Tag Archives: patient navigation

Navigation Metrics & Value-Based Care: Measuring Up

By Tricia Strusowski, RN, MSN

Compass pointing at answers-SMALLAs the move to value-based care and Alternative Payment Models (APMs) continues, oncology patient navigators need to become more business savvy and have a full understanding about value-based cancer care metrics.  Case in point: Medicare’s Oncology Care Model (OCM) pilot, the first oncology-specific alternative payment model developed by the Center for Medicare and Medicaid Innovation (CMMI). Data collection and reporting metrics are integral elements of this five-year pilot program, which seeks to achieve higher quality, more highly coordinated care, and smarter spending.

The challenge: Navigation programs lacked strong evidence-based metrics to demonstrate the impact of navigation on the key areas of quality, coordination, and cost-effectiveness.

The good news: the Academy of Oncology Nurse & Patient Navigators (AONN+) recently released 35 evidenced-based metrics in the key categories of patient experience, clinical outcomes, and return on investment.

These metrics were developed using the AONN+  evidence-based Navigation General Certification Domains:

  • Community Outreach and Prevention
  • Coordination of Care/Care Transitions
  • Patient Advocacy/Patient Empowerment
  • Psychosocial Support Services/Assessment
  • Survivorship/End of Life
  • Professional Roles and Responsibilities
  • Operations Management/Organizational Development/Healthcare Economics
  • Research and Quality Performance Improvement

The metrics were developed so that any cancer program or practice can utilize them regardless of the navigation model in place.  The goal in providing these standard metrics is for cancer programs and practices to use them “as a baseline to prove the efficacy and sustainability of their [navigation] programs.”1 Learn more and access metrics.

Partnering to Advance Value-Based Cancer Care
As oncology providers work to improve care coordination and demonstrate delivery of patient-centered, efficient, quality care, patient navigators can play an important role in establishing connections by partnering with physician practices.

For example, navigators can integrate with physician practices to:

  • Increase efficiency and timely access to services by providing comprehensive assessments and referrals to appropriate disciplines
  • Reinforce patient education and empowerment through decision aids and patient appointment checklists
  • Create standing order sets, physician profiles, pathways, and guidelines
  • Increase support for clinicians, i.e., provide early discussions about palliative care, goals of care, advance care planning, and pre-habilitation
  • Increase contacts with “frequent flyers” to decrease ER visits and avoidable admissions
  • Provide automatic referrals to financial counseling at time of diagnosis (generate self-referral reports)

On Thursday, March 30, I will present a more in-depth look at the potential for “Creating Partnerships Between Oncology Nurse Navigators & Oncology Practices” in a session at the ACCC 43rd Annual Meeting, CANCERSCAPE.  The oncology landscape continues to evolve at a rapid pace.  I believe now is the time to explore how navigators can support value-based care initiatives with physician practices, as we all work to keep patients at the center of care delivery.

I hope to see you at CANCERSCAPE, March 29-31, 2017, in Washington, D.C.


1 Strusowski T, Sein E, Johnston D. Academy of Oncology Nurse & Patient Navigators Announces Standardized Navigation Metrics. J Oncol Nav Survivorship. 2017; 8(2):62-68.


ACCC member Tricia Strusowski, RN, MSN, is a consultant with Oncology Solutions, LLC, with 20 years of experience in patient navigation.

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.

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: How Patient and Family Focus Groups Can Help

By Tricia Strusowski, MS, RN

ThinkstockPhotos-484468581Seeking a great way to enhance your navigation program and best understand the specific needs of your patients and families? Consider conducting a patient and family focus group. I have always gotten the best feedback and ideas for our navigation program from hosting a patient and family focus group.  And I now incorporate focus groups sessions into many of my cancer program site visits. It is easy, fun, and the rewards are tremendous.  The patients and families are so appreciative that their input is sought after and valued.

What is a Patient and Family Focus Group?  

Focus groups are a form of qualitative research, discussions with your patients and families to learn about their healthcare wants, needs, and perceptions.  All great patient experience outcomes begin with listening to the voices of the patients and their families, relying on their perceptions of healthcare to identify priorities and enhance performance improvement initiatives that can yield amazing results.

