PATIENT NAVIGATION BEST PRACTICES OHCS NAVIGATION PROGRAM AMY

PATIENT NAVIGATION BEST PRACTICES OHC’S NAVIGATION PROGRAM AMY SHELDRICK RN BSN OCN PATIENT CARE TEAM LEAD/NURSE NAVIGATOR

Navigation Patient Care Teams v. In office Patient Care Team Members v. Nurse Navigators - OCN certified v. Patient Care Coordinators - assist with nonclinical patient services including test scheduling v. Financial Navigators v. Centrally located Team Members v. Triage Nurses

Present Navigation Process v. Starts with a treatment plan and scheduling of an OCM appointment v. The Navigation Process begins prior to the patient starting treatment and continues through survivorship or end of life care

Oncology Care Model Appointment v Goal is for the patient to have their OCM appointment and start treatment within a few days to a week of their new patient appointment v A two hour appointment v Meeting with Advanced Practice Provider v Financial Navigator v Nurse Navigator v Tour of facility v Possible treatment

Oncology Care Model Appointment v ALL patients are treated as “OCM patients” Within the EHR the patients are “marked” as candidates. Then behind the scenes for billing purposes, are flipped to true OCM status if it is determined that they qualify for the program. Our Nurse Navigators are not disease specific navigators and help treat our oncology and hematology patients

Oncology Care Model Appointment v Advanced Practice Provider v Treatment schedule, disease status, advance care planning, distress and depression screenings v Financial Navigator v Insurance Coverage, copay and other financial assistance needs

Oncology Care Model Appointment v. Nurse Navigator vchemotherapy teaching vside effect management voffice information (access to care 24 hours a day) vneeds assessment vsupport group materials vtour of office and treatment suite

Present Navigation Processes v. IV infusion patients v. Receive a phone call 24 - 48 hours after first infusion and then follow-up as needed v. Oral treatment patients v. Follow-up calls are done two weeks after start of medication, monthly for six months, and then as needed determined by the nurse navigator/physician

Present Navigation Processes v. New treatments v. Patients who are changing treatments due to relapsed disease or maintenance therapy have an abbreviated OCM appointment as long as they have had treatment within the last six months v. If the patient has been off treatment for over six months, they will get a full OCM appointment again

Present Navigation Processes v. Triage Nurses v. Triages symptom calls v 24 hour follow-up calls for symptoms they were able to manage over the phone v. Monthly depression screening calls

Future Goals for the Navigation Process at OHC v Nurse Navigator introduction at the New Patient appointment v Ability to check in with the treatment patients (infusion and oral patients) at each office visit v Create more in-office support services for the patients v Better reporting and tracking processes for the treatment patients within the EHR to make sure all needs are met from business and patient care aspects

Future Goals for the Navigation Process at OHC v Weekly huddles to discuss needs of current patients v Assessing gaps in patient services that we offer v Stratification of patients into risk categories to personalize their care needs in greater detail v Investigate ways new technology options will allow us to better care for our patients on a day to day basis