Allyson Foor Debra Stevens Maryanne Mercier Gail Sullivan Catherine McFadyen

Allyson Foor Debra Stevens Maryanne Mercier Gail Sullivan Catherine McFadyen

American Cancer Society Patient Navigator Program Allyson Foor American Cancer Society Patient Navigator

American Cancer Society Patient Navigator Program The ACS Patient Navigator Program is one component of a broader navigation system offered by the American Cancer Society. The program involves the placement of trained American Cancer Society staff in strategically selected healthcare facilities with oncology treatment services. The aim of the Patient Navigator Program is to reach out to those who are in the greatest need of help, with a particular emphasis on the medically underserved and vulnerable populations.

Program Goals Facilitate an early connection to available programs and resources in order to reduce barriers to care. Serve as an internal, non-medical advocate for patients and caregivers. Ensure the medically underserved are connected with programs that may assist them.

Why Patient Navigation? Enhance patient and caregiver Quality of Life Access the medically underservedthe patients who need us the most.

Navigator Resources Cancer Information 800-ACS-2345 Cancer.org Personal Health Organizers Transportation Services Road to Recovery Medicaid Transportation Reimbursement Other community resources Assistance in finding a wig Wig Bank tlc catalog Insurance coverage

Navigator Resources Referrals to Financial Assistance Copay assistance Hospital programs National programs Assistance with Insurance concerns Referrals to community resources

Measuring Success Quantitative Number of patients and caregivers served. Number of patients who are uninsured or on Medicaid. Qualitative Enhancing Quality of Life Ensuring access to resources

Lessons Learned Communication between all support staff. Role Delineation Support within the entire facility Ensuring appropriate referrals from clinical staff

Thank you!!

Primary Care Edition (AKA: The Health Coach)

Health Coach Provides ongoing support and expertise Enhances the quality of patient care management Works as part of the care team

Ensure personalized patient experience Improve patient outcomes Program Goals Stretch the patient's health care dollar further Improve overall population health

Program Establishment Personalized Care Coordination Experience Patient-Centered Medical Home Medicare Shared Savings

Disparities / Problems / Focus Care coordination at Primary Care level Work collaboratively with the patient

Patient Barriers Overwhelmed Financial Constraints Knowledge Deficits Unmet Psychosocial Needs

Meeting goals as the Health Coach Oversees and integrates Medical Home mission Consults and collaborates with clinical staff and clinicians Works closely with clinicians and support staff Works in tandem with Patient Support Specialist Collaborates as needed with appropriate external resources and agencies Supports patient and family Serves as a patient advocate Participates in development of disease management strategies Participates in quality improvement processes

Measuring Success Integrated Electronic Health Record Core Composite Measures Readmission Rates Overall Improved Outcomes Follow-up Health Coaching Outcomes Aggregation & Tally Health Coaching Outcomes Trending Report

Challenges Identification of Health Coach Role Perceived Threat Role Confusion

Advice Flexible / Fluid MI training Communicate

What makes it work? Holistic / Alternative Background Accessible Health Coach Supportive & Cooperative Staff Caseload Patience Medicare Shared Savings Program

Contact Info: Deb Stevens, RN, CHC Mid-State Health Center 603-536-4000 x1380 dstevens@midstatehealth.org

Cancer Care Coordinator Role at SNHHS Presented by: Maryanne Mercier, RN, CHPN, OCN

Background of Navigation 1990 Breast Care Model developed by Harold P. Freeman, MD in Harlem, NY to address disparities leading to higher morbidity and mortality through grant from ACS

History of Role at SNHHS 2002 Development of Breast Health Coordinator Role 2006 Independent consulting group to examine complexities within SNHHS regarding cancer care Development of role of Cancer Care Coordinator to: Reduce barriers Increase access Increase coordinated care across continuum

Role of Cancer Care Coordinator at Role developed in 2007 SNHHS Decision made for RN navigation SNHHS employee (crossing over Foundation Hematology/Oncology and SNHMC) Provide coordination of cancer care throughout continuum of care (virtual cancer center) Provide service at time of diagnosis and during treatment

