the Commission on Cancer (CoC) Standards for Navigation?

Navigation Definition:
C-Change defines navigation as “individualized assistance offered to patients, families, and caregivers to help overcome health care system barriers and facilitate timely access to quality medical and psychosocial care from pre-diagnosis through all phases of the cancer experience.”

Commission on Cancer Standards, Chapter 3: Continuum of Care Services

Standard 3.1: Patient Navigation Process
A patient navigation process, driven by a community needs assessment, is established to address health care disparities and barriers to care for patients. Resources to address identified barriers may be provided either on-site or by referral to community-based or national organizations. The navigation process is evaluated, documented, and reported to the Cancer Committee annually. The patient navigation process is modified or enhanced each year to address additional barriers identified by the community needs assessment.

Standard 3.2: Psychosocial Distress Screening
The Cancer Committee develops and implements a process to integrate and monitor on-site psychosocial distress screening and referral for the provision of psychosocial care.

The psychosocial representative on the cancer committee (oncology social worker, clinical psychologist or other mental health professional trained in the psychosocial aspects of cancer care) is required to oversee this activity and report to the cancer committee annually.

Timing of screening: Patients with cancer are offered screening for distress a minimum of 1 time per patient at a pivotal medical visit to be determined by the program. Some examples of a “pivotal medical visit” include time of diagnosis, presurgical and postsurgical visits, and first visit with the medical oncologist to discuss chemotherapy, routine visit with a radiation oncologist, or a post-chemotherapy follow-up visit. Preference is given to pivotal medical visits at times of greatest risk for distress such as at time of diagnosis, transitions during treatment (such as from chemotherapy to radiation therapy) and transitions off treatment.

Standard 3.3: Survivorship Care Plan

The cancer committee develops and implements a process to disseminate a comprehensive care summary and follow-up plan to patients with cancer who are completing cancer treatment. The process is monitored, evaluated, and presented at least annually to the cancer committee and documented in the minutes.

Include navigation position statements based on your navigation model. Use the following organizations:

Oncology Nursing Society Nurse Navigation Core Competencies

Academy of Oncology Nurse and Patient Navigators, Definition of Models of Navigation

Oncology Nursing Society, Association of Oncology Social Work, and National Association of Social Workers joint Position Statement on Navigation

Example 2:

How can the Navigator and Support Staff help your office?
Call us at _______________________________________

Nurse Navigator:
A nurse navigator provides patients and their families with education and assistance to overcome healthcare barriers and assist with timely access to quality medical and psychosocial care across the continuum of care.

 How can the nurse navigator help? 

  • Provide a comprehensive assessment/psychosocial distress screening of the patient/family needs, introduction of appropriate support services.
  • Reinforce education with patient patients/families regarding disease, treatments, side effects, and adverse reactions.
  • Link patients with community agencies and resources.
  • Make follow-up calls to patients/families at home.
  • Review support groups and educational programs for patients/families.
  • Educate patients on reportable signs/symptoms, based on physician’s plan of care.
  • Follow-up with patients’/families’ status post (s/p) discharge to ensure services are set up as planned. Coordinate with inpatient staff.
  • Conduct performance improvement (PI) projects.
  • Participate in Tumor Site Team and tumor conferences.

Social Worker:
A social worker can assist patients and their families with information on internal and external resources, financial, practical, and emotional concerns during their cancer journey.

 How can the social worker help? 

  • Provide counseling for patients and families.
  • Perform psychosocial assessments.
  • Offer and facilitate Support Groups.
  • Assist with completion of charitable application/patient assistance applications.
  • Assist with medication applications.
  • Evaluate patient for Medicaid/Medicare eligibility.
  • Provide transportation resources.
  • Identify community resources.
  • Coordinate Community Assistance Program.
  • Educate on Hospice.
  • Assist with end-of-life decision making.
  • Provide bereavement follow-up.

Registered Dietitian:
A registered dietitian is an expert in dietetics; that is, human nutrition and the regulation of diet. A dietitian advises oncology patients on what to eat in order to lead a healthy lifestyle or to achieve a specific health-related goal.

 How can a registered dietitian help?

  • Screen high-risk patients.
  • Provide group and individual nutrition counseling.
  • Connect patients with community and national resources.

 Genetic Counselor:
A genetic counselor can offer education, testing and counseling for patients (and families) with a history of cancer. Cancers may or may not be inherited.

How can a genetic counselor help? 

  • Provide risk assessment.
  • Provide genetic testing.
  • Provide genetic counseling.
  • Discuss strategies for risk reduction.

These are just two examples of how to create a tool to clearly and concisely explain the roles and responsibilities of navigators and support staff at a cancer program. These can be modified to describe the specific responsibilities for these roles at your cancer program. I encourage navigators to go forth and educate about your role.


Guest blogger ACCC member Tricia Strusowski, MS, RN, is a consultant with Oncology Solutions, LLC.