History of Patient Navigation 8/26/17. Cancer Navigation September 26, Agenda

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1 Cancer Navigation September 26, 2017 Eric T. Kimchi, MD, MBA Medical Director, Ellis Fischel Cancer Center Agenda History of Patient Navigation Principles of Patient Navigation UAB Experience EFCC Initiative Resource Utilization (UAB) History of Patient Navigation 2 1

2 History of Navigation Harold P. Freeman, MD Residency at Memorial Sloan Kettering Cancer Institute Faculty, Harlem Hospital Center in 1967 Noted disparities in cancer care President of the American Cancer Society 1988 to 1989 Report to the Nation on Cancer in the Poor Consistent theme of barriers faced simply trying to enter the health-care system Coined the term patient navigation Returned to Harlem and started the first patient navigation program in 1990 History of Navigation Reviewed 22-year period ending in breast cancer patients treated at Harlem Hospital Center 50% without insurance Stage I 6% Stages II and IV 49% 5-year survival 39% 325 breast cancer patients Intervention: Free or low-cost examinations and mammograms Patient navigation Early Stage 0 and I 41% Stages II and IV 21% 5-year survival 70%. Resource Utilization (UAB) Principles of Patient Navigation 2 2

3 Principles of Patient Navigation Patient navigation is a patient-centric healthcare service delivery model. Patient navigation serves to virtually integrate a fragmented healthcare system for the individual patient. The core function of patient navigation is the elimination of barriers to timely care across all segments of the healthcare continuum. Principles of Patient Navigation Patient navigation should be defined with a clear scope of practice that distinguishes the role and responsibilities of the navigator from that of all other providers. Delivery of patient navigation services should be cost-effective and commensurate with the training and skills necessary to navigate an individual through a particular phase of the care continuum. The determination of who should navigate should be determined by the level of skills required at a given phase of navigation. Principles of Patient Navigation In a given system of care there is the need to define the point at which navigation begins and the point at which navigation ends. There is a need to navigate patients across disconnected systems of care, such as primary care sites and tertiary care sites. Patient Navigation systems require coordination. 3

4 Goals of Patient Navigation Reduce Emergency Room visits Unnecessary hospital days Unnecessary ICU days Use of therapeutic (curative) chemotherapy in last 2 weeks of life Encourage Evidence based clinical pathways Earlier adoption of hospice care, as appropriate Provide the highest quality of life for people diagnosed with cancer Navigator-Patient Partnership Empower Patients (3 Es) Engage, Educate, and Encourage patients to Identify resources Recognize clinical symptoms Understand disease and treatment Have end-of-life discussions with their providers Take an active role in their healthcare 4

5 Empower Patients Stress Screening Pro-active management guided by frequent distress screening Areas of Focus: Practical Informational Financial Family Emotional Spiritual Physical Navigator Role Eliminate Barriers Support communication between multiple providers Link patients with resources and providers to address issues Ensure Timely Delivery of Care Help patients navigate the health care system Assist with access to appropriate care Navigator Role Identify potential complications/problems, early Help patients recognize potential complications early Empower patients to avoid unnecessary utilization Encourage planning for advanced illness Empower patients with tools/resources to make informed decisions 5

6 What Navigators Are Not Doing Making clinical decisions/recommendations about care Replacing nurses Replacing social workers Trying to steer patients away from appropriate care Promoting specific services over others Interfering with standard patient care activities Referral Process Referral from physician offices Referral from case managers Tumor board meetings Patient self-referral 1. Referral from physician offices 2. Referral from case managers 3. Pathology reports from medical records 4. Tumor board meetings 5. Census reports 6. Patient self-referral 2 6

7 Navigator s Role in Patient Assessment CoC required distress assessment Guides interview/conversation Allow early, proactive detection and intervention Quantify patient s global level of distress Detect common areas or problems associated with the patient s distress level Drive patient focused care planning Professional referral Interventions Assess effectiveness of interventions in decreasing distress level Drive data collection University of Alabama Resource Utilization (UAB) Experience CMS INNOVATION CHALLENGE GRANT 3 Year Award $15,007,263 Effective Date: Resource Utilization July 1, (UAB) 2012 Creates approximately 50 new jobs Potential savings: $49.8 million 7

8 CMS INNOVATION CHALLENGE GRANT Eligible Patients Medicare beneficiaries 65 years old diagnosed with cancer after 2008 and with Medicare A/B coverage Outcomes Healthcare Utilization: ER, Hospital, ICU admissions Cost: Resource Utilization (UAB) Total Medicare reimbursements to providers Inpatient, Outpatient, Provider and Free-standing Services (Carrier), Skilled Nursing Facility(SNF), Hospice, Home Health No prescription drug cost included Resource Utilization (UAB) Resource Utilization (UAB) Hospitalizations By Group (UAB) 8

9 ER Visits By Group (UAB) ICU Admissions By Group (UAB) Overall Costs Per Group (UAB) 9

10 Costs 1 st Year After Diagnosis (UAB) Cost For Survivorship (UAB) Costs Last 6 Months of Life 10

11 Patient Satisfaction with Navigation (UAB) Navigation Analysis Decreased utilization and cost may be multifactorial Patient Navigation Health System Improvements National and Local Influences Trends show clinically significant reduction in healthcare utilization and Medicare costs Center for Medicare and Medicaid Innovation is conducting an independent analysis of impact on costs Navigation at Ellis Fischel Cancer Center 11

12 EFCC Disease Teams Breast Oncology GI Oncology (HPB/Colorectal) Thoracic Oncology Urologic Oncology Head and Neck Malignancies Neuro-Oncology Cutaneous Malignancies Sarcoma Gynecologic Oncology Hematologic Malignancies EFCC Navigation Initiative Previous paradigm Disease focused navigation system Nurse Navigators Focus on clinical care needs Care coordination Incomplete coverage of disease teams EFCC Navigation Initiative Ongoing Initiative Disease focused navigation system Nurse Navigation Focus on clinical care needs Lay Navigation Care coordination Coverage for all disease teams 12

13 Current EFFC Navigation Staff Nurse Navigators Dawn Frederick, RN Breast Blanche Lasta, RN Thoracic Alyssa Tauber, RN GI Oncology Jennifer Woods, RN Endocrine Oncology Sue Sinele, RN Cancer Screening Becca Wilkinson, LPN Breast Imaging Lisa Holm, RN TIGER Protocols Lay Navigators Barbie Morgan Lindsay Figge Edward Johnson Navigation Summary Patient-centric healthcare service delivery model. Virtually integrate a fragmented healthcare system for the individual patient The determination of who should navigate should be determined by the skills required at a given phase of navigation The core function of patient navigation is the elimination of barriers to timely care across all segments of the healthcare continuum Thank You kimchie@health.missouri.edu 13