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Patient Care Connect: Experiences with Lay Navigation in Cancer
Gabrielle Rocque, MD, MSPHEd Partridge, MD
November 1st, 2018
DisclosurePortion of this work was made possible by Grant Number 1C1CMS331023 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The research presented was conducted by the awardee. The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.
• Research Funding (Rocque): Carevive, PackHealth, Medscape, Genentech, Pfizer
• Employment (Partridge): Guideway Care
Learning Objectives1. Describe a lay navigation program 2. Identify benefits of lay navigation3. Understand how lay navigation can be used to
support advance care planning
Agenda
1. Patient Care Connect Program2. Lay-navigator led advance care planning3. Considering sustainability of navigation4. Reflections from the field5. Q & A
Patient Care Connect Program• Goal of improving VALUE• ~40 Lay (non-clinical) navigators • Provides extra layer of support to cancer patients across the
continuum of care• Activities anchored by distress screening
2012 CMMI Innovation Award
Rocque GB, et al. The Patient Care Connect Program: Transforming Health Care through Lay Navigation. Journal of Oncology Practice 2016 Jun;12(6):e633-42. PMID: 27165489.
4
3
2
11
1
5
8
10
7
9
6
12
Site LocationNumber of
Affiliated Medical Oncologists
Rural vs. Urban Status Practice Structure
Memorial Hospital (1) Chattanooga, TN 15 Urban Private Practice
Northside Hospital Cancer Institute (2) Atlanta, GA 58 Urban Hospital Owned
Gulf Coast Regional Medical Center (3) Panama City, FL 4 Urban Private Practice
Ft. Walton Beach Medical Center (4) Ft. Walton Beach, FL 4 Urban Hospital Owned
Singing River Health System (5) Pascagoula, MS 5 Urban Hospital Owned
SE Alabama Medical Center (6) Dothan, AL 6 Urban Private Practice
Russell Medical Center (7) Alexander City, AL 2 Rural Hospital Owned
NE Alabama Regional Medical Center (8) Anniston, AL 5 Urban Private Practice
Marshall Medical Center (9) Albertville, AL 2 Rural Hospital Owned
Mitchell Cancer Institute (10) Mobile, AL 6 Urban AMC
Medical Center Navicent Health (11) Macon, GA 14 Urban Private Practice
UAB Comprehensive Cancer Center (12) Birmingham, AL 28 Urban AMC
Navigator Training• 80 hours of didactic training
• Health promotion, empowerment, navigation principles, time management, managing compassion, fatigue, and setting boundaries
• 80 hours of practical skills training• Communication, conducting distress screening, problem solving to overcome
barriers to health care, data collection using navigation software, and use of care maps
• Site orientation and shadowing in clinical settings
0
2,000
4,000
6,000
8,000
10,000
12,000
Num
ber o
f Pa
tient
sEnrollment in Navigation
PCC Patient Contacts (3/2013-12/2015)N
umbe
r of C
onta
cts
0
10,000
20,000
30,000
40,000
50,000
Person toPerson (0-15
minutes)
Person toPerson (16-30
minutes)
Person toPerson (31-60
minutes)
Person toPerson (>60
minutes)
Telephone (0-15 minutes)
Telephone (16-30 minutes)
Telephone (31-60 minutes)
Telephone (>60minutes)
>88K contacts
0
500
1,000
1,500
2,000
2,500
3,000 2,556 2,4452,126
1,080 931 889 866 851 776 769
Number Reported Requested Assistance Addressed
(49%)(57%)
(23%)(62%)
(26%)
(77%) (75%)(73%)
(36%) (27%)
(74%)(80%)
(94%)(95%)
(95%)
(98%)(95%)(95%)
(93%)
(95%)
Num
ber o
f tim
es T
imes
Repo
rted
Distress Screening
Rocque GB, et al. Guiding Lay Navigation in Geriatric Cancer Patients Using a Distress Assessment Tool. Journal of the National Comprehensive Cancer Network : J Natl Compr Can Netw, 2016. 14(4): p. 407-14. PMID: 27059189.
Hospitalizations by Navigation Status
0
50
100
150
200
250
300
350
400
450
500
1 2 3 4 5 6 7 8Hos
pita
lizat
ions
per
1,0
00 p
atie
nts
Quarters after Enrollment
Matched comparison
Navigated
Per quarter reduction(Navigated compared to matched comparison)• 6% in ER visits• 8% in hospitalizations• 10% in ICU visits
Rocque GB, et al. Lay Navigation for Geriatric Cancer Patients Reduces Resource Utilization and Medicare Costs. JAMA Oncology. 2017 Jan 26. PMID 28125760.
Cost by Navigation Status
$3,000
$4,500
$6,000
$7,500
$9,000
$10,500
$12,000
$13,500
$15,000
1 2 3 4 5 6 7 8
Tota
l cos
t to
Med
icar
e ($
)
Quarters after Enrollment
Matched comparison
Navigated
$781.29 reduction per quarter for navigated patients compared to non-navigated patients
Rocque GB, et al. Lay Navigation for Geriatric Cancer Patients Reduces Resource Utilization and Medicare Costs. JAMA Oncology. 2017 Jan 26. PMID 28125760.
