Transcript Presentation Title Here - Wisconsin Cancer Council

Patient Navigation Across the
Cancer Continuum
Marlene A. Runyon, RN, BSN, OCN, CHTP
Mayo Clinic Health System, Franciscan Healthcare
La Crosse, Wisconsin
WICCC Summit, Madison, Wisconsin
March 29, 2012
©2011 MFMER | slide-1
Current State/Roles
Cancer Guide
Introduction to
supportive services
Symptom management
Integrative therapies
Mind/body tools for
coping
Social Worker
Clinical trial referrals
Advanced care planning
Behavioral health
referrals
Coordination of care
(schedules/appts)
Psychosocial support
Drug assistance
Coordination of care
between settings (inpatient
& outpatient)
Finances
Insurance
Transportation
Navigation During Treatment
• Facilitate chemotherapy education class
• Provide support /assessment at first chemo
treatment
• Referral to social worker, dietitian, integrative
therapies, support groups
• Complete psychosocial assessment
• NCCN distress tool at each chemo
treatment and follow-up provider visits
• Accompany providers for clinic /hospital visits
• bad news, change in treatment plan , etc
©2011 MFMER | slide-3
Navigation During Treatment
• Provide support during patient clinic
appointments as needed/requested by pt/family
• Initiate referrals to OT Cancer Fatigue Program,
exercise programs, group acupuncture, etc.
• Support nursing and other staff with difficult
patient situations
• Facilitate support groups
©2011 MFMER | slide-4
Successes of Current Program
• Early support of patient and family
• Support team collaboration
• NCCN distress thermometer
• Chemotherapy education class
• Integrative therapies and mind/body skills
• Survivorship program
• Survivorship group
• Survivorship care plans for breast patients
• Team buy-in
©2011 MFMER | slide-5
Comparing Patient Navigation Model
to Current State at MCHSFH
MCHSFH
Patient Navigator
•Cancer care orientation
•Advocating for patients
•Arranging transportation
•Referral for financial needs
and other community services
•Scheduling appts. and
arranging diagnostic tests
•Facilitating communication
between health care
providers, pts. and/or families
•Coordinating multidisciplinary
services
•Educating patient
•Resource identification
•Providing counseling
•Emotional support
•Follow up phone calls
Gaps
•Continuous care coordination
•Provide patient education
surrounding disease and
treatments
•Facilitate communication with
and between health care
provider, patient and families
•Follow up on appointments
•Assuring ability to make
appointments
•Follow up on missed
appointments
•Main contact for patient
•Follow up phone calls
•Drug assistance
•Coordination of care
between settings
(inpatient & outpatient)
•Finances
•Insurance
•Transportation
•Clinical trial referrals
•Advanced care planning
•Behavioral health referrals
•Coordination of care
as needed (schedules/appts)
•Psychosocial support
•Symptom management
•Integrative therapies
•Assistance with coping
Challenges During Transition
• Communication of changes and processes in current
model
• Budget neutral?
• Outcome measurement
• Lack of training/role needs definition
• Time: management of other issues and requests,
constraints of time
• Lack of clarity with navigator role nationally
• Role transition for cancer guide and social worker
• What happens with current roles (financial assistance,
Healing Touch, volunteer involvement, etc)
©2011 MFMER | slide-7
Next Steps
• Development of assessment tool
• Determine how the flow process for the
navigator role gains access to the patients
• Conduct rapid cycle of change
• Initial assessment
• Measure outcomes
• Distress tool scores
• Patient satisfaction
• Implement comprehensive patient navigation
model