Some Sample Guidelines for Facilitating a Patient and Family Focus Group

The following guidelines will help foster a robust, information-rich discussion:

  • Invite 8-12 participants of different race, ethnicity, age, gender, and cancer disease site. Invite their family members and/or caregiver, so that you can conduct a separate caregiver group at the same time.
  • Hire or invite an expert facilitator to run the sessions.
  • Choose no more than 10 carefully selected questions that allow for open dialogue.
  • Tape your session as well as invite a scribe to assist with notetaking. (Be sure to inform participants that you will be recording the discussion.)
  • Review focus group participation ground rules with all participants.
  • Provide a light snack and/or small thank you gift for participating in the focus group discussion.

Introduction and Ground Rules for the Focus Group 

Here are tips for getting the conversation started: 

  • Introduce yourself and ask each participant to introduce themselves.
  • Explain that the cancer program wants to know what they like, what they don’t like, and how they feel programs might be improved.
  • Remind the group that the cancer program leadership is interested in both negative and positive comments. 

Next, review the ground rules with your focus group members. Explain that the facilitator/moderator’s role will be to guide the discussion: 

  • Assure participants of complete confidentiality.
  • Emphasize that there are no right or wrong answers, only differing points of view.
  • Ask participants to please speak one at a time so the scribe can accurately capture the conversation.
  • Remind everyone that they don’t need to agree with each other, but it’s important to listen respectfully as others share their views. Everyone should feel free to share openly.
  • Request that everyone please turn all cellular phones to vibrate. If anyone needs to respond to a call, please do so as quietly as possible and rejoin us as quickly as you can.

Some Possible Questions for your Focus Group(s)

  1. What was important to you and your family as a newly diagnosed cancer patient?
  2. What is important to you and your family now that you have started your cancer treatment?
  3. Were you aware of the support services at the cancer center?  What services would you like at the cancer center?
  4. Was the patient journal and/or patient educational materials you received helpful? How could they be better?
  5. Patient- and family-centered care is extremely important, what does this mean to you and your family?
  6. What is important to you and your family in a survivorship program?

Once your focus group is complete, consider keeping the momentum going by creating a Patient Caregiver Advisory Committee.  Learn more in this recent Oncology Issues article that explores how improving patient engagement can help to improve your cancer program.

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.

Patient Navigation—Process Mapping by Disease Site

By Tricia Strusowski, MS, RN

ThinkstockPhotos-467463476For this patient navigation blog post, let’s talk about a recent hot topic on ACCCExchange, the online discussion forum for ACCC members: At what point in the care continuum do you initiate navigation and support services?

Many cancer programs have a difficult time identifying when to initiate these services. Cancer programs know that staff are duplicating services, but they don’t want anything to fall through the cracks for patients and their families. At busy cancer programs, staff may be challenged to find the time to sit down and work out these details. Plus, getting all the healthcare professionals together for one more meeting can be a daunting task. Cancer programs want to provide the best experience for their patients while utilizing staff efficiently. One way to support this goal is by involved the entire team in creating a disease-site-specific process map to review the continuum of care; discuss staff roles and responsibilities; identify gaps, barriers, opportunities for improvement; and goals of care—all with the patient at the center of the discussion. Simply put: Increasing communication among the team and decreasing duplication for the patient.

Who Should Participate?

Ideally, the team participating in the disease-site mapping process should be representative of the offices and departments that will touch the patient during his or her journey. Keep in mind: You need to include the “worker bees,” the staff who really know the details of the patient flow. Let’s consider a head and neck cancer patient for example. In this instance, the following individuals should be invited to participate:

  • Surgery
  • Medical oncology
  • Radiation oncology
  • Inpatient unit case manager and/or discharge planner
  • Speech/swallowing therapist
  • Navigator
  • Social worker
  • Financial counselor
  • Behavioral health
  • Rehabilitation/Prehabilitation
  • Dental office
  • Others (We all know there is always someone we forget to invite!)

