RN Navigator - Oncology

Oncology Nurse Navigators provide resources, support, assessments, referrals, education, care coordination and general guidance throughout the cancer care continuum.

They help people "navigate" through the maze of doctors' offices, clinics, hospitals outpatient centers, insurance and payment systems, patient-support organizations and other components of the health care system.

Services are designed to support timely delivery of quality standard cancer care and ensure that patients, survivors and families are satisfied with their encounters with the cancer care system.

Navigators promote communication between the patient and health care providers, eliminate barriers to care, and ensure timely delivery of services. Once a patient is in the navigation system, it is the navigator's responsibility to monitor that patient through the continuum from screening to survivorship.

Responsibilities

Navigators provide education and support to patients, caregivers, families, healthcare professionals, communities, etc.

Provides education to patients, families, providers, caregivers, multidisciplinary colleagues and the community about cancer and the role of the oncology nurse navigator

• Serves as primary contact and advocate for patients
• Provides support for patients across the cancer continuum
• Acts as a liaison among the patient, family, caregivers, and healthcare team
• Practices evidence-based processes including use of clinical guidelines and specialty resources
• Educates and assess patients’ understanding of the disease process and treatment options required for informed decisions
• Assists patients with their treatment goals
• Provides comprehensive documentation of patient encounters, education and referrals
• Provides and reinforce education in all phases of cancer continuum including, but not limited to: treatment, care plan, symptom management and survivorship concerns
• Educates and reinforce the issue of adherence to the treatment plan

Develops Oncology-related Education Materials

• Possesses clinical trial awareness and promote trial types and requirements, and engage with research team as appropriate
• Understands criteria for molecular testing and genetic counseling

Maintains current trends and evidence through lifelong learning with continuing education and evidence-based practice

Discusses physician visits with patients and families to assess understanding, interpret information as needed, and answer questions

Contributes to the knowledge base of the healthcare community through involvement in professional organizations, presentations, publications and research

• Empowers patients with education and knowledge to help improve patient outcomes and satisfaction
• Attends community health fairs and screenings; provides community education presentations as appropriate
• Facilitates/participates/attends support groups and family/patient center programs, as appropriate
• Provides patient information on available services, community resources, and/or support groups.
• Contacts provider offices to establish check and balance of referrals
• Possesses a basic understanding of insurance (co-pays, deductibles, co-insurance)

Contacts patient at diagnosis, high stress points, pre- and post-surgery, time of initiation of therapy and any other flag touch point

Meets with patient by phone or in person “within designated time” following “designated event” and follow patient per navigator- or facility- specific guidelines

Facilitate and coordinate timely care coordination throughout the cancer continuum in collaboration with the multidisciplinary team.

Facilitates keeping care in the system by identifying opportunities to retain diagnostic testing, radiation oncology services, etc.

Communicates with ancillary departments to define and resolve specific problem areas and ensure timely delivery of patient care, including but not limited to diagnosis and treatment

Contacts patient at diagnosis, high stress points, pre- and post-surgery, time of initiation of therapy and any other flag touch point

Coordinates and schedules appointments with providers to ensure timely delivery of diagnostic services, treatment services, and appropriate survivorship or hospice/palliative care

Accompanies patients to appointments (particularly if there are multiple barriers to care) and/or providing clarification and literacy-level-appropriate education related to the visit

• Assists with the post-treatment transition to survivorship clinic and/or primary care
• Collaborates & communicates frequently and consistently with providers & other appropriate healthcare team members, ensuring seamless plan of care and follow-up care
• Ensures timely delivery of test results to patient by a care team member

Assists in selecting patients to be presented at Tumor Board and gather necessary patient information to present patient to physicians for discussion

Provides telephone triage services (e. g. symptom management, emotional support, education, resource referral) for patients/families

Facilitates communication with patients, survivors, families and the health care providers to monitor patient satisfaction with the cancer care experience

Ensures Patient Adherence with Treatment Plan

Gets referrals that are needed, explaining the referral process and facilitating scheduling appointments with surgeon, medical oncologist, radiation oncologist, and other necessary services as appropriate

Follows patient through the care continuum/experience, eliminating operational barriers (such as scheduling, test results, etc.) as well as other barriers to cancer services

Works closely with other healthcare disciplines to coordinate care and ensure timely appointments, result reporting, financial need and other referrals, communication, patient care and follow-up

• Maintains an active role in disease specific Tumor Conferences, including follow up on recommendations
• Provides comprehensive documentation of patient’s diagnostic testing, treatments, and referrals

Works with a variety of diverse and complex patients, families and both internal and external health care providers.

Assures that the patient is connected to prevention services upon completion of active cancer treatment and into survivorship

Nurse navigators utilize appropriate screening and assessment tools to make referrals that are appropriate for each individual patient based on their needs.

Assesses & identify patients’ needs and make appropriate referrals based on patient’s needs, which may include case managers, social workers, registered dietitians, financial assistants, genetic counselors, chaplains, counselors, psychologists/psychiatrists, PT/OT, speech, home care, hospice, palliative care, interpreters, multi-disciplinary conferences (tumor board), support groups, lymphedema clinic, oncology rehabilitation, survivorship clinic

• Assesses for, identify, and assist in mitigating barriers to care and make appropriate referrals
• Utilizes appropriate screening and assessment tools (e. g., distress screening, etc.)
• Maintains/uses a comprehensive database of local, regional and national resources
• Understands resources available to patients experiencing financial hardships and/or are uninsured/underinsured

Assists patients with access concerns (for screening, diagnosis or treatment) and assists with paperwork and addressing access barriers as indicated.

Provides appropriate resources in a timely manner to meet patient’s specific needs, local and national resource list in binder.

• Facilitates individualized care based on culture, health literacy, ethics, psychosocial needs, etc.
• Assists patients with advance directives, palliative care and end-of-life concerns

In conjunction with the Department Director, Navigators are responsible for systematically, and continually performing the functions of assessing, planning, implementing, and evaluating care according to the nursing process and the standards of accrediting bodies.

• Performs data entry and prepares reports for Director to monitor program outcomes
• Demonstrates problem solving skills and a win/win attitude
• Participates in tracking and monitoring metrics and outcomes
• Actively participate in tumor boards, interdisciplinary meetings, cancer committee and other meetings

Reports navigation program outcomes to key stakeholders, including but not limited to multidisciplinary teams, cancer committee, etc.

Collaborates with other navigators internally & externally to share best practices and increase patient resources

Ensures timely and appropriate documentation of all patient interactions into navigation tracking and documentation system and any databases to keep patient record up-to-date

• Assists with ongoing navigation program assessment and identification of process improvement opportunities
• Develops action plans for improvement, as necessary
• Identifies, implements and measures quality and process improvement initiatives
• Documents non-compliance of patients
• Pursues continuing education opportunities related to oncology and navigation
• Performs job duties and functions in an organized and time conscious manner
• Partners with patients, families, the interdisciplinary team and community resources to provide well-coordinated, timely, compassionate, exemplary, interdisciplinary care
• Forms recommendations and develops action plans that address options for improving care
• Evaluates own practice related to job specific performance expectations
• Identifies, implements, and monitors multiple QI initiatives to demonstrate program improvement and financial contribution and cost savings services of navigation (ie compliance to plan of care)
• Maintains disease site dashboard at least monthly
• Identifies and implement opportunities to improve patient satisfaction
• Demonstrates a productive work ethic, ensuring the delivery of efficient & effective care
• Performs the functions of assessing, planning, implementing and evaluating the care delivered according to the nursing process and Oncology Nursing Society Standards of Practice
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