Oncology Nurse Navigators: Putting the Value in Value-Based Payment Models

The US healthcare system is in a transition from traditional fee-for-service reimbursement to value-based contracts in cancer care delivery through oncology medical homes (OMHs), fostered by both CMS’ Oncology Care Model (OCM) and by commercial payers, such as Cigna and Horizon Blue Cross and Blue Shield of New Jersey (BCBSNJ). OMH models are designed to address all 3 parts of the triple aim: decrease the total cost of care while keeping quality and patient experience high. These initiatives have resulted in many innovative ideas to make practice transformation as smooth as possible.

Implementing these constructs requires the engagement of people, the creation or revision of processes, and the deployment of reliable technology, to make disruption¹ as minimal as possible to patients and physicians, keeping routines as normal as possible, and to achieve the payers’ requirements. Disruption requires people in roles that can accelerate the changes or practice transformation,² thereby providing the value in the new value- based payment world. The most recognizable accelerators in this transition are oncology nurse navigators (ONNs).

The role of the ONN was developed in the early 1990s by Harold Freeman, MD, who sought to diagnose cancer at earlier stages among underserved patients in the neighborhood of Harlem in New York, New York. Through a controlled experiment, Freeman showed that patients guided by a navigator after a suspicious cancer screening were more likely to follow through with biopsies—and in less time—than those who did not receive help.³ Over the next 2 decades, the nurse navigator’s role within the care team rose in importance⁴ even if fee-for-service payment models did not always recognize it.⁵

ONNs provide the “constant” in what seem to be undulating waves of changes to workflows, the adoption of new technology, the near-weekly onslaught of new drugs, and the need to ensure every nuance of documentation is entered in discrete fields in electronic health records (EHRs) so the practice meets reporting requirements. A practice could have 1 ONN or a team of nurses who work with other clinicians and support staff to transform practices into OMHs. The ONN keeps the care team, including the oncologist, in rhythm, making sure the office is operating as smoothly as possible in the eyes of the patients and their families. The ONN can be dedicated to performing 1 or all the following functions, depending on the number of oncologists and patient volume in a practice:

• Ensuring safe and reliable care is provided in the treatment and infusion rooms, by periodic reviews of policies and procedures and by visual checks utilizing Quality Oncology Practice Initiative safety standards,6 which ensure safe delivery of chemotherapy
• Anticipating patient and family needs for new patients
• Triaging and managing patients on the phone and making assessments and decisions using a technology-driven decision support of clinical pathways: for instance, whether to bring the patient in to avoid an emergency department (ED) visit or hospital admission, or to instruct the patient to take medications for adverse effects, with a computer notation to call back in 2 hours to make sure the patient will not go to the ED
• Providing regular updates to referring physicians, such as primary care physicians (PCPs), on their patient’s prognosis, chemotherapy, and goals of treatment

The ONN must be a compassionate person, armed with clinical skills that nurses, of all healthcare professionals, have best developed: ONNs can “float” from uplifting conversations with patients and families about survivorship and community linkages, to staying solid as a rock when initiating end-of-life conversations. The ONN must explain the concept of Medical Orders for Life Sustaining Treatment, and must become an advocate to ensure that the patient’s wishes are honored throughout and at the end of the cancer journey. The ONN must also track which patients are due to come to the practice each day and which ones are eligible for clinical trials.

Care coordination, according to the Agency for Healthcare Research and Quality, is the deliberate organization of patient care activities among providers, and among provider visits, to ensure care is provided at the right place, at the right time, the first time and all the time.⁷ Sometimes it is called “managing the white spaces,” referring to the spaces between sites of care. Value-based reimbursement means 24/7 access to providers: not just ensuring that patients are adherent to oral therapy, but, to name a few examples, providing chemotherapy instructions to new patients who are of child-bearing age, serving patients whose cancer has progressed, holding the hand of a patient having another bone marrow aspiration, and calling back the spouse of a patient who needs to be told that “vomiting is expected and will pass.” It means hugging a mother who has just been told her child has cancer. This is cancer care delivery in a patient-centered OMH led by an ONN or a team of nurse navigators working in conjunction with oncologists.

At Regional Cancer Care Associates (RCCA), this is how we practice nursing, enabled by partnerships with commercial payers such as Horizon BCBSNJ and Cigna, as well as by participating in OCM. These payment models are still relatively new and may evolve. But nursing, despite challenges of shortage, burnout, and aging, is here to stay: for our patients, their families, and the communities we serve.

A recently announced pilot program between RCCA and Horizon BCBSNJ will provide ONN services from the time the patient is identified as participating in this program through survivorship care planning or palliative care services.8 The goal of the pilot program is to reduce care gaps by having nurses reach out to patients between treatments and identify issues that could lead to a trip to the ED. Horizon will pay a monthly management fee for the nurse navigators to manage each patient.⁹

The pilot will be powered by Cota, an analytics platform based on real-world data that helps payers and providers optimize outcomes of individual patients while holding down costs.¹⁰ Once RCCA receives the lists of qualified patients from Cota, the RCCA practices are notified about these patients. The navigators then review the patients’ medical records and identify any gaps in care before the patient comes to the office. If the triage system shows that the patient has called in about any symptom, the patient is immediately contacted by the ONNs and either managed over the phone or brought to the office to be seen by the oncologist. The ONNs will utilize data from the EHR or analytic platforms to address any further gaps in care. The ONNs may access Jersey Health Connect,¹¹ a nonprofit health information exchange, to find out if the patient has been admitted to the hospital, or access Health Sphere, a platform developed by Horizon to create a comprehensive care plan for the patient.¹²

When the patient comes to the office, the ONN spends time with the patient, sometimes even during treatment, to further assess the patient’s needs. This includes educating the patient and family members about the crucial process of calling the ONN about any issues the patient may be going through before they think of going to the ED. If the patient has any comorbid conditions, the ONN will also contact the PCP or specialist who is co-managing the patient to create full care coordination.

If the patient’s journey is moving toward palliative care, through markers such as stage, ECOG scores, pain scales, and frailty scores, the ONN will work with the oncologist and, where appropriate, the clinical social worker, to meet with the family and discuss the patient’s wishes. The ONN will help providing information regarding power of attorney, physician or medical orders for life-sustaining treatment, and a durable do not resuscitate order, if desired; the ONN will also help the family with the decision about placing the patient on hospice, when the time comes.

Through the pilot, Horizon will track many measures about the patients, including time to treatment, medications used, unplanned read- missions within 30 days, number of ED visits, and number of inpatient admissions. By serving about 2000 patients through this pilot over 3 years, RCCA will help Horizon develop valuable best practices that will advance cancer care for patients across New Jersey.⁸

Author Information

Lani M. Alison, BSN, MS-HCQ, PCMH CCE, is vice president of clinical affairs for Regional Cancer Care Associates, which has 30 locations in New Jersey, Connecticut, and Maryland.References

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