Abstract: While providers and care systems can agree that effective patient navigation programs are essential to positive patient outcomes, there have been no standard metrics that could be used to measure the success of navigation programs and establish benchmarks for improvement. In the present climate of a health system shifting to value-based care and reimbursement, standardized metrics are needed. Previous research has touched on various measures that could be used to capture the impact of patient navigation programs in care, but few discuss the broad range of measures that validate the role of navigation in all areas of oncology patient care. In 2017 the Academy of Oncology Nurse & Patient Navigators announced 35 national evidence-based oncology navigation metrics. Authors expand on the utility of these metrics, the need for partnerships and improved communication between providers and navigators, and how these metrics can be cross-referenced and used in conjunction with other oncology metrics to achieve more integrated, comprehensive care.
Received March 28, 2018; Accepted April 5, 2018.
The aspiration of every oncology program is to provide excellent clinical care to their patients with superb clinical outcomes. Patient navigation programs play a significant role in facilitating excellent oncology care along the continuum of care, starting at diagnosis then throughout treatment, survivorship, and potentially end-of-life care.
Introduced in 1990 by Harold P Freeman, MD, to oncology care, navigation has shown its utility in decreasing time to care for oncology patients.1 But it was not until 2012 that the Commission on Cancer (CoC) mandated patient navigation to be a standard of care met by cancer programs seeking approval in the year 2015.2 CoC defines navigation as providing individualized assistance to patients, families, and caregivers across the entire continuum of care by removing barriers and increasing access to medical and psychosocial care.3 For example, as navigators, we are expected to provide a comprehensive psychosocial assessment of the patient and family’s needs at a period of high distress utilizing a validated tool such as the National Comprehensive Cancer Network psychosocial distress screening tool.4 This tool, which is to be completed in person, will assess for practical problems such as insurance, financial and treatment decisions, family problems such as dealing with your children and partner, emotional problems such as anxiety and depression, spiritual concerns, and physical concerns such as fatigue and eating concerns.
While it is clear to providers and systems of the utility of navigation programs in cancer care, it is necessary to be able to demonstrate its value with data and metrics. Value-based cancer care is our reality; it is our present landscape in health care. The introduction of Medicare Access and CHIP Reauthorization Act (MACRA), which includes alternative payment models and the Merit-Based Incentive Payments System (MIPS); the Oncology Care Model (OCM); Quality Outcome Physician Initiatives (QOPI); as well as other nationally accepted oncology metrics and national standards (eg, CoC, National Accreditation Program for Breast Centers [NAPBC])5,6 has confirmed the need for navigation programs to demonstrate their worth.
While oncology navigation programs have been in existence for decades there is an evident gap in the literature around metrics. This gap has resulted in the lack of solid benchmarks and limited research in navigation. Navigation services are not reimbursable to date, and administrators need to take the lead with their navigation programs to create metrics that support value-based cancer care. These metrics should support the CoC definition of navigation across all phases of the cancer trajectory and should include outcomes in patient experience, clinical outcomes, and return on investment. Navigation metrics must also be applied to the entire continuum of care, ie, screening/outreach through survivorship or end of life.
The shift to value-base care has resulted in many questions from administrators and providers on how to create and demonstrate the value of the care provided, including how patient navigation can show its value with concrete data (Box 1). With these issues and the overall goal of value-based care in mind, the beginning of the answers to these questions begins with (1) identifying appropriate metrics with your key stakeholders; (2) discussing metrics implementation based on national guidelines and value-based cancer care metrics with your providers and administrators; and (3) utilizing national benchmarks or creating internal benchmarks. With those tools and plans in place, the return on investment can then be determined. The multidisciplinary team through “metric synergy” will reflect in outcomes that will be achieved quicker and demonstrate sustainability for the cancer program.
Evidence-Based Metrics for Patient Navigation
Oncology navigation programing can be challenging in regard to meeting the needs of patients and families while also incorporating metrics that will ensure sustainability. Developing national evidence-based metrics to help create benchmarks and research is the goal; however, many programs tend to create program metrics in silos. Synergy and harmonizing metrics among providers, administrators, and support services is powerful and necessary to achieve value in cancer care.
