Tag Archives: quality cancer care

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.

Getting Engaged

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

ThinkstockPhotos-484468581When first hearing of a cancer diagnosis, I imagine a patient’s mind spinning with a cyclone-like ferocity … Am I going to die? How will I tell my family? What about all of my plans? It’s cancer … of course I am going to die … but how soon? Suddenly, life spins out of control.

Engaging patients in their care can dramatically reduce anxiety by giving back some control. Of course they can’t control the diagnosis, but they can control how they face it – on their terms, with their beliefs, wishes, and desires at the forefront of every decision.

In a recent Oncology Issues article, “Talk to Me: Improve Patient Engagement; Improve Your Cancer Program,” author Chad Schaeffer, MS, FACHE, lays the foundation for developing strategies to connect patients and the decision-making process relating to their care. Improved patient engagement can alleviate some of patients’ burden in feeling as if they are hapless victims of heinous misfortune and allow them to regain some semblance of control over their future. Schaeffer is executive director at the Edwards Comprehensive Cancer Center at Cabell Huntington Hospital, Huntington, WV.

Defining patient engagement in simple, broad terms as “the ongoing and mutually beneficial interaction between patient and providers,” he notes that putting the patients’ needs and aspirations first will improve engagement and, ultimately, satisfaction for all.

What are the goals?

Patients’ treatment goals vary and are individualistic. Some desire to extend life at any cost; others prefer quality over quantity. Many want as little disruption to their daily lives as possible. As Schaeffer points out, evening and weekend hours, though not always pleasing to cancer center staff and physicians, will allow some patients and caregivers the flexibility to carry on with their routine (work, childcare, etc.) while receiving treatment and care at a time that is convenient.

Are we meeting your needs?

Cancer center physicians often struggle with the difficult conversations regarding the “end of life,” resulting, as Schaeffer points out, in decisions that may not coincide with a patient’s wishes. According to an end-of-life study at Stanford University, family members whose loved one died in an “institutional setting” reported poor symptom management, lack of physician communication and patient engagement, and a dearth of emotional support for loved ones and caregivers. Conversely, those who passed with home hospice services reported a considerably higher degree of satisfaction with regard to unmet needs and physician engagement.

Is there something you aren’t telling me?

In addition to reviewing Press Ganey and CGCAHPS surveys, the leaders at the Bassett Cancer Institute in upstate New York have instituted a process where they can – in real time – monitor patient satisfaction. Throughout the course of their treatment, patients are offered a tablet on which they answer a few questions about their care. Questions are flagged so that when a patient expresses dissatisfaction, a member of the leadership team can address the patient’s concern during his or her visit. It gives both the patient and staff an opportunity to more effectively understand what drives patient satisfaction while giving patients an active voice in their care.

Engaging patients from the outset of their diagnosis and throughout their care is critical to their satisfaction and ultimately, as Schaeffer points out, a more effective, patient-centered cancer treatment center.

Patient–centered care is a key focus of the upcoming ACCC Annual Meeting, CANCERSCAPE, March 2-4, in Washington, D.C. Learn more here.

Read the current edition of Oncology Issues here.

ACCC member Susan van der Sommen, MHA, CMPE, FACHE, is Executive Director, DSRIP, Bassett Healthcare Network. She currently serves as chair of the ACCC Editorial Committee.

Improve Your Bottom Line with Commission on Cancer Accreditation

by Don Jewler, Guest Blogger

cocSure, Commission on Cancer (CoC) accreditation shows your cancer program’s commitment to quality care. Beyond that, what are the practical benefits for your institution?

For CoC surveyor William Laffey, MBA, the top benefit is that cancer programs gain access to data that they could not otherwise get about their own program. “They also gain access to comparative data to help them improve quality and understand why patients are coming to them and which patients are not. You can’t get access to the National Cancer Data Base unless you are accredited,” said Laffey, who will speak at ACCC’s upcoming 31st National Oncology Conference in San Diego, on October 9, 2014.

One set of data is on “Class 00” patients, those who come to a cancer program for diagnosis but never come back for treatment. Through analysis of the data on these patients, the cancer program can find out where they went, what treatment they had at that other facility, and, in some cases, even the referring physician.

“I’ve run into situations where large numbers of these Class 00 patients all went to a competing hospital,” said Laffey. “Their first course of treatment was for surgery. As I dug deeper, I found that most surgeries were for breast cancer. This hospital needed to improve its breast cancer surgery to keep these patients.”

When cancer programs peel back the onion, or in this case the data, they can determine exact areas to improve, including surgery, equipment, and scheduling, and they can dramatically improve their bottom line.

