Abstract
58 Background: Despite evidence backing the use of navigation along the cancer care trajectory, existing programs struggle to deliver services efficiently and equitably. To bridge this gap, we developed and implemented a patient-centric, data-driven navigation program that leverages a risk-stratification approach to prioritize and address unmet needs. Methods: Our program was developed with key principles to address inefficiencies in existing navigation systems. First, we embedded the program within our institution’s Epic environment, using data-driven risk calculators, dashboards, flowsheets, and templates to support the navigation curriculum. Second, the program structure aligned with the patient’s journey from initial consult through treatment, focusing on early identification of unmet needs, centralized resourcing, and remote symptom monitoring for high-risk patients. Third, we unified the workflows of navigators, intake personnel, triage nurses, and providers, fostering system-wide collaboration. Results: The program has been successfully implemented in patients with new consults in gastrointestinal, breast, and hematologic oncology. To date, 2,080 patients have had an initial assessment leading to a Navigation Assessment Score (NAS) that predicts longitudinal burden of unmet needs and directs subsequent resourcing. 226 referrals have been generated to: cancer rehabilitation (76), nutrition (60), psychosocial oncology (48), tobacco cessation (39), and palliative care (3). Remote symptom monitoring was piloted in 34 gastrointestinal oncology patients meeting the calculated highest decile risk for unplanned acute care event use. Proportions of patients with a NAS score (N=2,080): 69.3% White, 17.7% Black, 3% Latinx, 1.8% Asian, 0.9% American Indian; referrals (N=226): 61.2% White, 23.0% Black, 4.9% Latinx, 1.1% Asian, 0.5% American Indian; remote symptom monitoring (N=34): 79.4% White, 11.8% Black, 5.9% American Indian. Except for Latinx patients, these distributions align with the patient population in gastrointestinal, breast, and hematologic oncology (N=4,267; 68.0% White, 22.5% Black, 6.4% Latinx, 1.9% Asian, 0.9% American Indian). Conclusions: Development and implementation of our program is feasible, and the approach has potential to mitigate disparities in cancer service delivery and outcomes. Ongoing efforts include exploring accessibility among Latinx patients and developing the business case for sustainability and scaling.
Published Version
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