Beyond Patient Navigation: Expanding Nurses’ Role in Care Coordination

Gail Thompson

January 2018, Vol 8, No 1 - Practice Operations

Patient navigation is a valuable tool for cancer centers, and the Lipson Cancer Institute of the Rochester Regional Health System, NY, has modified its patient navigation to Registered Nurse (RN) Clinical Care Coordination, with significant results.

At the ACCC National Oncology Conference in October 2017, Bonnie Hoover, RN, MSN, OCN, Clinical Coordinator; Kathleen Doerner, RN, BSN, Senior Nurse Manager; and Michelle Rose, Medical Oncology/Hematology Practice Manager, of the Lipson Cancer Institute, discussed the expanding role of navigation at Lipson Cancer Institute. The cancer center serves more than 2200 new patients annually, with a team of 12 hematologists/oncologists, 11 advanced practice practitioners, 14 infusion nurses, 2 triage nurses, and 4 clinical coordinator nurses.

Navigators Are Essential

Navigation provides significant benefits to patients, but the expectations and responsibilities of navigators are often not well-defined, and vary so much that the targeted population is not necessarily reached. The Oncology Nursing Society, Association of Oncology Social Work, and the National Association of Social Workers define patient navigation as “individualized assistance offered to patients, families, and caregivers to help overcome healthcare system barriers and to facilitate timely access to quality health and psychosocial care from prediagnosis through all phases of the cancer experience.”1

As in many cancer programs, the role of patient navigators at the Lipson Cancer Institute was initially focused on breast, lung, and colorectal cancers, but their role was implemented without consistency. Within the center’s health system, the historical approach to patient navigation was to divide the responsibilities in a manner similar to most health systems. This included providers discussing the medications, administration schedules, major side effects, toxicities, and informed consent; navigators provided patient and family education in 1 session on medications, schedules, side effects, and home management for breast, lung, and colorectal cancers only, and also provided ongoing support for patients undergoing treatment; triage nurses fielded patients’ phone calls before initiating infused or oral medications and were dependent on patients calling the center; infusion nurses provided drug-specific education on side effects, toxicities, and home management to all patients undergoing chemotherapy infusion.

But this division of roles created problems for the health system. First, the system only served limited diagnoses, in an uncoordinated fashion, and with limited space affecting the educational sessions. In addition, many patients were arriving to their first treatment unprepared and anxious. Another problem was the limited accountability of those providing patient education and the limited communication between clinicians and those administering the treatment, leading to a disjointed program with minimal success.

Adjusting the Role of Navigators

The management of oral drugs was becoming a major concern for the health system and the Lipson Cancer Institute. Patients were managed in an uncoordinated fashion starting with the provider, and then involving financial counselors, specialty pharmacy, triage nurses, and patient visits. Often patients had a delay of 2 to 6 weeks before starting treatment with oral agents.

When reviewing optimal navigation options, it was obvious that navigation is an essential component of cancer services, particularly for addressing underserved community populations. But any navigation services must function to the limits of the scope of the practice for the assigned staff member. The social workers, nurses, and lay navigators should function as a multidisciplinary team for optimum patient outcomes. Navigators should have the education and knowledge to provide community and cancer program assessments, resolve system barriers, address the cancer continuum and cancer care disparities, and provide individualized assistance to patients with cancer, their families, and caregivers.

A New Clinical Coordinators Program

Ultimately, the health system redefined specific goals for a new clinical care coordination program. The goals were grouped into several categories.

Patient Outcome and Experience Improvements

  • Improve patient education for intravenous and oral treatments
  • Improve distress screening and referral for services
  • Decrease the time from prescribing to drug in hand for oral agents
  • Improve the monitoring of patients using oral drugs
  • Improve patient adherence to oral therapy plans
  • Improve patient preparation for therapy
  • Provide a single point of contact for patients
  • Provide navigation and coordination across the health system.

