Coordination OF CARE

  • Patients with recurring disease were less apt to say that comprehensive/supportive care is being provided by their healthcare team with only 20% indicating this compared to 42% of those newly diagnosed

    Coordination of Care - Involving Treatment Nurses

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  • Quick Quiz

    I intend to discuss with my infusion nurse colleagues options to add more details to EMR notes to support SDM

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  • To mitigate the bureaucratic pitfalls and optimize resources, consider these simple ways to engage members of the clinical care team to promote and support SDM:
    • Leverage your infusion nurses— encourage your infusion nurses to be more detailed in their EMR notes (patient experience while receiving treatment)
      https://www.cancercare.org/publications/18-treatment_up

    • Use pharmacists to sit down with patient and communicate the adverse events and when to call if these should arise

    • Train support staff with classes on communication with patients

    • Consider using the AHRQ-SHARE workshop to support the training of health care professionals on how to engage patients in their health care decision making

  • Quick Tips
    • How do we ensure patients have access to well-coordinated care across the cancer continuum? More and more, cancer centers are turning to patient navigation and advocacy programs as the answer.
    • The benefits of patient navigation, both to the patient as well as hospital, continue to be elucidated. As a patient intervention it can help increase health literacy, improve treatment adherence, address disparities and language barriers, and address access to care issues such as transportation or insufficient insurance coverage. For hospitals, patient navigation can improve financial performance by increasing revenue, reducing readmissions and avoiding cuts to reimbursements as well as meeting value-based purchasing program goals and receiving shared savings.
    • When considering the cost of cancer care, the financial implications for patients are significant across the continuum of care. Patient navigation programs can help mitigate negative implications and support SDM considerate of financial resources. The Association of Community Cancer Centers published guidance to successfully create and sustain an effective advocacy and financial guidance program. Key elements include:
    • Proactively identify and evaluate how to maximize the patient’s health benefits

    • Manage, track, and report on all financial advocacy and patient access services interactions

    • Proactively reduce economic barriers to care by having a working knowledge of available patient assistance and financial programs

    • Ensure the providers and cancer program staff are aware of ongoing policy requirements from payers for coverage of services

    • Accurately explain insurance coverage and assistance options and skillfully communicate with patients and their caregivers focusing on issues of cost of care, patient assistance support, and additional resources

    • Help mitigate institutional financial toxicity

    Effective in 2016, the American College of Surgeons Commission on Cancer (CoC) requires that cancer programs seeking CoC accreditation establish a process to identify and navigate potential barriers to care, and document that process each calendar year.

    The Oncology Nursing Society, Association of Oncology Social Work, and the National Association of Social Workers issued a position statement on oncology nursing and oncology social workers in patient navigation. Included in the statement was:

    • Patient navigation processes are essential components of cancer care
    • Navigation services can be delegated to non-professionals and/or volunteers and should be supervised by nurse or social workers

    The National Cancer Institute Patient Navigator Research Program’s core functions of a patient navigator include:

    • Coordinate appointments with clinicians inside and outside the practice to ensure timely delivery of diagnosis and treatment services.
    • Maintain communication with patients and families across the care continuum.
    • Ensure appropriate medical records are available at scheduled appointments.
    • Arrange language translation or interpretation services.
    • Facilitate connections to follow-up services.
    • Provide access to clinical trials.
    • Build partnerships with local agencies and groups (e.g., cancer survivor support groups); maintain a list of community and social services available to patients

    For a comprehensive list of competencies for patient navigators and diverse roles they can play in supporting and improving cancer patient outcomes, check out the Oncology Nursing Society:

    For more evidence supporting the effectiveness of patient navigation programs visit AHRQ:

    To what extent are you as an oncology nurse navigator part of the shared decision making?

    Michelle Keating
    RN, OCN, MSCN

    Benefits of Patient Navigation

    • For the patient: increase health literacy, improve treatment adherence, and address disparities, language barriers, and access to care issues.
    • For the hospital: improve financial performance, reduce readmissions, avoid cuts to reimbursements, and meet value-based purchasing goals.
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    Customizing Patient Resources

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  • Quick Quiz

    Does your hospital have a patient navigation program?

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