Plan your first session for 1.5 to 2 hours. Admittedly, this may be a challenge to schedule but it can be done, and the results will be amazing. Utilizing a large paper flowchart (i.e.,15 feet long x 4 feet wide), the group needs to talk through and record the process starting at the patient’s earliest point of entry. Each detail must be discussed, including length of time from one episode of care to the next, delays, gaps, and opportunities for improvement. Encourage participants share their goals during the discussion and write everything down!

Revisit & Revise

Process mapping exercises are not a one-and-done experience. It takes several meetings to review and revise the process map. There may be key individuals or a process that are missed in a previous session; no big deal, add them to the group. A great facilitator is key to keep the team on task and keep the discussion moving.

After the entire disease-site process is complete, overlay when you would like the navigator and the support staff to intervene. Remember: the goal is to provide the intervention as soon as possible, hopefully in a proactive manner so that you are “staying one step ahead of the patient.” Incorporate when you would like to initiate the distress screening process, identifying periods of highest distress for the patient/family.

The draft process map is also an excellent tool to share with the disease-site-specific healthcare providers who are often are not aware of all the details, delays, and opportunities to enhance the patient experience. Further, your process map will also be excellent tool for on-boarding new staff and for succession planning. Review and update your process map on a bi-yearly or annual basis.

 Go Team!

I always share that the disease-site-specific team is like a football team; the better all the players understand everyone’s role and how to best support the patient and each other, the stronger the team will be. Every team always wants what is best for the patient. The mapping process is a valuable approach to not just identify gaps or delays in the care continuum, but to also then go the extra mile to identify “what is best for the patient.”

Work smarter not harder; teamwork makes the dream work!


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

Meals or Mammograms? A Decision No One Should Have to Make

By Renea Duffin

Guest blogger Renea Duffin is Vice President of Cancer Support and Outreach, Mary Bird Perkins Cancer Center in Baton Rouge, LA .

Mary Bird Perkins Cancer Center Mobile Medical Clinic

Mary Bird Perkins Cancer Center Mobile Medical Clinic

For many people living in Southeast Louisiana, choosing between paying for a mammogram (or other preventive health screening) or a meal for their family is a decision that can lead to a late- stage cancer diagnosis. And, unfortunately, this happens far too often in many Louisiana communities. Read on to learn how Mary Bird Perkins Cancer Center, a 2016 ACCC Innovator Award winner, has grown its outreach and screening efforts to improve early detection of cancer for the medically underserved.

Collaboration for Comprehensive Outreach

In Louisiana, one in five residents live in poverty, so it is no surprise the state’s cancer mortality rate is the fourth highest in the nation. There are only three other states with a greater uninsured population. In 2002, Mary Bird Perkins Cancer Center began its comprehensive community outreach program to address Louisiana’s disproportionate cancer death rates. Through this innovative initiative, the Center collaborates with many community partners and generous donors to provide free breast, prostate, colorectal, skin and oral cancer screenings for the underserved, underinsured and uninsured members of our 18-parish service area.

Integrating Patient Navigation to Improve Access

As the program continued to grow and evolve, it became evident that not only were screening participants medically underserved, but they faced many other barriers to care such as low health literacy levels, unreliable transportation, and other restricting socioeconomic factors. This led to the implementation of a patient navigation program in 2008 that assists patients receiving an abnormal screening result in accessing additional testing, physician specialists, financial resources, as well as removing other barriers to care.

By the Numbers—Education, Screening, & Early Detection

The following are some additional facts and information about the Center’s education and early detection program:

  • Each year, two mobile medical clinics deliver more than 8,000 free screenings for five types of cancer.
  • More than 74,000 screenings provided and 503 cancers diagnosed since 2002. The Cancer Center’s screening program rate of cancer diagnoses is nearly double the national rate per 1,000 adults screened.
  • Provides screenings outside regular business hours in convenient locations and in areas where they are most needed. Locations and populations are targeted based on zip code data using a powerful database solution.
  • Average time from screening to resolution (diagnosis or all clear) is 10 days compared to the national standard of care, which is 60 days. This expedited timeline is due to collaborative, close working relationships with service providers and the patient navigator’s hands-on approach to patient interactions.

