Teri Banman, RN, BSN, OCN, is the nurse manager, navigation and intake department, for The University of Kansas Cancer Center in Westwood, Kan.
Q: When and how did your nurse navigation program start?
Teri Banman: It was created in 2011 with one named navigator at the time: me. Our program, and more specifically my position, was originally funded with philanthropic funds through a generous family from Kansas City.
I spent about a year researching navigation programs across the country and identifying barriers in our system at the University of Kansas (KU). I was looking at how could we help our cancer patients even further. I was also looking into the role for a nurse in a navigation program. I am an RN, and knew a lot of navigation programs used lay navigators.
What I discovered during that time was our greatest barriers were getting patients in our doors to the right providers with all of the information necessary and helping to support those patients until they started their treatment. Once that treatment plan is established, we have a lot of great staff who pick up the ball from there and run with it, but the patients were struggling through that initial intake and treatment planning phase.
Our mission for the nurse navigation program is to decrease time from initial presentation to start of therapy. We are very much a program focused on improving timeliness to care, but we can also help identify needs for a particular patient, such as transportation, lodging, emotional support, fertility, genetic counseling — all of those really important services that go along with a diagnosis of cancer.
Q: How many nurse navigators are in your program now and what are their areas of focus?
TB: We are up to 27 nurse navigators who are all RNs. We have 22 who are devoted to cancer patients and are disease-site specific. We have five breast cancer nurse navigators and five hematology nurse navigators. Those diseases are assigned the most navigators because they are our two largest patient referral volumes per month. We see about 250 breast patients and 220 hematology patients a month.
Then we have navigators assigned genitourinary, gastroenterology, gynecology oncology, thoracic, head and neck, melanoma, sarcoma and neuro-oncology. Every single disease group is covered with one or more navigators.
Not all patients we help present with a cancer diagnosis. We also help when a patient has an abnormal mammogram that needs to be worked up by a surgeon and possibly requires a biopsy. We take this patient all the way through that process. Our navigators are very much involved with the diagnostic phase to help expedite the process so patients do not fall through the cracks.
If we get a patient who discovers a breast mass and is advised by their doctor to call KU, we would help that patient get to the next step, which would be for our provider to see them and set up imaging. If the diagnosis turns out to be cancer, we get them set up with a surgeon and/or medical oncologist. We hold their hand through that whole phase.
We have two nurse navigators who are devoted to our outpatient palliative care program. Their role is very unique. They provide a lot of education and nursing visits, emotional support, and goals planning for patients who are referred to our palliative care team. They follow those patients all the way through their treatment. If they go to hospice, they follow them there as well. It’s a very unique and wonderful role.
We also have a navigator assigned to the transition to survivorship for patients who were treated for a childhood malignancy and now need long-term adult survivorship care. This position is shared with a local children’s hospital.. This navigator helps transition them from the children’s hospital to KU and follows them in our survivorship clinic.
We recently expanded outside of oncology, with a cardiology navigator who started in January. This was a very exciting development. We had the vice president of our cardiology services reach out, compliment our efforts helping cancer patients, and tell us that cardiology needed help. Patients were coming in with chronic conditions and the department needed somebody to make sure patients saw all of the right specialists and received timely care. Our cardiology navigator’s goal is to a group of her own navigators one day.
We have one other nurse navigator not connected to cancer care and that is our executive health navigator. This is a new role developed to help assist our hospital executive office when they receive referrals. For example, this office might get a text message from an important person in town saying their son broke his ankle and they need assistance in getting him care. We have a nurse dedicated to those patients who will also be overseeing the executive health physical program we are starting in 2018.
Q: How is the value of your program measured?
TB: I have a long list of outcomes I have tracked from the very first day of the program. I knew doing so was going to be very important because of how we were initially funded (philanthropic). If we were going to have the hospital eventually invest in the program, I knew I needed to show the benefit of what we do. We established goals from day one focused on what was the intent and mission of the navigation program. Then we set out to determine how we were going to measure and show that we met these goals.
