Tricia Trammell, CRA, R. T. (R) (M) (QM), CN-BI, is manager of Virginia Clay Dorman Breast Care Center at Texas Health Harris Methodist Hospital Southwest Fort Worth in Fort Worth, Texas. The center features advanced technology and care, allowing clinical staff to focus on screenings, diagnostics, needle localizations, cyst aspirations, breast sonograms, breast MRIs and image-guided breast biopsies. They perform over 1,000 procedures per month.
Q: What role does nurse navigation play at Virginia Clay Dorman Breast Care Center?
Tricia Trammell: As a comprehensive breast imaging center, navigation is something that we greatly value because we are identifying disparities or barriers to care and helping patients overcome those barriers as it relates to breast care.
Our hospital is a Commission on Cancer (COC)-accredited hospital. Our breast program is our strongest cancer program. I have one full-time nurse navigator —Vanessa Pierce, RN, BSN, CBPN-IC – and I am a certified breast patient navigator, but am an imager by background.
We are one of the only comprehensive breast centers within our system that has a nurse navigator for imaging. The reason why is because we feel navigation should begin at the point where the radiologist recommends a biopsy. In some cancer programs, the navigator does not intercept the patient until the patient is on the schedule for breast cancer surgery. We feel it is very important in our program for our navigator to intercept the patient much earlier, identify barriers to care much earlier and establish rapport with the patient much earlier.
By the time the patient is scheduled for surgery, that patient has already gone through biopsy and been navigated to a surgeon by someone or herself. She has already gone through so many things that she could have had a partner — a navigator — to help her through, and she could have her care more expeditiously if she had a navigator. We have profiled cases where a patient did not have a navigator. Having a navigator involved improved timeliness of care so significantly — sometimes by weeks.
Being somewhat of an early adapter, I can tell you that a lot of navigation is a one-on-one interaction in a room; its hand holding; it’s time on the phone making calls; it’s simply being that person for another person. There’s no software or brochure that really can explain what that means, and every navigator will know what I am talking about. There’s no numerical value for what that does for another person. I have a huge file full of letters from people who have said how much it meant to them that we do what we do.
Q: What’s the history of nurse navigation and care coordination at your system?
TT: Navigation has always been part of breast imaging, but not all breast imaging centers utilize navigation. Comprehensive breast imaging centers tend to utilize navigation, especially if they have a cancer program. Not all cancers have navigation that is as specific or detailed as breast navigation. For breast navigation, there is a matrix that outlines all the steps in the navigational process for a patient while on her journey. We navigate according the National Consortium of Breast Centers’ breast navigational matrix.
In that matrix, there are two spectrums within breast navigation: imaging navigation and cancer navigation. Within my breast center, we navigate primarily on the imaging side, but we do dip over into the cancer side. That would include referrals to oncologists and surgeons; referrals for genetic testing; follow-up on the day of surgery; fitting for mastectomy camisoles; cancer support groups and continuing to direct patients to resources to overcome barriers throughout the entire cancer continuum. That is the true role of a navigator: to help a patient overcome barriers.
Q: Why is it so important for navigators to fill this role?
TT: One of the greatest things we can do as a navigator is improve timeliness to care. We establish a rapport with the patient very early and maintain that relationship throughout their continuum of care so we can continue to navigate them to resources should a barrier arise during their care. If we intercept them only once they are placed on the schedule for surgery, there are so many things that could have already happened to that patient that would have benefitted from support, and we’ve missed those opportunities. Additionally, so many quality measures regarding timeliness of care have already elapsed, leaving the navigator no opportunity to improve quality.
That’s why we start the navigation in the imaging spectrum versus the cancer spectrum. That earlier encounter — the ability to influence the patient in a positive way, direct them to resources early and establish that rapport very early — is very important. That’s really what is going to keep that patient and navigator connected throughout that journey.
Q: What do you think are the biggest challenges facing nurse navigation and care coordinators?
TT: Sometimes, unfortunately, our biggest challenge is insurance as far as completing pre-certifications. We would love to see a patient who needs a biopsy tomorrow, but if a pre-certification takes a week, it is out of our control, and that can be a real frustration for us. We want to remove every barrier possible, but we can’t remove an insurance barrier. Patients need their insurance.
Every navigator will tell you that sometimes physicians can be a barrier if they do not understand navigation, the role it plays as an extension of their office and that navigators are here to serve them and their patients. We are not here to take control away from physicians. We are here to expedite the patient’s care and honor the patient’s navigational preferences as well as the physician’s navigational preferences.
Q: How do physicians at your center feel about navigation?
TT: Overall, our physicians have been very receptive. We have been doing comprehensive services with navigation for almost five years. We rolled it out with physician education, which was critical. One of the things we did when we were developing our program was we engaged a physician steering committee. On that committee, we brought in at least one physician from every physician service line. From some of the heavy-hitting service lines, such as family practice, OB/GYN and surgical, we brought in several physicians. We tried to bring in our top referring doctors as well.
Of this physician steering committee, we asked what it was that they were looking for as far as a navigation program. They wanted to make sure we would send patients to the right place, keep their navigational preferences confidential and communicate to them on what we were doing with their patients. If we were sending their patients to a certain surgeon or oncologist, they wanted to be notified.
We made sure we honored all of their preferences in setting up our navigational program — that is what protects the integrity of the program and has earned the trust of the referrers on our campus — but we also promised to honor the navigational preferences of patient first. If a patient says she wants to go see this surgeon or this oncologist, but the primary care physician has a certain surgical or oncological preference that is different from the physician’s, we’re going to honor the patient’s preference first. If the patient does not have a preference, then we are going to set the patient up with the surgeon or oncologist of the primary care or referring physician’s choice.
Our full-time nurse navigator has a great rapport with all of the physician offices. She communicates with them extensively, and we have set up some standardized forms to communicate patient’s appointments and workflow. She also has a great relationship with office staff and nurses. That all takes time, but is very important to our success.
Q: What role do you think technology can play in effective care coordination?
TT: It seems like navigation is somewhat of a new concept in medicine. As a result, tools to support navigation also seem relatively new and are somewhat underdeveloped. In imaging, we have fabulous tools to detect breast cancer, but tools to document navigational encounters are less available.
Software development or implementation, particularly with the ability to interface with your current EMR, could be extremely helpful with providing surveillance plans, risk reduction strategies, survivorship care plans, distress assessment tools and other tools for meeting cancer program accreditation standards. As a COC-accredited program, I have seen firsthand some of the difficulties of not having some of those tools available for our breast patients and other cancer patients as well.
There are definitely tools available, and as cancer programs get more recognition, gain a better understanding of the value of navigation and navigation takes a greater role as it relates to cancer program accreditation, then more hospitals and other cancer program owners will get on board with implementing tools that will support navigators. It will be imperative for navigational software to be able to interface with the current EHRs and not be too cumbersome for navigators.
Q: What do you hope for as the future for care coordination in the United States?
TT: I think there is no limit to care coordination. I think that most comprehensive cancer programs are moving towards or are already in pursuit of a quality program accreditation and, therefore, quality tools are needed to support a navigator and the cancer program. Care coordination is becoming more accepted, understood and valued by value-based healthcare systems. I would love to see navigators feel fully supported and have all of the tools they need to be able to support patients throughout their continuum of care.
When I say the tools, I really mean not only resources in their center, but I’m also talking about software and the ability to generate a surveillance program and risk reduction strategies based on a patient’s individual risks. Those are the kind of tools I would love to see navigators have available to them as navigation becomes more and more accepted and appreciated.
Equipping navigators with the tools they need to support a patient throughout their continuum of care is only going to improve the patient’s outcome.