After over a decade of providing education, early detection and navigation services to the medically underserved, we know there is still much to do. We constantly reassess our programs and strategies to ensure we are meeting the needs of those we serve in the hope there will be a day when no one must choose between accessing healthcare services and feeding their family.

At the upcoming ACCC 33rd National Oncology Conference October 19-21, in St. Louis, Missouri, Mary Bird Perkins Cancer Center and all the 2016 ACCC Innovator Award winners will describe their inspirational approaches to complex challenges in delivering quality care to serve their communities. View conference agenda and register today!

Navigation Documentation Tools Can Support Compliance with Commission on Cancer Standards

By Tricia Strusowski, MS, RN

ThinkstockPhotos-180686516Documentation by oncology patient navigators can play an important role in your cancer program’s efforts to comply with the new Commission on Cancer (CoC) Standards that became effective in 2015.  This blog reviews documentation-tool compliance—in other words—how your documentation tools can help you demonstrate compliance with CoC Standard 3.1 Patient Navigation Process and Standard 3.2 Psychosocial Distress Screening.

Let’s start with a review of key elements of these standards:

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 . . . .

Prior to establishing the navigation process, the Cancer Committee conducts a community needs assessment to identify the needs of the populations served, opportunities to improve cancer health disparities, and decrease gaps in resources. This assessment reoccurs at least once during the three-year survey cycle.

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 one 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, pre-surgical and post-surgical visits, and first visit with the medical oncologist to discuss chemotherapy, routine visit with a radiation oncologist, or post chemotherapy follow-up visit. Preference is given to pivotal medical visits at times of greatest risk for distress, [emphasis added] such as at time of diagnosis, transitions during treatment (such as from chemotherapy to radiation therapy), and transitions off treatment.

Method: The mode of administration (such as patient questionnaire, clinician-administered questionnaire) is to be determined by the program.

Tools: Preference is given to standardized, validated instruments with established clinical cutoffs; however, facilities may use a measure of their choice.

The complete CoC Cancer Program Standards: Ensuring Patient-Centered Care  (2016 Edition) is available on the CoC website here.

Navigation Tools & Reports Can Support Compliance

Here are five tips for creating your navigation tools and reports so that they support CoC standard compliance:

  • Ensure that the fields in your tools are specific to the standard. Many navigation programs tend to over collect information that is not needed to be compliant with the standard, resulting in additional work for the staff and/or patient and possible confusion about what information needs to be reviewed at cancer committee.
  • Keep your documentation tools and reports simple. Be sure to define your documentation fields on your tools and reports; this will ensure that the navigators are collecting the information in a consistent manner.
  • Create evidenced-based tools. For compliance with the CoC standards, tools should be evidence based. For distress screening, examples include the NCCN psychosocial distress screening tool or the FACT (Functional Assessment of Cancer Therapy) tool.
  • Use your EHR or an Excel file. Since the navigation program needs to be reviewed at the cancer committees on a yearly basis, using your EHR or an Excel file makes it easy to aggregate information for these presentations.
  • Make the most of your Community Needs Assessment (CNA). Your CNA is essential because it helps identify your population of patients and their specific needs and barriers. The CNA can also be used to identify performance improvement activities for your program.  Further, it provides an excellent review for the navigators, as well as all cancer program support services, to more fully understand their patients.

Community Needs Assessment (CNA): A Valuable Resource

Cancer programs are not as familiar with creating Community Needs Assessments; however, there are great resources to help you identify the data you will need. For example, the information and data needed for your CNA can come from:   American Cancer Society Facts and Figures, American College of Surgeons Commission on Cancer, Academy of Medicine (formerly known as Institute of Medicine), the Centers for Disease Control and Prevention Cancer Data and Statistics, U.S. Census Bureau, State Health Department and Internal Revenue Service, and National Cancer Institute Surveillance Epidemiology and End Results.

