Abstract

The use of an Oncology Nurse Navigator care model can be used to define the ONN role, define facility tracking metrics, and expand patient cancer care. Using the Care Model and metrics in relation to ONN tasks, providers and navigators can track ONN processes, outcomes, and improve patient care processes.

Purpose: This quality improvement project aims to integrate the Academy of Oncology Nurse & Patient Navigators (AONN) guidelines, tracking metrics, and physician feedback about patient needed resources to implement an ONN Care Model to expand current cancer patient care processes.

Methods: Physicians were surveyed for needed patient resources, knowledge about the ONN role, and satisfaction with ONN care outcomes. Creation of an ONN Care Model and role definition of the ONN were defined for facility needs and improvement. Physician post-surveys and qualitative data were gathered. Aggregated data was gained through anonymous surveys.

Results: Post-survey results indicated that improvements were needed to expand the ONN role. Qualitative data suggests that using an ONN care model and metric tracking would benefit patient care and the multidisciplinary team.

Discussion: Defining and Implementing an ONN Care Model and Role and Responsibility Program increased the multidisciplinary awareness and resources of current evidence-based practices.

Conclusion: Incorporating a defined structured process for ONN cancer patient navigation can expand the role of the ONN, increase multidisciplinary team involvement, and provide holistic patient care.

Key words: Oncology Nurse Navigation, Cancer Care, Cancer Guidelines, Oncology Metrics, Multidisciplinary Coordination, United States Cancer Statistics, Oncology Navigation Guidelines.

Introduction

Community-based cancer treatment is increasing; about 85% of patients with cancer are treated through community-based hospitals/ patient clinics [1]. The physical and psychological effects of cancer and the complexity of cancer treatment require holistic patient care for successful treatment and patient survivorship. High-quality treatment and care close to the patient’s community can be beneficial to both patients and caregivers [2].

The ONN role is recognized as a crucial component of patient- centered cancer care, in identifying needs and barriers of cancer patients, coordinating care, and employing a holistic approach to patient needs, while also serving as a resource for patients and families [3]. The Academy of Oncology Nurse and Patient Navigators (AONN) defines the ONN role as “A nurse navigator is a clinically trained individual responsible for identification and removal of barriers to timely and appropriate cancer treatment” [4].

Literature reveals that using an ONN for cancer care can have a positive fiscal impact, including a reduction in complications and barriers to care [3,5-7]. Additionally, it can improve the patient’s quality of life, enhance patient function, and increase preventive post-cancer care [8-10]. Ultimately, advocacy and a holistic approach to cancer care are essential for successful care outcomes and patient survivorship [11].

Expanding Patient Care

At a community hospital in Utah, an investigation of accreditation requirements for the Certified National Accreditation Program for Rectal Cancer (NAPRC) and the existing ONN care process prompted the development of a quality improvement project team to define and expand the role of the ONN. The care process consisted of limited patient navigation resources and minimal patient contact; the program consisted of an initial meeting with the nurse navigator, who reviewed the initial follow-up appointment with the oncology provider team.

Pre-project implementation, approval was obtained through the Institutional Review Board (IRB) at Weber State University and did not require formal review. IRB approval was not required at Community Hospital, as there was no direct patient interaction, no patient testing, and no protected health information was involved. The team members and stakeholders were defined and organized, and a plan and timeline were developed.

Initial needs data for the project were gathered through ONN and quality department meetings, and anonymous Qualtrics surveys of the oncology tumor board physician team and the hospitalists team. The pre-survey was presented to the multidisciplinary physician team in a Likert scale evaluating needed patient resources, ONN processes, and ONN collaboration with the physician team (see Appendix A). However, with the low survey response, needs assessments were also evaluated through collaborative meetings within the tumor board and hospitalist meetings.

Evidence-based practice incorporates current research recommendations, clinician knowledge, and patient preference input [12]; it also provides nursing practice a foundation for nursing judgment to implement safe, operational, and efficient care [13]. After review of evidence-based and professional resources and review of the limited facility fiscal budget, a defined care process utilizing open-access ONN resources was deemed necessary to outline ONN expectations.

To define care processes, a Community Hospital ONN Care Model was developed (see Appendix B), inspired by the 2017 Oncology Nurse Navigator Core Competencies and visual care model [14] (referenced with permission). Defining the role of the ONN is crucial for providing direction, adoption, implementation of interventions, time, and fiscal measurability, and improving patient care [5]. It also meets requirements for hospital cancer program accreditations, which ensure care metrics are being met.

