Expert Commentary From Susan Gardner, RN, CBEC

Program Support

A Word From the Experts
Expert Commentary From Susan Gardner, RN, CBEC
12/08/2008

 

Patient Navigation—An Incredible Opportunity

Since October 2005, Susan Gardner, RN, CBEC has been the nursing care coordinator for the First Hill Breast Care Centers, a component of the Swedish Cancer Institute (SCI) located in Seattle, Washington. In her words, "My role as patient navigator has given me an incredible opportunity to be involved in patient advocacy and to participate in development of a program that reflects the needs of both patients and physicians." Ms Gardner is a registered nurse with a specialty in oncology and breast health. She has been with Swedish for 10 years, working first in the inpatient oncology unit and, prior to her present position, as a case manager in the hospice home-care setting.

The Role of Patient Navigator

Approximately 500 women are newly diagnosed with breast cancer and approximately 900 women are undergoing treatment each year across all 3 of Swedish Cancer Institute's campuses. Ms Gardner is currently the only designated patient navigator within the Swedish Cancer Institute. Her role was initially developed as a pilot project within the breast centers and its success has inspired plans to expand the program in the very near future. Her office is in 1 of the 4 dedicated breast imaging facilities at Swedish, and her responsibilities involve navigating approximately 250 women a year—or 20 women a month—who are diagnosed with breast cancer or other high-risk pathology such as atypical ductal and lobular hyperplasia, radial scars, etc. through that center. Ms Gardner reports directly to the person who manages Swedish's breast imaging services Karen McInerney, RT, RM. She also receives support from the clinical nurse specialist for the cancer institute Nancy Thompson RN, MS, AOCNS, who was one of the original champions of the patient navigation program.

As other patient navigators have discovered, at times Ms Gardner has found it a challenge to clearly differentiate the designated navigator role from others who "hold a piece of navigation." These include medical assistants at the imaging center who help guide patients through the procedure; oncology social workers who navigate patients through the psycho-social and financial component; and nurses who support patients during their surgical, medical, and radiation oncology visits. Ms Gardner works collaboratively with these and other people to make sure patients' needs are met along the entire breast cancer care continuum.

The Goals of the Program

The stated goals of the Swedish Cancer Institute's pilot patient navigation program are to:

  • Help coordinate patient-care activities to support the transition from diagnosis to treatment
  • Provide respectful, knowledgeable, compassionate, and timely support through the continuum of care
  • Facilitate interaction and communication among patients, health care staff, and providers in order to decrease fragmentation of care
  • Provide ongoing communication with breast cancer patients to answer questions, access needs and make appropriate referrals for financial, social or internal and community based resources

Results

One of the challenges of the program has been how to effectively track key variables that will not only help with administering the program but will provide the data needed to show its success. After working with the information technology (IT) department of Swedish, Ms Gardner created an Excel spreadsheet to facilitate tracking and to log data from the various tracking systems. However, recently Swedish has begun using an electronic medical record system, which has helped simplify data collection and has improved communications between the various specialists.

In addition to the positive comments from the many grateful patients helped by Susan, the success of the patient navigation pilot has been demonstrated through the following statistics:

  • In 2004, prior to the inclusion of a nursing care coordinator, the number of internal referrals to surgeons was only 54%, with 32% being referred outside of the organization and 14% of women receiving no follow up. These numbers have improved over the last 3 years. Through October 2008, of the 184 women diagnosed through the Swedish Breast Center 77% of them have seen surgeons at the Swedish Cancer Institute, 21% have seen surgeons outside of the organization, and only 2% of women have chosen no follow up.
  • Women with biopsy-proven carcinomas or high-risk pathology can see one of the breast surgeons within 1 business day after initial diagnosis compared with up to 2 weeks previously

Reception of the Program

Building the trust of referring physicians has been critical in gaining credibility for this program, both internally and within the community. From the beginning, many of the key stakeholders, such as Dr. Albert Einstein, Jr, Executive Director of the Swedish Cancer Institute, believed in the program and were the driving force behind it. Surveying has helped identify the needs of both physicians and patients. As private-practice physicians refer to the SCI, Ms Gardner must keep in balance the desires of the physicians and the needs of the patients. "Any time there were questions or issues from either individuals or organizations, we've worked with them to identify their concerns and address them," Ms Gardner said. "The physicians recognize that we have a program in place that will take good care of their patients."

Importance of Networking

Over the last 3 years Ms Gardner has been sharing challenges and best practices with about 15 navigators in the community who are developing their own programs. She is also very involved with the Oncology Nursing Society, the National Consortium of Breast Centers (NCBC), the Washington Breast & Cervical Health Program, and Check-Your-Boobies, a not-for-profit organization whose primary purpose is community outreach and education to help encourage early detection. She serves on a committee of several breast health specialists and navigators from around the country who are developing a core curriculum for a patient navigation certification course. The first time it will be offered is during NCBC's 19th Annual National Interdisciplinary Breast Center Conference in March 2009 in Las Vegas, Nevada.

Words of Advice

Ms Gardner had a few words of advice for those interested in patient navigation. She emphasized that each woman's cancer journey is different and patient navigators need to be able to make a plan of care that is flexible and open minded. In developing a program, it is important to research other programs, talk to your peers, get buy-in from your organization, create program goals, make sure the right people are doing the right job, track outcomes, and have a supportive management team. Most of all, she said, "It has shown to be a key part of best practices for our patients. Enjoy the opportunity. Once you get into it, you will realize that this is where cancer care should be, and there will be no going back."