The National Cancer Data Base (NCDB), which is available only to CoC-accredited programs, has 15 to 20 different variables that can be compared on its 30 million patients.

Susan Rubin, MPH, of the Commission on Cancer, will join William Laffey at the ACCC National Oncology Conference. Rubin will examine key marketing strategies that cancer programs can use to maximize the value of their accreditation.

“Do you advertise the fact that your cancer program is accredited? Do you put the CoC seal on your newsletter?” Rubin asked. “It’s good to do so.”

Rubin noted that some cancer programs that go through the accreditation process do not publicize their accreditation. “Some staff in the hospital don’t even know the program is accredited,” she said. “Go out and explain to your staff the value of accreditation, their access to the National Cancer Data Base and to the Rapid Quality Reporting System.”

The Rapid Quality Reporting System (RQRS) is a reporting and quality improvement tool which provides real-clinical-time assessment of hospital-level adherence to National Quality Forum-endorsed quality of cancer care measures for breast and colorectal cancers.

If you want more practical advice on how to use the information that CoC accreditation opens up to your cancer program as well as tips on how to market that accreditation, join Laffey and Rubin at ACCC’s 31st National Oncology Conference in San Diego, on October 9, 2014.

William Laffey, MBA is the system vice president of oncology for Presence Health in Chicago, Ill. He provides a program administrator perspective to the Commission on Cancer survey process. Susan Rubin, MPH, is manager, Accreditation Program, at the Commission on Cancer.

ACCC members will recognize the byline of guest blogger, Don Jewler, former ACCC Communications Director. We coaxed Don out of retirement to contribute to ACCCBuzz.

Is Your Cancer Program Indispensable?

In April, ACCC held its 40th Annual National Meeting, with a focus on policy, economics, and business. The session on “Strategies for Growth in Cancer Care Delivery,” with Sg2 Vice President Trever Burgon, PhD, was standing room only. ACCCBuzz invited Dr. Burgon to share some key takeaways from his talk. Read on and find out why the term “indispensable” is the way you want patients and payers  to describe your cancer program.

Person in information spaceby Trever Burgon, PhD, Vice President, Sg2

Let’s start with a provocative statement: There is no service line more important to your hospital, practice or health system’s future competitive position than cancer services. Here are three areas of evidence to support this claim:

1. Growing demand – An aging population and expanding treatment options will drive strong demand for cancer services. At the recent ACCC 40th Annual National Meeting in Arlington, Va., I shared data from Sg2’s Impact of Change® forecast model, which projects demand for healthcare services over the next decade. Much of this growth will happen in the outpatient setting, in fact, Sg2 forecasts stronger outpatient growth for cancer than for any other service line. Nationally, we anticipate that demand for ambulatory cancer care will increase 15% over the next five years and 31% over the coming decade. Demand growth will be softer on the inpatient side, increasing only 3% over the next decade. There is an important nuance in these inpatient numbers. Many inpatient surgical procedures will see strong growth of +9% over the next 10 years, while non-surgical admissions are expected to fall by 5%. This expected decline will be the result of improved patient management in the ambulatory setting and expanded access to appropriate palliative and end-of-life care which will reduce avoidable hospitalizations. Meeting this demand will require hospitals and health systems to develop and expand strong systems of care that coordinate services across the care continuum, from screening and diagnosis to outpatient and inpatient treatments through survivorship and end-of-life care.
2. Changing economics – Per person, cancer is the most expensive disease to treat in the U.S. For providers and health systems, cancer care represents an important source of revenue that helps subsidize other care delivery services. At the same time, spending on cancer is increasingly coming under the scrutiny of public and private payers looking to control healthcare spending costs. As we heard multiple times at the recent ACCC meeting, various new payment reforms, including robust benefits management, bundled payments, and narrow networks, all have the potential to materially impact cancer services. Successfully navigating these changing economic structures has the potential to impact the entire enterprise.
3. Connecting with patients and families – Cancer occupies a unique and important part of our healthcare landscape. It is a terrifying disease that will impact virtually each one of your patients and prospective patients either through a personal diagnosis or that of a loved one. Meeting the needs of these patients and their families with seamlessly coordinated, patient-focused services that span the care continuum represents a powerful opportunity to engage and care for these consumers over their lifetime. Guiding a patient from initial diagnosis to treatment, providing critical but under-reimbursed psychosocial support services, or ensuring that patients’ end-of-life treatment plans are aligned with their quality of life goals, can be some of the best opportunities to establish your program as the go-to place of care for all of a family’s healthcare needs. If you can provide this level of coordinated, patient-centered care for a complex disease like cancer, you can do it for any disease.

