Tag Archives: navigation

Dietitian as Navigator: A Winning Combination

By Kelay Trentham, MS, RDN, CSO

Compass pointing at answers-SMALLIn cancer care, the use of patient navigators has grown substantially over the past decade. In 2012, the American College of Surgeons Commission on Cancer added Standard 3.1 requiring that accredited programs have a patient navigation process in place.

While the navigator’s role and responsibilities may vary from institution to institution, clinical navigators typically:

  • assess patients’ clinical, financial, spiritual, and other needs;
  • ensure patients are referred for appropriate supportive care services such as financial counselors, social workers or psychologists, palliative care, and rehab services;
  • provide needed patient education on their disease and its treatment;
  • assist patients in overcoming barriers to care; and
  • assist in discharge and advanced care planning.

Given this list, it may come as no surprise that nurses and social workers are often in navigator roles. Some programs may also employ non-clinical navigators who assist patients with some services, as is the case with the American Cancer Society’s resource navigators, who educate patients about ACS and other community resources. Patient navigation often involves a variety of multidisciplinary team members, with nurse or social work navigators referring patients to physical therapists or dietitians for their specialized care, for example.

For diagnoses that require intensive nutritional support, such as head and neck or esophageal cancer, a Registered Dietitian Nutritionist (RDN) can effectively serve as a patient’s principal navigator, as these patients may see the RDN as often, if not more often, than other team members. In initial medical and radiation oncology consults, these patients are often told that they will need a feeding tube. For many patients, the idea of having or using a feeding tube can be frightening and overwhelming. Prior to receiving feeding tube education, patients may have many concerns such as that the tube is very large and cumbersome, how it might impede normal daily activities, that tube placement is permanent, or that they or their caregiver(s) won’t be able to learn how to use it. Meeting with an RDN for immediate education can allay any fears and concerns about this component of their care plan and reduce distress. In addition, the RDN can reassure patients and caregivers that he or she is available to assist with any questions about using the tube throughout the course of treatment. Further, the RDN navigator can assure the patient that their experience and training places them in a unique position to best advocate for the patient with respect to nutrition support issues.

The RDN’s knowledge base makes this member of the cancer care team an excellent fit for ensuring coordination of care with a patient’s home infusion agency. An RDN navigator can work with the medical team to ensure proper documentation so that enteral feedings are covered by insurance, assist patients with locating donated tube-feeding supplies and formula in the event of limited or a lack of coverage, and work with pharmacy services to get medications converted to crushable or liquid forms for use in feeding tubes. In addition, the RDN navigator would continue to see the patient regularly during the transition from tube feeding back to an oral diet, coordinating care with the speech therapist or surgeon as needed. For example, after esophagectomy, patients experience significant changes in oral diet tolerance and may require considerable education and coaching to adapt to their “new normal.”

Much like the nurse or social worker navigator, the RDN would refer patients to other disciplines when needed, such as to an RN for education about port placement, to a social worker or financial counselor for financial concerns, or to rehabilitation services (physical and/or lymphedema therapy). For some patients, intensive nutrition support may be required from before treatment until long after treatment is completed, making it a central component of care that an RDN is well equipped to navigate.

For cancer patients requiring intensive nutritional support, having an RDN serve as the patient’s navigator can be a winning combination, improving care and the patient experience.


ACCC member Kelay E. Trentham, MS, RDN, CSO, is a past chair of the Oncology Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics. She is currently an oncology dietitian at MultiCare Regional Cancer Center in Tacoma, WA.

For more, learn about a weekly outpatient nutrition clinic for head and neck cancer patients developed by 2014 ACCC Innovator Award winner Beaumont Cancer Institute, Royal Oak, MI.

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.  

How Navigation Can Help in Decreasing Readmission Rates and ER Visits

By Tricia Strusowski MS, RN

Patient Navigation Healthcare CompassFACT #1: The last place that cancer patients and their family want to be is in the hospital. Hospital stays also increase the chances of hospital-acquired infections, which can result in a longer length of stay and complications.

FACT #2: Patients and family members do not feel well equipped upon discharge from the hospital, especially when it comes to how to handle procedures at home such as dressing changes, central lines, injections, and drains, just to name a few. Medications can also be very confusing, in particular when there have been changes—adding or removing medications, and/or dosage changes.

How can a nurse navigator help? Let’s start by reviewing the roles and responsibilities of the navigator, which often encompass the following:

  • Coordinate the care of the patient and family from pre-diagnosis through survivorship or end-of-life services, removing barriers across the continuum
  • Provide education and access to clinical trials, utilizing proper health literacy techniques
  • Improve patient outcomes through education, psychosocial support, and performance improvement monitoring
  • Collaborate and facilitate communication between patients, family members/ caregivers,
    and the healthcare team
  • Coordinate care across the continuum with the healthcare team
  • Provide cancer program and community resources, and follow-up
  • Participate in multidisciplinary clinics, tumor conferences, and cancer committee, functioning in the role of patient and family advocate

Given these responsibilities, how can nurse navigators help keep our patients out of the hospital?
First, we need to listen to our patients and their caregivers, and we need to share their story with the entire healthcare team. What are their specific concerns and educational needs? Keep in mind that these may have little or nothing to do with their diagnosis or plan of care. A comprehensive assessment of needs is essential for patients and caregivers to become empowered and successful during cancer treatment and to prevent avoidable admissions and ER visits.