As you develop your tools:  Make sure they work for YOU, and that you are NOT working for your tools.  


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

Patient Navigation: 20 Years in Review & My Lessons Learned

by Tricia Strusowski, MS, RN

Patient Navigation Compass for HealthcareIt is amazing how the world of patient navigation has changed over the last 20 years! Fate has aligned me with many wonderful opportunities, and over the years I’ve been honored to be an active participant both in the navigation role itself and in navigation program development. The journey has been a labor of love, a true passion, and extremely gratifying.

I was first introduced to the concept of navigation through my role in case management in the mid-1990s. Identifying the needs of the patients even before their cancer care commenced became a necessity to help transition the patients to the correct level of care. The goal was to provide the best services, decrease duplication of care, contain costs, and increase communication among the healthcare team. The patient and the family were active participants in their plan of care.

Toward the end of the decade, in 1998, my then-employer, Christiana Care Health System, Helen F. Graham Cancer Center, identified the need for “care coordination” for oncology patients and families (navigation was not yet a familiar term). We were one of the earlier adopters of “care coordination” or what we now call navigation. Our team consisted of disease-site-specific oncology nurses and social workers. We were under the “administrative microscope” to coordinate care across the continuum from cancer diagnosis through end of treatment or end-of-life care. After a bumpy start, we developed and then standardized our program.  We created pathways, guidelines, standing order sets, a patient journal, and patient tools, which are now called decision aids.  Learn more here.

Here are some navigation lessons learned over the years.

Lesson learned #1: Create tools and reports to reflect American College of Surgeons Commission on Cancer (CoC) national standards; identify metrics to demonstrate the success of your program. Define your reports and metrics for the staff so that information/data is collected in a consistent manner. 

As a new navigation program we initially made our patients and families too dependent on our services and as our volume increased, the caseloads became unmanageable. The staff became overwhelmed and we needed to address this immediately to provide the best service for our patients.

Lesson learned #2: Empower your patients with decision-aid tools/educational materials and provide health literacy training for staff. Monitor the caseloads and close cases when active treatment is completed. Hold morning meetings or huddles to share patient information with the healthcare team across the continuum.  Keeping your healthcare team updated increases productivity. 

In 2007 Christiana was an original member of the NCI Community Cancer Centers Program (NCCCP) initiative. I co-chaired the Quality of Care Subcommittee.   As a result of navigation discussions we created the Navigation Networking Committee and listserv; we held monthly conference calls to discuss our programs, best practices, document tools, and models of navigation. Our committee grew to more than 90 attendees. It was a fantastic learning and bonding experience; many of us are still close colleagues today. One resource developed through the NCCCP was a Navigation Assessment Tool for growing a program. Learn more.

Lesson learned # 3: Collaborate with your internal and external resources to identify best practices. Use the internal resources/experts in your healthcare system, i.e., pastoral care, finance, volunteer department, etc.  Partner with your external resources, such as the American Cancer Society (ACS), state Breast Cancer Coalition, Leukemia & Lymphoma Society, and Cancer Support Community. 

From 2008 to 2009 ACCC provided me with an exceptional opportunity to teach a two-day patient navigation workshop at six community cancer programs. I met with the teams and we discussed the goals, roles and responsibilities, documentation tools, job descriptions, guidelines, reports, and performance improvement initiatives. The programs were all very appreciative of the information because there really were not many resources available at the time. At the end of these training sessions ACCC held its first webinar on navigation.

Lesson learned # 4: Don’t reinvent the wheel. Today there are many resources available for navigation through ACCC, AONN+, ONS, AOSW, NCI, IOM, and  ASCO, just to name a few.  Network with your colleagues via listservs.

Navigation at times can be a “catch all” service; navigators may get bogged down with scheduling appointments, calling insurers, and data entry as well as other clerical duties.  Although some of these responsibilities are inevitable, it is important to identify support staff to assist with these tasks.

Lesson learned # 5: As a professional navigator it is essential that you function to the top of your license. You don’t want to turn into an expensive clerk.