For example, one goal is to decrease the time from initial diagnosis or presentation to the start of therapy. Part of what we do in our logs is track the date we learned about the patient, the date they are seen by the physician, the date they have a diagnosis, and the date they receive a treatment. When you compare this data to our previous data, it’s significantly better. Evidence such as this is what really drove us to receive more nurse navigators as we were able to show value with better patient outcomes.
There is also a financial benefit for the hospital as we are retaining these patients. We are performing all of the work here as opposed to primary care physicians guessing at what diagnostic tests need to be done and ordering them at an outside facility. Now the primary care physicians just call the navigators and we work with our physicians to set everything up here and we do so in a more timely manner.
Another value we bring that helps improve outcomes and delivers a financial benefit is the decrease in no-show rates. When we look at our hematology population, many of those patients present with an abnormal lab or some abnormality that is not yet diagnosed. Their primary care physician tells them to see a hematologist at our cancer center, but 26% of the time these patients were not showing up. We put a navigator in who speaks with patients about their case and why it is important to come here. That no-show rate went to 5% in late October 2012 and has remained low ever since.
Q: Have you launched any new initiatives through the nurse navigation program?
TB: We started a lung screening program in 2012. The navigator who runs this works to ensure everyone meets high-risk criteria and then schedules their scan, gives them their results, and makes sure they come back in for their next scan.
We started a gastroenterology cancer prevention clinic that is coordinated by a nurse navigator, gastroenterologist, and medical oncologist in partnership. That started in October 2014.
We also started a prostate prevention clinic coordinated by a navigator.
It was a goal of our cancer center administrators to offer these services. Thanks to our navigation program and the dedicated nurses working within disease groups that cross over so many care settings, we can support these initiatives.
Q: Can you share a particular patient story that demonstrate the value of nurse navigation and your program?
TB: One of our patients wrote a letter to Bob Page, CEO of KU. This patient said he wanted to tell his story, which essentially said, “I have leukemia. I am a very wealthy man. I could have gone anywhere in the country. I called KU, and because of my nurse navigator, I came to KU.”
When I saw that letter, I felt so appreciative of our patients and also thought about how much downstream revenue we brought in. This patient was admitted to the hospital, provided induction chemotherapy, and our navigator helped get him set up as an outpatient.
I think this experience was one of the drivers for Bob and Tammy (Peterman, executive vice president, chief operating officer and chief nursing officer) to expand the navigation program.
Q: What would you say to someone working to develop a new nurse navigation program?
TB: Find your champion, and do your background research. I had the luxury of not initially having a patient load when I started this position. Leadership basically said they knew we needed a nurse navigator and wanted me to improve the patient experience, but they really did not know what I was going to do every day.
I went out and started researching like crazy. I talked to our doctors and every nurse coordinator and nurse practitioner in the cancer program. Then I started calling patients and asking them what was the biggest barrier for them. I thought it would be “I didn’t get my results in time” or “I couldn’t get through to my doctor.” What it usually turned out to be was issues like “I didn’t know where to park when I got there” or “I didn’t have the address to the center.” With that information, I partnered with marketing to come up with better materials to give our new patients.
My advice to leadership is to give your navigators time to really assess the barriers for your organization because every place will be different. Start with one nurse navigator, if that is all you can initially afford.
I recently returned from a navigation meeting in Texas that included navigators from all across the country. Our roles were very different because our organizations are different. Some of the navigators came from tiny centers that did not have a lot of nursing support, so the navigators were focused on following patients all the way through treatment. In our center, we have a lot of nurse coordinators who are assigned to a particular physician. My role as a navigator is that I am not assigned to one physician, but to the patient, and I am here to make sure that patient crosses care settings seamlessly and is not lost between providers and departments.
We draw people from a wide area, including the entire state of Kansas. You can imagine going from a small town in Kansas to us, situated right in the middle of the metropolitan area. It can be very scary.
One of our patients said the navigators were a brightly lit path for them in a very dark time. We shepherd them to us and through their experience at KU.