Pancreas Cme - The role of the nurse navigator

Finding Hope: Nurse Navigation Hi my name is Carrie Callahan and I am a Nurse Navigator, a term you may not have heard before, in part because it is relatively new in terms of the history of nursing. The term “patient navigation” was first created in 1990 by Harold Freeman, who partnered with the American Cancer Society to establish the first patient navigation program in the country in the Harlem neighborhood of New York City. The original program was designed to increase the rates of breast cancer screening in low-income women by removing barriers that these women often encountered. Nurses and other health care workers assigned to these women helped the patients overcome financial, communication, psychological and transportation barriers while smoothing their coordination of appointments. The service demonstrated that patients who partnered with these health care professionals had positive outcomes. Women in the program took advantage of the screening, were diagnosed with earlier and more treatable cancers, and had greater access to treatment. It was an excellent method to reduce barriers that patients may encounter in their local community. Since that time, the model has been adapted to several types of cancer. In addition, the model has expanded from just screening and detection to assist patients through the entire health care experience, from prevention, early detection, diagnosis, treatments and supportive or end of life care. My background is fairly typical of other nurse navigators. I began my career as a registered nurse on a general surgery unit and became a nurse clinician, expanding my depth of patient care. Working closely with physicians, patients and hospital staff to coordinate patient care was extremely rewarding. However, the care that was coordinated was usually within the scope of the patient’s stay or immediately thereafter. Some surgeons whose patients I had provided care for recruited me as their first nurse navigator when they opened a multidisciplinary Liver and Pancreas Tumor Clinic. My job was to coordinate the care of patients in a timely and thorough fashion, from the time that they were referred to the clinic, through treatment and in follow up visits. Although each patient’s case was unique, it was not unusual to coordinate the patient’s visits with up to six different specialists – medical oncologists, radiation oncologists, surgeons, interventional radiologists, dietitians and social workers. My role as the patient's advocate and caregiver evolved as I determined their needs. After a few years in this clinic, I was offered a similar position in a private practice that provided complex surgical care. While providing care in this setting is slightly different, my philosophy of care is the same. I still care for patients who need expedited care delivered with the utmost compassion. While there are published guidelines and job descriptions of nurse navigators, the job varies from day to day, sometimes minute by minute as you interact with patients, families and physicians and determine immediate and long-range needs. For the patients, the navigation portion of my job begins when the patient enters the system as symptoms present or abnormal test results occur. The physicians recommend a course of action for diagnosis but we can also use protocols to refer the patients to other specialists for timely diagnosis. As treatment plans are created, the nurse navigator works with the patient’s and clinicians’ schedules to coordinated further testing, complex treatments and supportive therapies. In addition, if the patient participates in clinical trials or research, the nurse navigator often coordinates all of that activity as well. But our roles reach well beyond appointment scheduling. We look after the patient as a whole. For example, it is not unusual for us to make travel arrangements for patients and their family members if they are coming in for surgery or other treatments. We also help connect the patient to the right individuals if there are financial concerns. One of the things I did as a navigator in the clinic was to develop and maintain an up-to-date working list of local and national resources to share with patients and their families for all of their needs. We are often the source of information for the patients. Many times, the patients are not medical professionals and have a limited understanding of their condition, the diagnostic tests or the medications and other treatments. Occasionally there is a need to educate patients about the nontraditional or non-research based treatment options that may attract vulnerable patients and that have potentially no survival benefit. Providing patients with my time to answer their questions and supplementing it with easily understandable information that they could share with friends and family is a requirement of the nurse navigator. But perhaps my most crucial role with patients is helping them through their cancer diagnosis and treatment by just being there for them. As a nurse navigator, I play several different roles, including friend, listener, confidante, daughter, or other family member. Fairly consistently, however, you have to remain calm, compassionate and sympathetic, always offering hope and a positive outlook. This was especially true due to the nature of this specialty clinic. Every day, I cared for patients who faced what most would consider scary diagnoses or either pancreatic or liver cancer. The patients entrusted me to help them through this process of a