The community hospital's ONN Care Model defined three areas of patient ONN engagement with corresponding three major patient touchpoints (patient interactions) that could be measured through documentation: 1. Touchpoint 1: Initial patient meeting and patient assessment plan [15], resources provided, care coordination time, and Bimonthly patient touchpoints, 2. Touchpoint 2: Post Treatment/Post Surgery, resources provided, care coordination time, patient assessment using the Patient Distress Thermometer [16], and 3) Touchpoint 3: In-person visit or phone call, including needs assessment, resources provided, and survivorship care plan implementation [15].

Due to corporate instability and significant physician turnover during the implementation phase, a post-survey was not feasible. Consequently, feedback was gathered through discussion at administrative meetings. The ONN Care Model was presented to the quality improvement team, administration, and physician teams for review and adoption. Positive feedback was received for the expansion of ONN processes to enhance patient care and track quality improvement, as well as for the discussion of fiscal impacts on hospital budgeting metrics.

The marketing team was involved in creating updated formal ONN Process Binders, including the ONN Community Hospital Care model, as well as updated patient/physician ONN pamphlets. The materials were distributed to the stakeholders, and the multidisciplinary team adopted new patient care processes. Review processes were scheduled to revise processes as necessary.

Discussion

It is important to note that the role of the ONN is comprehensive and requires role development certification and continuing education, as mandated by the Commission on Cancer (COC) for cancer program accreditation [17]. The Oncology Nurse Certification Corporation offers the Oncology Nurse Certification (ONCC, n.d.), and the Academy of Oncology Nurse & Patient Navigators (AONN) provides certificates of an Oncology Nurse Navigator- Certified Generalist (ONN-CG), and a Certified Oncology Patient Navigator requires a background in patient navigation [18].

The Oncology Nursing Society [19] has updated the Oncology Nurse Navigators Core Competencies since the implementation of this project. In addition, the AONN, along with the American Cancer Society, provides nurse navigation metrics to guide patient navigation to qualify and quantify patient care points [20]. As of January 2024, the Centers for Medicare and Medicaid (CMS) validate the ONN role and its positive impact on patient care by allowing ONN as billable treatment inclusions [18], with an aim to provide a broader scope of health and equitable patient care [21].

This project provided the structure and outline for the ONN role expansion and patient care expansion in a community hospital, along with continuous improvement evaluation methods. The project outcomes aligned with the existing literature to support successful patient care processes. It also aligns with metric tracking to allow for tracking and billing through the CMS [18]. The project plan utilizes current National and professional evidence-based resources to provide a low-cost approach to improving patient care and can be adapted widely in community cancer care settings that provide ONN. Using these approaches, community hospitals can align programs with national standards, but more importantly, can have a greater positive impact on patient care.

Challenges and barriers to the implementation of the project could include workplace culture, administrative support, stakeholder buy in, time allowances, corporate structure, and provider engagement. Nurse leaders should promote and evaluate their clinical culture setting for engagement of quality improvement practice, and value nursing engagement and multidisciplinary team engagement in promoting quality improvement as a needed positive and inclusive process [22].

Limitations

During the various stages of the project evaluation and implementation, there were several limitations. This includes low participation in the initial data collection, unexpected physician team turnover, and a pending hospital merger. The project also did not evaluate patient feedback on ONN coordination; this was discussed for future implementation for a holistic evaluation.

Conclusion

ONN is a comprehensive process that can be essential to cancer patient treatment and care outcomes. It can also be used to enhance and support patients, patient support persons, and the multidisciplinary team, therefore, it is imperative to implement patient care models and metric tracking methods to provide better patient outcomes. The frameworks developed in this quality improvement project used the multidisciplinary team to identify gaps in patient care and current recommended ONN processes that would close the gaps in practice. The dissemination of resources and project guidelines can be translated into practice to improve patient care at community hospitals. Furthermore, recommendations to develop an evaluation of resources and community ONN practices periodically will allow for a progressive patient care process.

Competing interests

The author does not have conflicts of interest in personal, corporate, judicial, economic, or political matters that relate to the content of this submission.

Acknowledgements:

My sincere gratitude to Dr. MaryAnne Reynolds for her support and mentorship, and Dr. Kelley Trump for her mentorship and project review. I would also like to thank the Quality Improvement Team, Administration, and the Multidisciplinary Team for their support and continuous encouragement of this quality improvement project.