What must cancer programs do to position themselves for success in the face of growing demand, changing economics, and unique opportunities to connect with patients? Build a differentiated program that is indispensable to both patients and payers.

There are many ways to build this type of program and no two cancer programs will establish their indispensability in the same way. One area that will be consistent across all successful programs, however, will be a robust system of care that delivers value by ensuring patients and data flow seamlessly between the many providers and sites that span the cancer care continuum. At ACCC’s Annual National Meeting in April, we discussed a number of clinical opportunities for differentiation, including protocol-driven lung screening, easy-access one-day multidisciplinary clinics, and cancer-program-embedded outpatient palliative care services. In addition, we examined a number of oncology-specific bundled payment and accountable care pilots that progressive organizations are using to differentiate themselves with payers.

There are not enough resources to build every clinical program you would like, and not all of the new payment pilots will be successful and scalable. But these types of investments and innovations will be the key to making your cancer program indispensable in your market. And it will be these indispensable programs that succeed, to the benefit of your hospital, practice, or health system and more importantly, your patients.

Introducing ACCC’s New President Becky L. DeKay, MBA

by Amanda Patton, Manager, Communications, ACCC

Becky DeKay 2014Becky L. DeKay, MBA, became President of the Association of Community Cancer Centers (ACCC) on April 2, during the ACCC 40th Annual National Meeting. Ms. DeKay is Director of Oncology Services at the Feist-Weiller Cancer Center in Shreveport, Louisiana. In a Q&A interview with ACCCBuzz, she talks about what drew her to oncology and why she’s chosen “Quality” as the theme for her ACCC presidency.

ACCCBuzz: Can you tell us how you first became involved in the oncology field, a bit about how your career has evolved, and how you were first introduced to ACCC?

Ms. DeKay: My career has taken a circuitous route. I began in marketing, research actually, and joined a private hospital in 1990 as Director of Marketing. I then moved to Medical Staff Development. In 2001 I stopped working when our son, Chris, was diagnosed with Burkitt’s lymphoma, B-cell leukemia, Stage 4. I am happy to say that, thanks to St. Jude’s Children’s Research Hospital, he is 13 years cancer free. This episode ignited my desire to help others who are living with cancer. Before joining Feist-Weiller Cancer Center, I had chaired one of their fundraisers, Life Savers Ball. Through this experience, I learned more about FWCC, how they help patients, and the wonderful care they provide. After the event, the medical director at the time, Jonathan Glass, MD, graciously offered me a role in the management of FWCC. Ever since, I’ve been Director of Oncology Services at FWCC, LSU Health Shreveport.

ACCCBuzz: What would you like to accomplish during your term as ACCC President?

Ms. DeKay: Immediate Past President, Virginia Vaitones, MSW, OSW-C, highlighted the multidisciplinary team that takes care of the patient. We all know oncology care today takes an enormous amount of coordination and interaction. I hope, during my term as president, to focus this team on quality in cancer care. We all practice high-quality medicine, but how do we communicate that? How can we best demonstrate, replicate, and share our quality practices with other stakeholders—patients, providers, and payers—so they can understand and appreciate the work we do.

ACCCBuzz: What do you see as the most significant challenges facing the oncology community today?

Ms. DeKay: The pressure from the payers—private and government—is increasing daily. Rules change, reimbursement decreases, new therapies cost more money…all of these things create tension in the system. In the middle are our patients who are extremely sick and in the fight for their lives—physically, literally, emotionally. How can we help these most vulnerable patients while staying “alive” in this business?

ACCCBuzz: How might ACCC help its membership in meeting these challenges?

Ms. DeKay: ACCC can help the membership by continuing to provide the quality advocacy and education that has become the stalwart strength the members rely on. All of us are out in our communities every day. We must have a consistent message to share with our elected officials—on the state and national level—and speak up with a unified voice for the patients living with cancer. If that voice is loud enough, eventually it will be heard.

ACCCBuzz: You will be focusing on quality as the theme of your presidency. In this time of healthcare reform, this is a key issue. What role do you see for ACCC supporting its membership in the delivery of quality care?

Ms. DeKay: Quality is a key issue and it should be. I wanted to focus on quality in cancer care as my theme so that our cancer community can begin to define the measures we need to share rather than a payer group—any payer group—defining them for us. ACCC members are on the front lines of cancer care in communities across the country. We know what makes sense, what data can be collected, and which benchmarks should be reviewed. ACCC can help facilitate this discussion and work with its membership on how best to demonstrate and communicate quality. We need to be able to communicate the same message to various stakeholders—including those who are just learning the language of cancer. The quality is there…we just need to prove it!