Here are helpful tips for navigators to understand and meet these needs:

Patient and Caregiver Education

  • Discuss the preferred learning style of the patient and caregiver during the intake process
  • Create a disease-site-specific patient appointment checklist that includes information on why their appointments are important
  • Use decision-aid tools to empower the patient and caregiver with the appropriate questions to ask their providers and healthcare team
  • Proactively screen your patients for specific support service needs, e.g., dietitian, social worker, etc.
  • Provide safety tips for the home environment or have a home assessment completed
  • Use the same educational materials across the care continuum to decrease confusion for the patient and family
  • Teach patients/caregivers about reportable side effects and adverse reactions and when to call the physician
  • Provide support, resources and guidance for the caregiver as well as the patient
  • Increase contacts/calls with high-risk patients, our “frequent flyers”
  • Use home care resources to educate patients and their family on new procedures or information on their diagnosis and treatment as outlined by their provider
  • Provide community resources for the elderly and disparate population to set them up to succeed at home, e.g., Meals on Wheels, transportation services, child/elder care, etc.

 Clinician Education

  • Provide staff with health literacy training including “teach back” methods for educating patients (for example, the “Ask, Tell, Ask” method outlined in the Institute of Medicine report, Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis)
  • Provide medication reconciliation list/guidance and have patients explain their medications and fill their medication planner
  • Incorporate morning reports for the support staff to proactively identify patient needs and the need for phone calls to patients from the appropriate disciplines
  • Initiate early referrals to palliative care for education and symptom management
  • Initiate early goals of care and advance directives discussions
  • Incorporate rounding with inpatient multidisciplinary staff to discuss discharge disposition, barriers to care, length of stay (LOS), discharge delays, carve-out days, and follow-up calls for 24-48 hours after discharge
  • Monitor the patient’s treatment based on national standards and guidelines
  • Create disease-site standing order sets, physician profiles, pathways, and guidelines with timelines when appropriate
  • Research opportunities for creating an oncology medical home or oncology ER/urgent care triage process with protocols
  • Develop plan for avoidable ER visits, i.e., constipation, nausea/vomiting/diarrhea, pain and symptom management, etc.
  • Provide assistance with depression screening (beyond NCCN psychosocial distress screening)

To measure progress, what reports and metrics would be helpful?

  • Request 30-, 60-, 90-day readmission report with reason for admission/chief complaint
  • Request ER visit report for chief complaint
  • Monitor timeliness of appointments, tests, and procedures
  • Review with patients reasons for any missed appointment and assist in resolving issues
  • Create performance improvement projects and metrics to support decreasing readmissions and avoidable ER visits

Discuss and prioritize these ideas with your multidisciplinary team and watch your avoidable admissions and ER visits decline.

Of note: Many of the above examples also align perfectly with the Oncology Care Model (OCM) practice redesign approach, value-based cancer care, and oncology medical home initiatives. Partner with your navigator as healthcare transitions to patient-centered, value-based delivery models.


Contributing blogger ACCC Member Tricia Strusowski, MS, RN, is a consultant with Oncology Solutions, LLC.

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.

Creating a Navigator Orientation Checklist

By Tricia Strusowski, MS, RN

Compass pointing at answers-SMALLI remember when I first started our oncology navigation program in 1998; there were no national standards or core competencies for navigation. The only model I was aware of that followed the patient through different levels of care was the case management model. The goals of the case management model were to coordinate the patient’s care at the appropriate setting while keeping costs down. We discussed the plan of care with the physician and also spoke with the patient and their family to discuss their specific needs and whether their care could be handled at home or whether they needed an alternative care setting or level of care.  

Fast forward to 2016. Today navigation has support from the Institute of Medicine,  the Commission on Cancer has added a navigation standard to its Cancer Program Standards, the Oncology Nursing Society (ONS) has developed oncology nurse navigator  core competencies, and there is a joint position statement on the role of oncology nursing and oncology social work in patient navigation from ONS,  the Association of Oncology Social Work (AOSW), and the National Association of Social Workers (NASW). (Note: The George Washington University Cancer Center has developed core competencies for non-clinical patient navigators.) Today, our navigation programs follow the patient across the care continuum from the earliest point of entry though survivorship or end-of-life services.

Despite the fact that we now have navigation standards and core competencies in place, I still hear from navigators, “I was hired and told, ‘Go navigate.’ I had no idea what that meant.”

So, how do we teach our new navigators? Typically nurses come to the navigator role from varied backgrounds—the inpatient oncology unit, chemotherapy infusion suite, radiation oncology, and home care, just to name a few.