Cancer Care Facts Cancer is a chronic disease Cancer care is increasingly complex Complex cancer care requires coordination Nurse navigators improve outcomes and efficiency

Key Roles Contact with patients and families at high stress times Offer psychosocial and access to resources Educated to enable patient-led decisions Liaise between clinical specialists and family physicians Streamline care path transitions and logistical issues

Contact with Patient/Family at High Stress Times During diagnostic work up or at time of new diagnosis high level of interaction at this time Availability throughout treatment course as needed Contact with all hospitalized patients Contact at times of transitions, specifically with goals towards hospice with a high level of interaction

Offer Psychosocial Support and Resources Providing timely support through periods of crisis Responsiveness to patients through the grief experience Assessing needs for resources through other team members Examples: Social worker, counselor, dietitian, physical therapy, financial counselor, etc

Education Provide timely, accurate information to patients and their families to ensure informed treatment decision making Provide education to other team members Advocacy for patient s right for self determination

Liaise Between Clinical Specialists and Family Physicians Visibility is key for health system utilization of role, acting as point of contact and serving as a member on committees related to cancer care Ongoing communication liaise with all health care team members, both inpatient and outpatient Easy access to Oncologists to facilitate patient care (office in outpatient setting)

Streamline care Path Transitions and Logistical Issues Personal contact with all new patients in oncology practice (including the gathering of complete information for providers) Oversee and coordinate consultation appointments in tertiary care centers, other treatment centers Ensuring timely access to appropriate care

Summary Care within health care continues to be more and more complex. Flexibility is required for role to change as needed to help meet patients needs. There may be several layers of navigation needed in health system.

Questions/comments

New Hampshire Colorectal Cancer Screening Program (NHCRCSP) Patient Navigation Gail Sullivan RN, BS Senior Patient Navigator Gail.M.Sullivan@hitchcock.org

NHCRCSP Goals Increase high-quality colorectal cancer screening among persons 50 years and older to 80% statewide. Reduce disparities in colorectal cancer burden, screening and access to care.

Patient Navigation Guidelines Minimum requirements six calls Average is 8 calls Navigate Importance of Screening NHCRCSP Process Endo Site Process Obtaining Prep Taking Prep Barriers Client Follow Up

Notes Cont.

Outcomes-Quality of Prep Inadequate Prep 1.5% Inadequate, 0 0 Adequate Prep 98.5%

Outcomes-No Show Rate

Keys to Success Process Data Implement and monitor process Evaluation

Breaking Barriers A Health Plan s Approach New Hampshire Comprehensive Cancer Collaboration 8 th Annual Conference Catherine McFadyen RNP MSN Director, Care and Disease Management Harvard Pilgrim Health Care March 20, 2013 2012 Harvard Pilgrim Health Care

Oncology Program Goals Identify high risk members Support member, their families and medical team Reduce occurrence of side effects that result in ER visits and or unplanned hospitalizations Ensure coordination of care Support end of life decision making process 2012 Harvard Pilgrim Health Care

Harvard Pilgrim Oncology Program Members identified by algorithm, member, provider, employer or Nurse Care Manager (NCM) referral Members followed telephonically from early diagnosis and treatment and as needed thru recurrence or end of life Utilization of Motivational Interviewing (MI) skills to work with members collaboratively, supporting members throughout their illness and fostering efforts toward self efficacy 2012 Harvard Pilgrim Health Care

Oncology Program Components Clinical assessment including depression Coordination of care among multiple providers Collaboration re pain management planning Collaboration re behavioral health support Hospital follow-up Social worker referral Management of benefits 48 2012 Harvard Pilgrim Health Care

Oncology Program Components cont d Assessment of toxicities during treatment Identification of who will take responsibility for surveillance care Information about how to prevent and detect second cancers Late drug toxicity monitoring Psychosocial and vocational needs 2012 Harvard Pilgrim Health Care

Care Management Approach Build a relationship with member, family and provider Motivational interviewing: Quality of Life (QoL) and End of Life (EoL) discussions Referral to bridge and hospice programs Meet members where they are Support for member to remain at home 50 2012 Harvard Pilgrim Health Care