In 2017, the Academy of Oncology Nurse & Patient Navigators (AONN+) announced7 35 national evidence-based oncology navigation metrics at their national conference (Table 1).7 This project—a year-long project with 10 national experts in navigation from across the country that included all models—analyzed over 300 evidence-based source documents and national oncology standards during metrics development.8 The team created robust navigation metrics in the categories of patient experience, clinical outcomes, and return on investment. These metrics will finally allow navigation programs to measure and demonstrate their success and sustainability while creating—for the first time—oncology navigation benchmarks that can be used nationwide, which have been needed for decades.
Integrating Navigation Metrics With Oncology Metrics
In review of the AONN+ navigation metrics, it was evident that these metrics not only support navigation programs but also support value-based oncology cancer care. The natural next step with the navigation metrics was to cross-reference the navigation metrics with other value-based oncology metrics (Table 2).
As stated prior, the synergy that can be created by partnering together on metrics would be a powerful tool to advance cancer care in any setting. The AONN+ navigation metrics, value-based cancer care metrics, and national guidelines support the same performance improvement initiatives, allowing program administrators, providers, and navigators to choose and develop metrics together to meet the goals of their cancer program as a true team. The end result would be providing exceptional care to patients with superb clinical outcomes.
Creating Partnerships Between Providers and Navigators
With less and less resources available to them, the cancer care team must work together collaboratively to achieve the cancer program goals, this is established through partnerships and strong metrics. A successful navigator will partner with a physician champion who understands navigation and supports establishing strong metrics to measure the success of the program.
Partnerships between the navigator and the oncology/hematology practice has never been stronger than it is now, which has resulted in better communication among the care team and thus more integrated care delivery. Providers are now starting to understand the value of the oncology navigator through the national core competencies established by Oncology Nursing Society, the AONN+, Association of Oncology Socials Workers, and National Association of Social Workers, as well as the 2015 addition of Chapter 3, Continuum of Care Services to the CoC Standards.2 The creation and uptake of national evidence based navigation metrics will also help legitimize the role of the navigator as a member of the multidisciplinary cancer care team, as strong metrics are established and used in the categories of patient experience, clinical outcomes, and return on investment.
As an oncology navigator, it will be essential for the administrators and providers to utilize the navigator to the top of their license (Box 2). If the navigator is a nurse or social worker, they should not necessarily be completing clerical type duties; they can provide a much higher level of support by functioning in their professional role, such as providing comprehensive assessment of and education for patients as a nurse navigator. Navigators and support staff must also become more business savvy to demonstrate value and provide sustainability within their program.
Conclusion
The navigator and provider understand their individual roles and responsibilities well and can work closely together to enhance the care provided to their patients and families. Care coordination, which is a pillar of patient navigation, is also a key ingredient for value-based cancer care, MIPS, QOPI, and the OCM. Standard metrics for benchmarking, measurement of care, and return on investment calculation are needed in for the patient navigation field in order to demonstrate its value in health care and for reimbursement purposes.
References
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2. Freeman HP. The origin, evolution, and principles of patient navigation. Cancer Epidemiology, Biomarkers Prev. 2012;21(10):1614-1617.
3. Commission on Cancer. Cancer program standards: ensuring patient-centered care, 2016 edition. facs.org website. https://www.facs.org/~/media/files/quality%20programs/cancer/coc/2016%20coc%20standards%20manual_interactive%20pdf.ashx. Published 2015. Accessed April 3, 2018.
4. National Comprehensive Cancer Network (NCCN). NCCN Guidelines for Patients: Distress, version 1.2017. nccn.org website. https://www.nccn.org/patients/guidelines/distress/files/assets/common/downloads/files/distress.pdf. Published 2017. Accessed April 3, 2018.
5. Commission on Cancer (CoC). CoC quality of care measures. facs.org website. https://www.facs.org/quality-programs/cancer/ncdb/qualitymeasures. Updated January 30, 2018. Accessed April 3, 2018.
6. National Accreditation Program for Breast Centers (NAPBC); American College of Surgeons. NAPBC Standards Manual, 2014 edition. facs.org website. https://www.facs.org/~/media/files/quality%20programs/napbc/2014%20napbc%20standards%20manual.ashx . Published 2014. Accessed April 3, 2018.
7. Strusowski T, Sein E, Johnston D. Academy of Oncology Nurse & Patient Navigators announces standardized navigation metrics. J Oncol Navigation Survivorship. 2017;8(2):62-68.
8. Strusowski T, Sein E, Johnston D, et al. Standardized evidence-based oncology navigation metrics for all models: a powerful tool in assessing the value and impact of navigation programs. J Oncol Navigation Survivorship. 2017;8(5):220-237.