Today, as I continue my role as independent consultant, I always tell my clients that patients and families always come first. If you take excellent care of the patients using national standards and best practices, the rest will fall into place.


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

Caring for the Whole Patient—Two Cancer Programs; Two Approaches

One in an occasional blog series on topics from Oncology Issues, the journal of the Association of Community Cancer Centers.

By Susan van der Sommen, MHA, CMPE, FACHE, ACCC Editorial Committee Chair

Hands-creating-circle-of-supportThe pivotal 2013 Institute of Medicine* report, Delivering High Quality Cancer Care: Charting a New Course for a System in Crisis, effectively outlines what those of us working in the cancer setting inherently know: More than 1.6 million patients are newly diagnosed with cancer annually; a number that is expected to rise to 2.3 million by 2030. The same report notes that by 2022, there will be 18 million cancer survivors in the U.S.

Cancer is indiscriminate. The newly-diagnosed are old, young, rich, and poor; fathers, mothers, daughters, sons, and siblings; they are single, married, bisexual, and gay; some are working, retired, on disability, or collecting social security. Two things these patients have in common are (1) they are people who are performing the activities of daily living—whatever  that may be—and  (2) cancer has changed their lives forever.

On a positive note, achievements in clinical science and treatment have led to earlier detection of many cancers, significantly increased life expectancy, and cured many of the disease. However, these same people may face other challenges often not detectable by the untrained eye: they are scared, anxious, depressed, and often suffering from considerable physical impairment that may dramatically impact their daily lives. As the 2008 IOM report Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs notes, these emotional, mental, and physical symptoms may be an exacerbation of issues the patient had prior to the cancer diagnosis.

The March/April edition of ACCC’s journal Oncology Issues includes feature articles that detail how two cancer programs have dramatically improved the lives of their patients (and patients’ caregivers) by instituting psychosocial distress screening and support programs. In their article, “Building a Navigation and Psychosocial Support Program from the Ground Up,” Lori McNulty, RN, and Faye Flemming, RN, BSN, OCN, describe how the Southside Regional Medical Center implemented a newly-developed patient navigation program as the foundation of their psychosocial support services. As with many cancer programs, Southside Regional Medical Center, though committed to furnishing these services, couldn’t justify the financial outlay needed to hire additional staff. By partnering with a local community organization, Southside Regional Medical Center was able to facilitate a patient-centered—and financially sustainable—approach to providing these vital services to their patients. Additionally, its  support program was established in such a way that the cancer program was able to meet many of the accreditation standards set forth by the Commission on Cancer.

The Norton Cancer Institute in Louisville, Kentucky, embedded a psycho-oncology program in its center to more effectively meet the needs of its patients’ psychosocial needs. Noting that psychological distress is common among cancer patients and often goes unrecognized, this ACCC member program developed the Norton Cancer Institute Behavioral Oncology Program (NCIBOP). As described in their article “Building Bridges, Breaking Down Barriers: An Embedded Psycho-Social Program Improves Patient-Centered Care,” NCIBOP is “a comprehensive, embedded psychiatric program with an emphasis on integrating high-quality psychiatric care to medically complex patients.” The program offers a multitude of group and individual therapy services and consultations in both the inpatient and outpatient setting. Staffed by three advanced practice RNs, a psychiatrist, a part-time social worker, a nurse, and two administrative staff, the team addresses the needs of approximately 800 patients per year. NCIBOP’s evidence-based, patient-centered approach has allowed many patients to experience a dramatic improvement in the quality of their lives.

Two cancer programs with two different approaches to meeting the cancer patients’ needs—these articles illustrate the complexity of oncology care delivery. At the same time, these divergent approaches also highlight the opportunity individual programs have to develop a programmatic structure designed to meet the needs of their unique patient population. The result? Patient-centric care models that meet the needs of the whole patient, just as the IOM report recommends.


*Note: On March 15, 2016, the division of the National Academies of Sciences, Engineering, and Medicine (the Academies) that focuses on health and medicine was renamed the Health and Medicine Division (HMD) instead of using the name Institute of Medicine (IOM). For more information, visit www.nationalacademies.org.