As with any new job, a robust orientation is key; a full navigation curriculum including an orientation checklist and annual competencies is essential for a solid foundation. Here is one example of the elements a navigator orientation checklist might include:

Navigator Orientation Checklist

  • Hospital-specific policies/procedures and mandatory educational programs
  • Navigation history, definition, and models of navigation
  • Benefits and goals of navigation
  • Job description, roles and responsibilities of navigator, and support staff
  • Commission on Cancer Standards and Cancer Committee responsibilities
  • Institute of Medicine; Delivering High-Quality Cancer Care
  • NCCN, ASCO, and other national guidelines
  • Referrals to the navigation program
  • Internal resources, roles and responsibilities:
    Social workers
    Registered dietitian
    Financial assistant/advocate
    Health psychologist
    Pastoral Care
    Genetic counseling
    Cancer  registry
    Rehabilitation team
    Palliative Care team
    Hospice team
    Other, __________________________________________________
  • Community resources, list_____________________________________________
  • Patient educational materials, i.e., disease–site-specific information, clinical trials, patient journal, etc.
  • Caregiver toolkit and resources
  • Assessment tools, documentation and reporting
  • Communication and managing transitions with the patient, family and/or caregiver
  • Communication among the healthcare team, internal and external resources
  • Patient experience survey process
  • Performance improvement models and initiatives:
    Patient experience
    Clinical outcomes
    Business performance
  • Support groups and educational programs
  • Tumor conference responsibilities
  • Multidisciplinary participation and responsibilities
  • Professional organizations and certification
    AONN, Academy of Oncology Nurse Navigators
    Association of Oncology Social Work
  • Other, list _________________________­­­­­­­­­­­­­­­­­­­­­­­­_____________________________________

This orientation checklist is just a foundation for your new oncology navigator; adjust to your specific needs and navigation model. Remember: a good orientation is key for your new navigator’s success.


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

Patient Navigation: Reducing Delays in Care

By Tricia Strusowski, MS, RN

Solutions on corkboard-smallOur last navigation blog discussed how process mapping by disease site can help in managing transitions across the continuum of care.  Process mapping helps the cancer care team identify when to initiate patient navigation and support services as well as to identify goals, barriers, and gaps in care.

Removing barriers and gaps in care is a major goal for any navigation program. Many patients have shared with me that delays in care are the most stressful part of their treatment journey; they call it the “waiting game.” While they are waiting, their imagination can get the best of them. They are not only imaging “the worst” but also questioning “who is coordinating my care?” And if these delays occur time after time across the care continuum—they can have significant implications for the patient’s treatment journey. Is this acceptable?  Absolutely not.

So, How Do We Fix This?  

A great solution to eliminating delays is to create a continuum of care spreadsheet in your electronic medical record (EMR).  Use your process map to help identify the different departments and offices with visits that must be coordinated to avoid delays across the continuum.

The first step in creating your continuum of care spreadsheet is to identify the specific appointments and office visits in the correct order.  Each cancer disease site will look a bit different based on the specific needs of the patient.  For example, let’s consider what this might look like for a head and neck cancer patient. We all know that the patient must have dental clearance prior to any chemotherapy or radiation therapy treatment, but what is an acceptable time frame for this step? One week? Two weeks?  To avoid delays in the patient’s treatment journey, an early appointment for dental clearance is a must and should be completed as soon as possible.

Below is an example of the fields for an overly simplified basic continuum of care spreadsheet.  If an EMR is not available, you can use an Excel spreadsheet to create your continuum of care.  You can also add the initiation of navigation, support services, and survivorship care plan into the care continuum. 

  • Diagnostic work up, imaging, tests, and dates
  • Surgical consult, visit and date
  • Surgical biopsy and date
  • Pathology report results and date
  • Surgery and date
  • Medical Oncology consult, visit and date
  • First chemotherapy treatment and date
  • Radiation Oncology consult visits and date
  • CT simulation and date
  • First Radiation Oncology treatment and date.

Next, your multidisciplinary team needs to review the actual or “real” time period for the delays.  An audit will help you identify the true time lapse between each episode of care.

With these steps completed, you’re ready to initiate a performance improvement (PI) project to decrease delays. The team needs to discuss and create new acceptable time frames between the visits. Identify where the delay is occurring: Registration? Insurance verification? Scheduling?  Look for opportunities to meet with the different departments and offices to brainstorm how these delays can be reduced.  Many times you may also identify duplication of services. Eliminating these redundancies will help with staff productivity.

Sustainability is Key

Once you’ve reduced the delays, you will still need to monitor the new process to ensure that it is continuing to be effective—monitor monthly at first and then move to quarterly or bi-annual monitoring as needed. If the new process is not working, revisit the opportunities for improvement.  Finally, remember that the main goal of all of our programs is to work as efficiently as possible while keeping the patient at the center of all we do.

An efficient and timely patient-centered flow will enhance your patient experience!


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