Patient navigators are trained to engage high-risk, high-cost patients by phone and in person at community cancer centers.
An innovative program at UAB Health System, Birmingham, Ala., that uses patient navigators to help older cancer patients navigate the system may provide a template for other cancer programs as they move toward value-based payment.
A study published in JAMA Oncology found that among patients who were assisted by patient navigators, total costs decreased by $781.29 more per quarter compared with those who did not have patient navigators. This translates to $19 million in annual savings from reduced hospitalizations, emergency department (ED) visits, and unnecessary services for Medicare patients.
See related web extra: Patient Navigator Role
Inside the Model
UAB has a two-decade history of using lay patient navigators who do not have nursing or social work backgrounds, says Edward Partridge, MD, director of the UAB Comprehensive Cancer Center.
UAB’s first navigator program, which was funded by the National Cancer Institute, equalized rates of breast and cervical cancer screenings between African-Americans and Caucasian community residents by eliminating a 17-percent difference between the two groups.
Key to the program’s success were 883 predominantly African-American women who promoted such screenings in primarily rural communities. UAB also trained a select group of women to serve as navigators for patients with abnormal tests. Later on, the health system trained women to discuss the pros and cons of clinical trials with eligible African-American patients. If patients were interested, the navigators would help them overcome barriers to participation, such as transportation or child care. In three years, UAB doubled its accrual of African-Americans in clinical trials, from 11 percent to 22 percent.
Four years ago, leaders at UAB wanted to take their approach a step further. “We already had experience with lay navigation across prevention, early detection, and early treatment,” Partridge says. “The next question was whether we could extend that to survivorship and end-of-life care.” To help answer that question, UAB launched the Patient Care Connect Program, supported by a $15 million grant from the Center for Medicare and Medicaid Innovation.
As part of the program, 42 lay navigators received 80 hours of onsite training. They learned to work with Medicare patients through the stages of their healthcare journeys. Lay navigators also had monthly continuing education calls on various topics, such as removing barriers, improving communication, and identifying resources.
The navigators used a distress thermometer, based on the patient assessment used by the National Comprehensive Cancer Network, to identify patients who were having a difficult time coping and might need assistance. They triaged Medicare patients with complex cancers of the brain, blood, head and neck, lung, ovarian, and pancreas. They also prioritized patients with two or more comorbidities.
The Results
UAB found that navigators reduced hospitalizations by 7.9 percent, intensive care unit (ICU) admissions by 10.6 percent, and ED visits by 6 percent.
As part of the project, UAB received historical Medicare claims data on deceased cancer patients, which showed high utilization in the 14 days prior to death. “We found 41 percent had been to the emergency department, 33 percent had been admitted to the hospital, and 13 percent were admitted to the ICU,” Partridge says. Such trips to the hospital not only created unnecessary utilization that could have been avoided with better planning, but they also disrupted patients and their families. To that end, navigators were trained in a program called Respecting Choices, an evidence-based model of advance care planning originally developed at Gundersen Health System in La Crosse, Wis. As a result, more patients with navigators utilized hospice services.
The results of UAB’s Patient Care Connect Program also were reported in a separate analysis by Centers for Medicare & Medicaid Services (CMS) researchers in Health Affairs. Their evaluation covered two other care models that received Health Care Innovation Awards: an oncology medical home and palliative care. The authors noted that “patient navigation in particular appears to be very effective in increasing hospice uptake and reducing utilization and costs in the last six months of life.”
Partridge believes patient navigators are an important part of the care model because they develop unique relationships with patients. Such relationships have a different dynamic than those patients maintain with nurses and physicians. “When patients see how busy the physicians and nurses are, they are less likely to call about something they think is relatively trivial,” Partridge says. “But patients have no hesitation whatsoever in calling their navigator, who has spent time building the relationship with the patient.”
Lessons Learned
Partridge and other experts provide several suggestions for organizations that wish to launch a patient navigation program.
Allow each center to recruit its navigators from the local community. UAB did not conduct networkwide recruitment but asked each of its 12 community cancer centers across five states to hire navigators based on a common job description. The centers selected individuals with college degrees but not nurses or social workers, who would command higher professional salaries.
Consider your organization’s culture, workforce model, and staff capacity. This is crucial when designing and adopting a new model of care, according to NORC’s second annual report on Health Care Innovation Award winners, which includes UAB. Although some changes will certainly be necessary, adapting a program to fit your organization will facilitate successful implementation.
At the same time, it is important that organizations not take on too much at once when implementing models of care. They should already have robust quality improvement programs and IT capabilities before tackling new models of care, including those that include patient navigators. In addition, all members of care teams should understand the roles navigators will play to increase team effectiveness.
Follow the Choosing Wisely recommendations developed by the American Society of Clinical Oncology (ASCO). “Every time we deviated from the Choosing Wisely recommendations, it cost $1,000 to $4,000 more per beneficiary,” Partridge says. Leaders at UAB shared Choosing Wisely metrics across the community cancer centers in their network to help improve compliance.
Planning for the Future
To sustain their success after the grant was completed, UAB transitioned to CMS’s Oncology Care Model (OCM) in July 2016. The model provides a $160 monthly payment for each Medicare patient receiving chemotherapy care. Navigators earn salaries of $40,000 to $50,000 to manage a caseload of approximately 150 patients (typically two-thirds in active treatment and one-third in survivorship or at the end of life) each quarter. Such a model allows a cancer center to hire navigators and still have some funding to support part of a professional salary or help fund an after-hours clinic that can improve quality and decrease unnecessary costs.
UAB also is negotiating with the dominant health plan in its market to engage in an alternative payment model for its members with cancer. That approach would follow ASCO’s oncology medical home program, which provides more funding up front than CMS’s OCM. Such up-front funding helps organizations hire additional staff and make workflow changes needed to support this new type of care model, Partridge says.
Partridge believes alternative payment models could help sustain patient navigation programs in the future. “I see this as the intermediary stage between fee-for-service and bundled payment,” he says.
He is encouraged by healthcare innovations, thanks to the availability of better data and new payment models. “I’m as excited as I have been in 45 years of practice,” Partridge says. “We may finally have a chance to get this right.” He says greater accountability will lead to improved clinical and financial outcomes. “If we are not providing quality and not utilizing resources wisely, we are going to be penalized. So, it is going to be incumbent upon physicians to make sure that each one of us is delivering value-based care. The incentives are finally aligned.”
Interviewed for this article:
Edward Partridge, MD, is director, UAB Comprehensive Cancer Center, Birmingham, Ala. For more information, contact Beena Thannickal, communications director, UAB.