~$19M across health system
NORC Independent Report
Erin Murphy Colligan, Erin Ewald, Sarah Ruiz, Michelle Spafford, Caitlin Cross-Barnet and Shriram ParashuramInnovative Oncology Care Models Improve End-Of-Life Quality, Reduce Utilization And SpendingHealth Affairs 36, no.3 (2017):433-440 doi: 10.1377/hlthaff.2016.1303
Advance Care Planning (ACP)The Institute of Medicine (IOM) recommends ACP
• Robust literature showing benefit• Implementation challenges:
• Time-consuming
• Lack of infrastructure at many institutions
Integration of lay navigator-led ACP aligned with our mission
Rocque GB, et al. Implementation and Impact of Patient Lay Navigator-led Advance Care Planning Conversations. Journal of Pain and Symptom Management. 2017 Jan 3. PMID: 28062341
Respecting Choices®
Nationally recognized ACP program• Training in communication techniques• Scripted facilitation of ACP• Evaluation tools to assess training
Respecting Choice® Training1. Online curriculum
• 6 hour-long modules on ACP facilitation
2. In-person Skills training• Role play and communication
Respecting Choices Facilitator
Certification
UAB-specific support
3. Practice with site manager• Role play until navigator/site manager is comfortable
4. Monthly Phone calls across sites• Address administrative/implementation issues
All trained navigators(n = 50)
Navigators interviewed(n = 26)
All patients (n = 8704)
Medicare Claims Data• ER visits, hospitalizations, ICU admissions at end of life• Chemotherapy within last 30 days of life• Hospice use
Electronic Medical Record Data• ACP conversations completed, in-process, declined, not
approached
Navigator Surveys• Navigator self-efficacy• Navigator perception of site culture
Navigator Interviews• Barriers and facilitators to ACP
Convergent, parallel mixed-methods studyJune 2014 to December 2015
Quantitative
Qualitative
Results: Patient characteristics
Navigator-Led ACP:• 8704 navigated patients• 1319 patients approached
• 36% completed
• 36% in process
• 28% declined
Demographics of PCCP navigated subjects (n=8704)Completed/In Process Refused Not Approached
n=953 % n=366 % n=7385 %Age* mean, SD 73.3 7.3 73.0 7.0 72.9 7.5Gender Female 480 51.7 205 56.5 3840 53.2Race Black 167 18.1 64 17.9 913 12.7
White 751 81.3 288 80.5 6166 85.8
Comorbidity score mean, SD 2.5 2.2 2.31 2.2 2.27 2.3
Score-category 0 186 20.2 81 22.6 1843 25.71 192 20.9 80 22.4 1601 22.3
2-3 285 30.9 106 29.6 1961 27.34+ 258 28.0 91 25.4 1769 24.7
Results: Resource utilization
At end-of-life, patients engaging in ACP had:• Lower healthcare
utilization • Trends toward lower
chemotherapy use• Similar rates of
hospice use
Completed/In Process Declined
n=437 % n=171 % P-value
ER visit within 14 days of death 146 33.4 72 42.1 0.04
ER visit within 30 days of death 199 45.5 91 53.2 0.09
ICU visit within 14 days of death 64 14.7 34 19.9 0.11
ICU visit within 30 days of death 77 17.6 41 24.0 0.07
Hospitalization within 14 days of death 159 36.4 75 43.9 0.09
Hospitalization within 30 days of death 200 45.8 96 56.1 0.02
Chemotherapy within 30 days of death 62 14.2 32 18.7 0.17
Hospice less than 3 daysa 20 6.6 11 9.1 0.37
Any Hospice useb 296 67.7 121 70.8 0.47
aProportion of subjects in last quarter of life that who had hospice and were enrolled for less than 3 days before deathbIn the quarter of death P-values are from χ2 test
Sustainability
Payment reform only viable option for sustainability• Medicare Oncology Care Model • VIVA Oncology Care Model Collaborator
Acknowledgements
• Ed Partridge, MD (Principal Investigator)• Gabrielle Rocque, MD• Maria Pisu, PhD• Elizabeth Kvale, MD• Wendy Demark-Wahnefried, PhD, RD • Karen Meneses, PhD, RN• Michelle Martin, PhD• Mona Fouad, MD, MPH• Bradford Jackson, PhD• Yufeng Li, PhD• Kelly Kenzik, PhD
• Terri Salter, RN, MSN, MBA• Richard Taylor, DPN,CRNP• Aras Acemgil, MBA• Nedra Lisovicz, PhD, MPH• Carol Chambless• Valeria Pacheco-Rubi• J Nick Dionne-Odom, RN, PhD• Courtney Williams, MPH• Karina Halilova, MD• Soumya Niranjan• Sylvia Huang
Special thank you to our patients, caregivers, navigators, and UAB Health System Cancer Community Network Partners
Patient Care Connect Team
Reflections from the field
Questions?