References

1. National Institute of Health. (2017, September 21). Bringing research to the community to reduce cancer disparities. View

2. Tucker, T. C., Charlton, M. E., Schroeder, M. C., Jacob, J., Tolle, C. L., Evers, B. M., & Mullett, T. W. (2021). Improving the quality of cancer care in community hospitals. Annals of Surgical Oncology, 28(2), 632-638. View

3. Binner, M., Figlioli, A., Shanahan, J., Putscher, T., Davis, J., Stewart, K., & Waite, K. (2019). Oncology nurse navigators’ rapid improvement event: Improving processes and identifying metrics. Journal of Oncology Navigation Survivorship, 10(10). View

4. Kelly, R. (2021, February 23). Defining the role of the oncology nurse and patient navigator. Academy of Oncology Nurse & Patient Navigators Blog (AONN +). View

5. Paskett, E. D., Battaglia, T., Calhoun, E. A., Chappell, M. C., Dwyer, A., Fleisher, L. G., Greenwald, J., & Wells, K. J. (2023). Isn’t there enough evidence on the benefits of patient navigation? CA: A Cancer Journal for Clinicians, 73(6), 562- 564. View

6. Rocque, G. B., Pisu, M., Jackson, B. E., Kvale, E. A., Demark Wahnefried, W., Martin, M. Y., Meneses, K., Li, Y., Taylor, R. A., Acemgil, A., Williams, C. P., Lisovicz, N., Fouad, M., Kenzik, K. M., Partridge, E. E., & Patient Care Connect Group (2017). Resource use and Medicare costs during lay navigation for geriatric patients with cancer. JAMA Oncology, 3(6), 817- 825. View

7. Wood, T., Aarts, M. A., Okrainec, A., Pearsall, E., Victor, J. C., McKenzie, M., Rotstein, O., McLeod, R. S., & iERAS group (2018). Emergency room visits and readmissions following implementation of an Enhanced Recovery After Surgery (iERAS) Program. Journal of Gastrointestinal Surgery, 22(2), 259–266. View

8. Kagan, S. H., Morgan, B., Smink, T., DeMille, D., Huntzinger, C., Pauly, M., & Lynch, M. P. (2020). The oncology nurse navigator as "Gate Opener" to interdisciplinary supportive and palliative care for people with head and neck cancer. Journal of Oncology Navigation & Survivorship, 11(8), 259–266. View

9. Mertz, B. G., Dunn-Henriksen, A. K., Kroman, N., Johansen, C., Andersen, K. G., Andersson, M., Mathiesen, U. B., Vibe Petersen, J., Dalton, S. O., & Envold Bidstrup, P. (2017). The effects of individually tailored nurse navigation for patients with newly diagnosed breast cancer: A randomized pilot study. Acta Oncologica (Stockholm, Sweden), 56(12), 1682–1689. View

10. Monterosso, L., Platt, V., Bulsara, M., & Berg, M. (2019). Systematic review and meta-analysis of patient reported outcomes for nurse-led models of survivorship care for adult cancer patients. Cancer Treatment Reviews, 73, 62-72. View

11. Kousoulou, M., Suhonen, R., & Charalambous, A. (2019). Associations of individualized nursing care and quality oncology nursing care in patients diagnosed with cancer. European Journal of Oncology Nursing: The Official Journal of European Oncology Nursing Society, 41, 33-40. View

12. Abu-Baker, N. N., AbuAlrub, S., Obeidat, R. F., & Assmairan, K. (2021). Evidence-based practice beliefs and implementations: a cross-sectional study among undergraduate nursing students. BMC Nursing, 20(1), 13-8. View

13. Li, S., Cao, M., & Zhu, X. (2019). Evidence-based practice: Knowledge, attitudes, implementation, facilitators, and barriers among community nurses-systematic review. Medicine, 98(39), e17209. View

14. Oncology Nursing Society. (2017). 2017 Oncology Nurse Navigator Core Competencies. View

15. American Society of Clinical Oncology (n.d.) ASCO resources for patients and providers. View

16. National Comprehensive Cancer Network (2025). NCCN Guidelines Version 1.2025 Distress Management. View

17. Commission on Cancer & American College of Surgeons (2022). Standard 4.2: Oncology Nursing Credentials Frequently Asked Questions. View

18. Academy of Oncology Nurse & Patient Navigators (n.d.). Navigation Reimbursement Resources. View

19. Oncology Nursing Society. (2024). Oncology Nurse Navigator Competencies. View

20. Academy of Oncology Nurses & Patient Navigators & American Cancer Society (2020). Navigation Metrics Toolkit. View

21. Bonavitacola, J. (2024). Rule change for patient navigation billing is a boon to oncology care, practice leaders say. Evidence-Based Oncology, 30(2), SP110. View

22. Alexander, C., Tschannen, D., Argetsinger, D., Hakim, H., & Milner, K. A. (2022). A qualitative study on barriers and facilitators of quality improvement engagement by frontline nurses and leaders. Journal of Nursing Management, 30(3), 694–701. View