diagnosis and the creation of a treatment plan as fast as humanly possible. While the specialists were not always available for questions or concerns throughout the day, as the patient’s nurse navigator, I was readily available with an open door for whatever I could do to make their lives easier. At times, I provided appointment scheduling and direction, provided clinical information about their disease or the medications they took, explained the symptoms they were experiencing, talked to them about recovery expectations or gave them information on financial assistance. The patients were comforted to have someone guide them through the maze that is the medical system. And a wider group of patients agree. The Advisory Board of Oncology Round Table in 2007 polled a group of oncology patients based on criteria “Nice to Have versus Need to Have” As you can see demonstrated in the graph, the availability of a Nurse Navigator was the 3rd in line as a priority “Need” with Multidisciplinary Care and Symptom Management in the forefront. Patients and families place a high value on supportive services that are provided by the Navigator. The benefits of the role also extend the physicians and other clinicians involved in caring for that patients. Physicians want the best care for the patients and at the same time want that care to be a highly efficient process for them and their patients. Physicians can relate to the improved communication between all members: the nurse navigator, the patient, the physician and other physician specialists. When a nurse navigator is following a group of patients there is a definite ownership and follow-through on the physician’s medical recommendations. The nurse navigator is also able to field procedural, testing, medication and symptom management calls for the physician, which relieves their work load. The nurse navigator is also able to conduct nursing assessments to determine the need for patients to be admitted to the hospital or a transfer from one hospital to another hospital, and to determine if an emergency room visit is in order. The polling of physicians found that nurse navigators to be an essential part of the health care process that yields high quality of care that enables the best patient outcomes. Over the last 20 years there has been a considerable increase in the number of patient navigation programs across the country to facilitate the care for patients. Federal and private funding has ensured the survival of this proven worthwhile endeavor of patient navigation. A process that assists in the participation of cancer screening, early diagnosis and adherence to follow up care for all populations hasn’t gone unnoticed. Originally, the populations that the navigator targeted were low income and underserved and then it progressed to the entire cancer arena. Today, the patient navigator is coordinating care for many different chronic disease processes that are not necessarily cancer driven. As a result, physicians are beginning to demand the increased use of these nursing specialists. A recent Wall Street Journal article on Patient Navigation quoted that the American College of Surgeons issued new standards this year that will require all Cancer Centers to offer patient navigation services by 2015 in order to meet accreditation standards. And with increasing numbers of survivors, the population of nurse navigators is likely to grow as well. I’d like to close this talk by providing just a few case studies of how I was able to affect positive change in a few my patients’ lives through the work I do each day. In one instance, I was able to save a patient almost $3,000 a month. This individual had insurance but had unfortunately run of available funds to cover an injectable medication. The patient was unaware that the pharmaceutical company offered a patient assistance program. After completing a few forms related to the treatment plan and lack of coverage, the medication arrived within two weeks of completing the necessary paperwork; the patient now receives the medication free of charge. The solution to his financial problem was a matter of knowing what resources are available and how to go about utilizing them. Another patient called to schedule a consultation at a surgeon’s office when the surgeon happened to be from out of town, approximately 2 ½ hours away. After screening the patient, it was determined that other workup needed to be conducted before a treatment plan could be established. The ability to facilitate the patient’s care is essential when they are not from the local area. The patient’s consultation experience included an appointment with the surgeon, the medical oncologist, same day imaging and laboratory testing. Local overnight accommodations at a discounted rate were available as an option. The patient and their family were grateful not to have had made multiple trips to the area wasting time and money on their travels. The patient also left the appointment with a treatment plan in hand. Finally, I was the nurse navigator for a cancer patient whose daughter was to be married in a few weeks out of state. After speaking with the surgeon and based on his status and medical treatment plan, travel was not going to be possible. I was able to facilitate plans at the hospital so that he could be there to give his daughter away in matrimony. All the plans took place over one week and the outcome was unforgettable for all. I’d like to thank you for the opportunity to discuss nurse navigators and their role in providing coordinated, multidisciplinary care.