XYZ Cancer Program Community Assessment
(Standard 3.1: Patient Navigation)
Assessment- Identification of community
- Breast cancer patients within institution’s the primary and secondary service areas
- Description of the community: characteristics associated with challenges +/or barriers to care
- 2nd highest volume of cancer cases for the institution
- Primary and secondary service area include large proportion of women who have >1 of the following variables
- 40% African American
- 18% Hispanic
- 5% Asian
- 18-24 years old7%
- 25-34 years old8%
- 35-44 years old20%
- 45-54 years old16%
- 55-64 years old32%
- 65-74 years old15%
- 75 years or older13%
- 48% under insured (includes Medicaid population)
- 19% uninsured
- 28% unemployment
- 9% social security disability
- 7% workmen’s compensation
- 4%
(2012 US general population value in comparison 19.7%)
Risk factors associated with chronic disease and/or poor health outcomes: tobacco use (28%), obesity (34%), difficulty with physical activity (18.2%), history of hypertension (27%), diabetes (14%) asthma (14%), regular alcohol use (56%)
- All percentages above exceed national averages
- Identified gaps in service, barriers, challenges or disparities
- Transportation
- Financial issues: Ability to pay for insurance co-pays for physician visits and medications, cost of medications, lack of benefits
- Competing priorities: child care, elder care, job responsibilities,
- Difficulty scheduling doctor’s appointments or coordinating multiple appointments
- Adherence to treatment regimens
- Frequent missed appointments
- Lack of knowledge regarding preventive care practices (ie: screenings)
- Lack of single point of contact for medical care information
- Access to computer or internet
- Smoking cessation
- Community needs to address gaps in service, barriers, challenges or disparities
- Assistance with access and applications for local, state +/or federal sponsored support for health care, insurance, utilities, food stamps, shelter, transportation, child care, vocational training and other social support services
- Financial counseling and applications for patient assistance programs
- Access to free or low cost breast cancer education and screening programs
- Assistance with health care follow up for abnormal breast exam and/or screening mammogram: coordinated appointment scheduling for diagnostic and staging evaluation, treatment, follow up care
- Education regarding health practices and care associated with breast cancer diagnosis
- Assistance with adherence to cancer treatment and follow up care
- Community assessment methods, sources of information
- Cancer registry
- Focus groups with
Volunteer community representatives
Personnel from offices of breast surgery, medical oncology, radiation therapy and mammography
Infusion room nurses
- Literature references:
Nguyen, T and Kagawa-Singer, M (2008). OvercomingBarriers toCancer CareThrough HealthNavigationPrograms. Seminars in Oncology Nursing, 24, (4), 270-278.
Paskett, E, Harrop, J P, and Wells, K J (2011). Patient Navigation: An Update on the Stateof the Science. Ca Cancer J Clin, ;61(4), 237–249.
Philadelphia Department of Public Health (2010). Chronic Diseases by Planning District (2010). Retrieved 3/2/13 from
Philadelphia Department of Public Health (2010). Health Center Service Area Report (2009). Retrieved 3/2/13 from
Pleis JR, Lucas JW, Ward BW (2009). Summary health statistics for U.S. adults: National Health Interview Survey, 2008. National Center for Health Statistics. Vital Health Stat 10(242). Retrieved 5/28/14 from
Description of Navigation Process
- Personnel
- Qualifications
- Staffing
- Oversight
- Registered Nurse, experience with breast health care + navigation
- 1 FTE
- Reports to Cancer Program Administrator
- Point of entry or identification of patients
- Mammography technician to notify navigator of all abnormal findings
- MD referral
- Self referral-website based
- Services to be provided and length of service (ie: throughout cancer continuum; until initiation of first course of treatment; until treatment completion; etc.)
- Nursing assessment of physical, psychosocial and educational needs; distress screening
- Education concerning breast cancer diagnostic evaluation and treatment as well as reconstructive surgery options
- Introduction of potential for clinical trial participation
- Facilitated appointment scheduling for diagnostic evaluation, treatment planning and initiation of treatment
- Referrals as needed: social work, psychology, support group, financial counseling, nutrition, palliative care, home care, physical/occupational lymphedema therapy; referrals to community support programs through ACS and PA breast cancer coalition, Wellness community; prosthetics and wigs
- Assistance with access to smoking cessation programs as needed
- Interpreter services as needed
- Materials to be provided to patients, caregivers
- Assist pts with establishing access and using institution patient portal
- Patient packet that includes printed materials for education, community resources, provider contact information
- Methods of documentation and communication with health care team
- Documentation in medical record (EMR): assessment findings; identification of patient needs; interventions including referrals; for communication with other health care providers; outcomes of navigation services
- Communication with patients: in person and options for phone or email as per patient preferences
- Participate in multidisciplinary breast cancer conference (breast tumor board)
- Participate in Cancer Committee and Breast Program Leadership Committee
- Communicate with clinical research nurse regarding potential candidates for clinical trial participation
- Information collection and tracking methods
- Excel-based spread sheet
- Navigation evaluation: Outcome metrics
- Pt demographics
- Number of referrals to navigator and referral sources
- Outmigration including location and time point in continuum of care
- Time from referral to initial patient contact with navigator
- Time from abnormal finding to initial patient contact with navigator
- Time from abnormal finding to 1st surgical appointment
- Time from abnormal mammogram to biopsy
- Time from biopsy to surgical intervention
- Types of diagnostic procedures in addition to mammogram
- Histology, stage, molecular biomarkers, location of disease
- Documentation of patient being advised regarding type of surgical intervention
- Surgical intervention and outcomes
- Documentation of patient being advised regarding SLN vs axillary dissection if appropriate
- Documentation of patient being advised to obtain medical and/or radiation oncology consultation if appropriate
- Referrals to plastic surgery; patient decision regarding reconstruction
- Medical oncology treatment (if warranted)
- Radiation oncology treatment (if warranted)
- Clinical trial participation
- Patient satisfaction scores
- Types of referrals for support services and outcomes
- Metric reporting
- Cancer Program Administrator
- Cancer Committee
- Breast Program Leadership Committee
Year 2 and 3 Evaluation of Navigation Process and Community Assessment
(Must be documented in the Cancer Committee minutes at least once per year)
1.Are there any changes in the identified population?
- Data to support or describe the changes (if any)
2.Have there been any changes in the previously identified gaps in service, barriers, challenges or factors contributing to disparities?
- Describe changes and identify source of information
3.Have there been changes in the previously identified needs?
- Describe changes and identify source of information
4.Will any of the above changes necessitate amendment of the navigation process and if so describe
5.Will the evaluation process/outcome metrics require alterations; if so describe.
6.What modifications or quality improvements should be made to the navigation process?
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