Negotiating Lay and Clinical Issues: Implementing a Lay Navigation Program in Cancer Care

PURPOSE: Patients with cancer face daunting coordination problems at a vulnerable time. Lay navigation programs offer 1 approach to address these problems, but how to best implement these programs presents challenges. We sought to describe those implementation challenges at 1 academic cancer center to inform future efforts. METHODS: We performed a mixed methods study using standard implementation outcomes 1 year after program initiation. Quantitative data from the electronic medical record and qualitative data from in-depth interviews, focus groups, and ethnographic observations were included in analyses. The study took place at a National Cancer Institute–designated comprehensive cancer center across 12 tumor-specific clinics. RESULTS: Supportive care concerns, scheduling, and clinical-related issues were the most frequent issues navigators encountered. Effective navigation required continuous, time-consuming, invisible work, including building and maintaining a broad knowledge base of resources and health system processes, as well as cultivating relationships with diverse and changing clinical teams. The acceptability and appropriateness of lay navigator activities were mixed among clinic and social work staff, related to negotiating lines between clinical and nonclinical care. CONCLUSION: After 1 year of implementation, lay navigators still found it difficult to interpret and prioritize complex patient needs in a way that all clinical staff found appropriate. Negotiating these issues has made it difficult to develop the strong relationships with clinical teams that are needed for an integrated approach to patient care. To successfully coordinate patient care, it seems that lay navigation programs should be integrated with clinical teams to provide more seamless patient care.

IMPROVING SUPPORT FOR CAREGIVERS OF SERIOUSLY ILL OLDER VETERANS: STEPS TOWARD LAY NAVIGATION

This session will discuss mid-stage findings from a five-year, federally-funded study to develop lay navigation supporting informal caregivers, often family/friends, of older Veterans with advanced stage illness. Caregivers of Veterans report numerous burdens in their caregiver role related to food, clothing, shelter, utilities, and transportation. Current programs focus on Veterans’ needs rather than caregivers’ needs. Few programs focus on practical needs that can be met with VA and community-based supports. Lay navigator programs may be used to support caregivers’ social/practical needs. Lay navigation is used with patient populations, but models focused on caregivers do not readily exist. Dr. Boucher will discuss establishment of and input from the study’s Stakeholder Advisory Board and data from sample of caregiver and Veteran interviews informing a lay navigation training curriculum and pilot intervention. Feedback from audience members will be encouraged in this session exploring quality improvements in caregiver support applicable to multiple health systems.

Who are the cancer patients most likely to utilize lay navigation services and what types of issues do they ask for help?

229 Background: In 2017, the Stanford Cancer Institute implemented a lay patient navigation program directed towards patients receiving at least two treatment modalities with the thought that these patients likely need more support than those with single treatment modality. We would like to target future services, prospectively, to patients that need them most. The aim of this paper is to understand the characteristics and concerns of the highest users of the lay navigation services. Methods: Patients were included if they had been assigned a care navigator between February 2017 through November 2017 and had at least four months of potential follow-up with their navigator. High contact patients were defined as those with the total number of contacts in the top 10% and/or the duration of contact in the top 25%. Demographic and clinical characteristics of patients were obtained from the electronic medical record. Data that captured patient-navigator interactions were abstracted from a templated note in the electronic medical record. Descriptive statistics were calculated to describe demographic and clinical characteristics of patients and the concerns raised to navigators. Results: There were 436 patients who met the inclusion criteria, 115 (26%) of whom were classified as high contact. High contact patients were more likely to be younger (under 60 years), non-white, have private insurance and live more than 20 miles from the cancer center than medium/low contact patients. They were also more likely to have multiple non-life threatening comorbidities such as diabetes without complications. The high contact patients accounted for 44% of all navigator contacts and 75% of all contacts in which a patient expressed any concern. 55% of high contact patient concerns were clinical in nature, 19% related to scheduling issues; 14% social/mental health issues; and 12% were non-clinical. Conclusions: The patients that are in the top 25% of utilization of lay navigators are a complex mix of patients and account for roughly 75% of the concerns of the broader patient population.