The Importance of Navigating Quality and Metrics A

The Importance of Navigating Quality and Metrics: A Case Study Kris Blackley, RN, MSN, BBA, OCN June, 2018

Objectives • Review benefits of navigation • Keys to developing a business case for navigation • Discuss importance of standardization • Explain why metrics are needed • Review research results • Review lessons learned

Levine Cancer Institute A Carolinas Healthcare Facility • Academic, multi-site, community based, cancer center • 8 facilities within the Co. C Network • 12, 000 new cancer patients annually • 30 navigators across Co. C Network

Why Do We Have Navigation? • Harold P. Freeman-Breast Cancer study • American Cancer Society: Report to the Nation on Cancer in the Poor— 1989 • Commission on Cancer standard 3. 1 • CMS

What Are the Benefits? § Higher levels of patient satisfaction² § Reduced no show rate 4 § Fewer treatment interruptions¹ § Drive downstream revenue 5 § Recouped potential lost revenue 5 § Decreased time to first provider visit/treatment³ § Improved timeliness of treatment² § Patients have a better understanding of information² 1 Krebs et al, 2013, 2 Basu et al, 2013, 3 Gordils-Perez, J, Schneider, S, et al, 2017, 4 Luckett, R, 2015, 5 Korber et al, 2011

Why is it so hard to demonstrate? • Leadership is lacking • Navigators work in silos • Resources are not available • Infrastructure not in place • Navigation programs are often under developed

Where to begin? ?

Community Needs Assessment • Provides a road map • Brings stakeholders together • Address the areas of biggest need • Provides leverage with administration

Me Administration

Co. C Navigation Standard • S 3. 1 “ A patient navigation process, driven by a community need 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. ”

No Standardization • No standardized processes—different rolls and tasks in every clinic and at every facility • No standard documentation—Navigators not documenting in EMR, some excel spreadsheets with different fields • No way to track patients or collect information —No tools available

Standardization

Implications • Quality of care is not consistent • Navigation role is not clear to patients or providers • Metrics are not being collected • Valuable research cannot be done for Evidence Based Practice • Cannot demonstrate value

You Can’t Manage What You Don’t Measure

Standardized Metrics AONN+ has published 37 standard metrics that focus on: 1. Business Performance/Return on Investment 2. Clinical Outcomes 3. Patient Experience

Strength in Numbers

Navigation Informatics Systems • Develop IS systems to: • Support standardized navigation practice and data collection across multiple facilities • Help navigators manage large patient cohorts more effectively • Capture metrics for management of rapidly growing multicenter navigation program • Improved Communication

IS Tool within EMR

IS Tool for Patient Management

How does this help our patients? --22 y/o, Female, Spanish speaking only, sarcoma patient, admitted to critical care unit --60 y/o, Male, newly diagnosed MM, admitted for acute kidney injury --52 y/o, Male, homeless man, completed treatment for bladder cancer, DVT

Research and Outcomes

Research and Outcomes Reduced 30 day readmissions for navigated patients vs. Non navigated patients—Presented at ASPO • Approximately 1 in 7 hospitalized patients is readmitted within 30 days of hospital discharge (rates vary due to several factors) • The cost of readmissions to the healthcare system nationally are substantial – roughly $30 billion/year for Medicare alone • Non-Navigated patients were 52% more likely to have a 30 day all cause readmission than Navigated patient Tsai et al. N Engl J Med. 2013; 369: 1134 -1142 Fed Regist. 2012; 77(170): 53258– 750. N Engl J Med. 2009; 360(14): 1418– 28

Cancer site and UNPLANNED readmission rates among navigated and not navigated cancer patients

Research Study Design: • Retrospective study comparing navigated and not navigated patients Ø Analysis of overall survival restricted to individuals diagnosed with cancers with established poor relative survival (AML, Esophagus, Liver, Lung, Myeloma, Ovary, Pancreas, Stomach) • Rigorous matching methodology to reduce potential overt bias between groups; Variables matched included: Ø Patient characteristics - age, gender, race, ethnicity, marital status, employment status, insurance status, location of residence, median income by zip code, % poverty by zip code Ø Clinical characteristics - tumor site, tumor stage, tumor grade, lymphovascular invasion, cancer treatment, comorbidity score, inpatient admissions 12 months before cancer diagnosis, smoking history • Sensitivity analyses evaluating robustness of results

Research and Outcomes Survival benefit Navigated vs. non navigated patients—presented at ASCO

24 Month Survival Data

Research and Outcomes More frequent connection to oncology support services including palliative care, social work, nutrition

Research and Outcomes • No difference in time from diagnosis to 1 st treatment Ø 28 days NN vs 30 days not navigated (p = 0. 47) • Increased chemotherapy receipt (relative dose intensity, RDI) Ø 55% NN received >85% RDI vs 44% not navigated (p = 0. 01) • Decreased delays in attending outpatient oncology appointments Ø 12 days NN vs 30 days not navigated (p < 0. 01)

Lessons Learned • Must have buy in from key stakeholders • The larger the institution the harder change can be • One size does not fit all • Everyone has an opinion • Don’t operate in silos

Conclusion Standardization and metrics are the keys to improving quality and demonstrating the value of our role. We must work together to share best practices, to gain data and expand our volume of evidence based practice.

Tools for Standardization • AONN Standardized https: //www. aonnonline. org/images/articles/standardized_metrics/Metrics-Source. Document. pdf • ONS Standard Navigation Competencies https: //www. ons. org/sites/default/files/2017 ONNcompetencies. pdf • AONN Nurse Navigator Certification https: //www. aonnonline. org/certification/nurse-navigator-certification • Commission on Cancer https: //www. facs. org/quality-programs/cancer/coc/standards

Acknowledgements Collaborators: Special thanks to Carol Farhangfar, Ph. D, MBA Derek Raghavan, MD, Ph. D Victoria Morris Andrea Bouronich 6/13/2018 33