Clarifying the Role of Oncology Nurse Navigators

Tricia Strusowski, MS, RN

Tricia Strusowski has spent most of her career working as a navigator in the community oncology setting to ensure that patients receive appropriate care, at the right time, and at the right place. Currently, she works with Oncology Solutions, a consulting firm, working to improve and implement nurse navigation programs at treatment centers across the country.

This week at the 2017 annual CANCERSCAPE meeting of the Association of Community Cancer Centers, Strusowski, MS, RN, sat down with OncLive® to discuss the role of oncology nurse navigators, the important differences these professionals can make, and how their responsibilities tie seamlessly into the value-based care at the heart of CMS’s Oncology Care Model (OCM).

OncLive®: What are the essential tasks of an oncology nurse navigator?

Strusowski: Navigation has really been refined over the last 20 years, and that's how long I've been involved with oncology. We didn't have core competencies back then, but now we do. There are position statements from national organizations and we also have the Commission on Cancer (CoC) standards. A lot has happened.

The roles and responsibilities are mainly about the patient: coordinating the care for the patient and the family across the entire continuum. Providing education and support and performance improvement monitoring is a big piece: letting the patients know about the resources at the cancer centers as well as in the community. We also want to make sure we're educating the patient about clinical trials and providing access to the clinical trials department. We also want to make sure our navigators are involved with tumor conferences, with multidisciplinary centers within the cancer community. And the navigator’s role is very much a patient-centered mission.

The definition is: individualized assistance provided to the patient and family, to reduce barriers, and to increase access to medical and psychosocial care across the entire continuum.

Do those responsibilities differ between a big academic center and a smaller, community setting?

They shouldn't. There are more challenges sometimes for the navigator who is working with 100 new cancer cases per year all by herself. She might have limited resources. However, we all have the same roles and responsibilities and core competencies. There shouldn't be a tremendous amount of difference between locations.

I tend to always want to help the navigators who are out there on their own, who are trying to figure things out. They were probably hired—maybe not even oriented—and just told, "Go out and navigate." Well, what does that mean, when you don't have a navigation background? You may have been a bedside nurse, or a chemotherapy nurse, and you may not understand the whole history and responsibilities of navigation.

Is it more important to have a navigator in the community setting?

Community cancer centers are where 80% of patients get their care. They cannot afford to travel to comprehensive cancer centers. Plus, they want to get care in their own backyard. They want to have those services. From my perspective, it's very important that we help navigators and everybody involved with support services to help the patients, because it's such a scary time for anybody diagnosed with cancer, let alone having to travel for 3 hours for treatment, having additional concerns, and lacking resources, such as the money required for expenses.

I support all navigators in their role because it's a challenge no matter where they are, with the number of patients and the caseload and the responsibilities. We try to focus on providing the right care at the right place at the right time. And having that navigator stay 1 step ahead of that patient is a constant challenge.

What is an example of how a nurse navigator can make a difference in the care a patient with cancer receives?

For a patient with head-and-neck cancer, things have to happen in a particular order. If they don't get dental clearance before they start to receive their treatment, it can be catastrophic. One performance improvement initiative that 1 of the programs I work with started was to make things happen on schedule. For patients with head-and-neck cancer, the dental clearance, on average, was taking about 2-3 weeks. That's a significant delay. It's a worrisome time for the patient, knowing that their treatment hasn't started. Dental clearance must be taken care of before multiple other appointments can occur, before patients can even start their chemotherapy or radiation.

We put a new process in place for that group. We worked with the tumor site team and we looked at the national guidelines and we did a process mapping exercise, to look at barriers and where their opportunities were for improvement. We knew immediately the dental clearance was a concern. So, we created a dental clearance process. The navigator took lead and asked each patient, "Do you have a dentist? Can I contact your dentist so we can expedite the visit?" A problem that went from 2-3 weeks went down to 2 days almost immediately.

And we provided expert support for the community dentists so they could understand why the patients needed to have the dental clearance through our tumor site team. We also created standing order sets. The navigator—no matter who was covering those head-and-neck patients—provided the same high level of care, which is fantastic.

We also created appointment checklists. The patient could potentially leave with 7-10 referrals, and we provided definitions of the specialists the patient would be seeing. What is a medical oncologist? What is a radiation oncologist? What is a speech and swallowing therapist? What we did is we outlined and defined those terms and explained them so the patient would understand. We also created lists of frequent questions and answers to those questions, to serve as decision aids for patients. Sometimes, they don't even know what to ask their doctors. It could be as simple as, "What is my cancer?” “Where is it?” “What are my treatment options?” “What clinical trials are available?" We empower the patient, which is a huge piece part of helping.

Those are just a few examples of how a navigator can really enhance the care for the patients, as well as the entire cancer program.

How can oncology nurse navigators help achieve the outcomes and quality goals that CMS has set with the OCM?

At the 7th Annual Academy of Oncology Nurse and Patient Navigators, we were in the Evidence of Practice Committee, and we said, "We have core competences, we have the CoC standards, but we don't have navigation metrics." When I go to a program, that's the first thing I assess. Show me your reports, show me your metrics. Some places don't have any—which can be better because we can help them. Some places may have them and I'll ask, "Can you define that for me?" And if there's 3 navigators, I get 3 different definitions. There's no clarity.

We don't have a lot benchmarks in navigation. Over the last year-and-a-half, we put a proposal together and it was approved by the leadership of the Academy of Oncology Nurse & Patient Navigators. We had experts from across the country. We did a tremendous amount of research. We ended up with over 300 source documents that supported our 35 metrics, based on patient experience, clinical outcomes, and return on investment.

When you cross-reference these metrics with the value-based cancer care of the OCM, they're beautiful. It's a perfect fit. For the first time, we can truly partner and all be on the same page with the same mission and vision, to enhance the care for our patients and families. It's extremely exciting.