Oncology Program Provider Activities Palliative care articles in provider publication Educational conferences provided by Hospice Federation Collaboration re use of bridge and hospice programs Utilization of chemotherapy treatment plans sent by providers 51 2012 Harvard Pilgrim Health Care

Survivorship Cancer survivor includes anyone who has been diagnosed with cancer, from the time of diagnosis through the rest of his or her life Family members, friends, and caregivers are also part of the survivorship experience Survivorship Plan of Care (POC) is part of the initial assessment and developed in collaboration with the member The four essential components of survivorship are incorporated into the POC: care prevention, surveillance, intervention, and coordination 2012 Harvard Pilgrim Health Care

Outcome Metrics Decrease in ER and unplanned admissions due to most common side effects of chemo and radiation therapy ER and admissions rate have been consistently lower in managed vs. non managed members Overall lowering of medical expense Member satisfaction surveys 93% overall satisfaction program rate (excellent or very good) 99 % rating for professionalism (excellent or very good) 90% rating for usefulness of information provided 87% rating for improving member ability to adhere to tx plan recommendations 2012 Harvard Pilgrim Health Care

Challenges and Factors for Success Provider Acceptance Member Complimentary and Supplemental to provider practice 60% engagement rate which is defined as agreement to take calls from the NCM, and establishment of plan of care with follow up Health literacy Conflicting opinions, clarity around prognosis, discussions re quality of life after tx, coordination of care during tx Cultural issues 2012 Harvard Pilgrim Health Care

Challenges and Factors for Success Telephonic approach Development of rapport and trust with Nurse Care Manager Motivational interviewing Support for discussions of concerns not rushed, easy to obtain and or schedule No transportation required No cost to member or provider Other factors for success Staff education and training Motivational interviewing skills Belief in program from the top down 2012 Harvard Pilgrim Health Care

2012 Harvard Pilgrim Health Care Addendum

Member Tools http://www.cancersurvivaltoolbox.org National Coalition for Cancer Survivorship NCCS Website in Spanish and English: Free online tools in audio or text http://www.cancer.gov/cancertopics/coping/survivorship Facing Forward: Life After Cancer Treatment Booklet recommended to members asking for guidance after treatment 2012 Harvard Pilgrim Health Care

Cost of End-of-Life Care Cost Drivers Development/availability of high-cost technology Over utilization and/or inappropriate use of technology Increased aging population Complexity of patients with multiple diseases Differing costs depending upon location of patient Lack of /barriers to hospice or palliative care programs Lack of end-of-life care coordination Varying provider reimbursement strategies Lack of clinical measures to determine benefit of treatment in late stages Avoidance of discussion and lack of planning for end-of life Hidden Costs (for Patient/Family/Caregiver) Financial: Lost wages Transportation/parking Meals outside the home Over-the-counter medication Counseling Private pay when care needs exceed ability of family/caregiver Emotional: Stress Depression Burnout Cost Containment Strategies Rationing of health care Cost-sharing between members, families and insurance company Financial incentives to nursing homes to provide end-of life care Hospital DRG for end-of-life care Financial support to family Expansion of respite benefits Decision-making tools for family/caregiver Define/measure essential elements of quality, end-of-life care Make exceptional end-of-life care the norm, rather than the exception Eric Schultz, President and CEO Harvard Pilgrim Health Care October 26, 2011: End of Life Issues: Decision, Cost and Ethical Dilemmas 2012 Harvard Pilgrim Health Care

Hospice Benefit Traditional medical care and hospice care are usually reimbursed through two separate payment methodologies, without clinical or financial overlap Harvard Pilgrim covers both traditional medical care and all levels of hospice care, including residential care programs 59 2012 Harvard Pilgrim Health Care

Hospice Benefit Home Respite Residential Inpatient Routine: Nursing services and up to 4 hours per day of home health aide services for up to 180 days Continuous: More than 8 hours (up to 24 hours) of services (primarily nursing care) per day are medically necessary to support the member and family in a period of crisis at end of life 5 days every three months, to a maximum of 14 days per calendar year Covered requires physician review for medical necessity Harvard Pilgrim and the hospice provider determine that the member s treatment plan requires intervention that cannot be safely performed at a lesser level of care 60 2012 Harvard Pilgrim Health Care