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Navigating a Patient Across the Continuum of Care: Who Is in Charge?

November 11, 2010 | AONN+ Blog | Navigation
Featuring:
Lillie D. Shockney, RN, BS, MAS, HON-ONN-CG
Lillie D. Shockney, RN, BS, MAS, HON-ONN-CG
Editor-in-Chief, JONS; Co-Founder, AONN+; University Distinguished Service Professor of Breast Cancer, Administrative Director, The Johns Hopkins Breast Center; Director, Johns Hopkins Cancer Survivorship Programs; Professor of Surgery and Oncology, JHU School of Medicine; Co-Creator, Work Stride-Managing Cancer at Work

Often times there is a lot of education, support and resources available to a newly diagnosed breast cancer patient. She may meet with a nurse navigator, an NP involves in her surgical management, the surgical oncologist who will be operating on her, the OR scheduler, the appointment scheduling coordinator, and perhaps even other people involved in the first phase of her treatment plan. It's not unusual however for the nurse navigator's role and involvement to taper off after the surgical treatment and post op recovery period has been reached. The patient then moves onto chemotherapy and radiation therapy, but without the lifeline she had become attached to during her early days of diagnosis and treatment-you.

So how can this patient be managed and navigated the rest of the way? There are a few options.

For patients who are participating in a clinical trial, the research nurse will be serving in a navigation role, keeping in close contact with the patient, ensuring she is coming to her appointments and having her treatments, and addressing her physical and psychological needs.

The Advanced Practice Nurse who sees the patient with the medical oncology team may pick up this navigation role to some degree. Rather than having her re-invent the wheel though, you should be in communication with her and provide her a synopsis of this patient's medical history, navigation issues (barriers to care) that have arisen thus far, and make her aware of what resources are available to her if the patient should need them during her adjuvant therapy.

Consider developing a survivor volunteer team to serve as navigation extenders. These individuals do require special training and must have good communication skills but can be a wonderful benefit to your breast center program. By matching a newly diagnosed breast cancer patient to a survivor volunteer based on her age, stage of disease and treatment plan, the patient can have a mirror image of herself in her near future. The SV stays in touch with the patient as she proceeds through her adjuvant therapy and informs the medical oncology NP if there are any issues that warrant her assistance. The patient may have become ill after chemo and didn't report it, not understanding the criteria for being urgently seen. The patient also may say that she doesn't have transportation for her next chemotherapy session and therefore figures she'll simply have to miss it. The SV can be incredibly beneficial in bringing these issues to the attention of the nurses taking care of the patient so that proactive intervention can be done-i.e., the NP can call the patient and get her vital signs and instruct her what to do and where to go for urgent assessment and treatment. The NP can also utilize resources available for providing free transportation for cancer patients during their treatment.

The nurse navigator who was originally assigned to the patient at the time of her first clinic appointment remains in touch with her all the way through her treatment. (this is unusual though, given large volume of patients and limited navigator resources. If it is that way now, it might not be the way in the future, if your program, frankly, is successful.)

If there is a need to transition the patient away from the original nurse navigator who managed her care through surgical treatment, make the patient aware of this upfront. The worse case scenario is for the patient to have expectations that go unmet. Patients do well when we are able to lay out for them a time line of their treatment and who will be involved in their care during each treatment phase.

It's also important from the perspective of your own performance being measured to know where your starting point and ending parts are for your patient population.

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