Provider Satisfaction Improvements

  • Provide in-clinic nursing support for patient education coordination across the health system
  • Develop close professional relationship with 1-2 nurses who participate in the care of each patient.

Meaningful Roles for Nurses

  • Involvement in the care of patients across the treatment continuum
  • Increase nurse involvement in the oncology care team.

The implementation of the new program was rolled out in stages over 2 years from 2014 to 2016. The 4 clinical teams include nurses, doctors, a clinical coordinator, and an access associate. The teams stay in constant communication through face-to-face conversations, e-mails, and weekly team meetings. The responsibilities of the clinical coordinator nurses include:

  • Oral drug management
  • Chemotherapy instruction
  • Distress assessment
  • Coordination from inpatient to outpatient care
  • Home care and home oxygen referrals
  • Coordination with infusion nurses
  • Referrals for social work, dietitians, legal consultations, and wound care
  • Coordination of multidisciplinary tumor conferences
  • Development of patient education materials
  • Liaisons with pharmaceutical representatives for staff education, patient education materials, and assistance with drug access.

The new oral drugs management process identifies appropriate patients and initiates prior authorization and Risk Evaluation and Mitigation Strategy registration promptly. Other services include in-clinic education for patients and their families, liaison roles with specialty pharmacies, education for infusion and inpatient nurses about oral drugs that their patients are using and documentation in the health system drug monitor. Weekly telephone calls (at least 4 calls) with patients help to identify barriers to adherence and facilitate early intervention, while also helping staff to identify and manage side effects early to avoid treatment interruptions and delays.

New system standards for chemotherapy education under the clinical care coordination program address treatment expectations, general guidelines, concomitant medication use (eg, steroids, antiemetic drugs, and antidiarrheal treatments), and the patient’s schedule. Chemotherapy education is used as the point of contact for patients who are starting therapy, allows clinical staff to assess access to intravenous drugs, and teaches patients about vein hygiene and access devices. The staff also has developed patient education materials and teaching sheets for new intravenous and oral drugs.

Successful Strategies

Distress management is greatly enhanced under the new program. The staff identifies new patients and assesses their levels of distress using the National Comprehensive Cancer Network Distress Thermometer tool before patients meet with the oncologist. Staff members document the results and provide symptom management interventions for appropriate patients. The team also makes referrals, as needed, for social work, legal, financial, and home care concerns.

Care coordination can include the identification of inpatients who will soon become outpatients. Referrals are made as necessary for home care or hospice, home infusions, oxygen needs, nutrition, social work, legal consultations, and financial assistance. The team also serves as the point of contact for dialysis, nursing homes, hospice nurses, specialty pharmacies, and radiation and surgical oncology.

To date, there have been several indicators of the success of the program. The time from informing patients in need of oral drugs to drug in hand was reduced by 2 to 6 days. The number of patients receiving nurse education before starting oral drugs increased from <10% to >90%. The number of patients who receive nursing education before their first chemotherapy rose from <10% to >80%. Approximately 95% of all new patients with cancer are now surveyed for distress, a successful outcome for any value-based cancer program.

Future Enhancements

Plans for the future include filling additional clinical coordinator positions, with the following goals:

  • Improving the navigation component
  • Participation in survivorship counseling
  • Developing focused intervention teaching sheets for symptom assessment
  • Continue to develop patient education materials as new drugs come to market
  • Increase presence in the inpatient forum
  • Provide increased support and mentorship for affiliates.

The program has been a resourcing success. Providers have noted that they “don’t know how they functioned before they had this resource,” the presenters noted. Patients have noted, “It is wonderful that they have added this role, because it really makes a difference to those of us receiving treatments to know what to expect before we get there and to know how to take the pills.”


  1. Oncology Nursing Society, the Association of Oncology Social Work, and the National Association of Social Workers. Joint position on the role of oncology nursing and oncology social work in patient navigation. Oncol Nurs Forum. 2010;37:­251-252.