Rounds Preview: Models for Cancer Care Success

This article appears in the October 2012 issue of HealthLeaders magazine.

Editor's note: This piece is an excerpt from a full case study that is available as part of an upcoming Rounds Event, Cancer Service Line Leadership: Baylor Health Care System.

Cynthia Robinson-Hawkins, RN, remembers when she got her cancer diagnosis 23 years ago. She was a labor and delivery nurse at the time and even with her clinical training, was just as unprepared as any patient. "I didn't know anything about cancer and all of sudden you hear ‘The Big C.' You have cancer," she says. "I didn't know where to go, what was going to happen, or who was going to do what. I didn't know anything."

That experience is not unusual even today in cancer treatment, which can be a disconnected, confusing chain of appointments, tests, and results that can quickly overwhelm a cancer patient. Now in her role as manager of the patient navigation program at the Baylor Charles A. Sammons Cancer Center at Dallas, Robinson-Hawkins wants patients to be focused only on beating cancer, not on fighting through the treatment itself.

"I tell patients that they should not be worried about who, what, when, where, and how," she says. "They should be focusing on their cancer and getting well because we all know that the stress of cancer or the stress of trying to figure out where to go and what to do is not helping you overcome your disease."

Baylor Health has invested more than $275 million in improving cancer facilities in the past year with the opening of the outpatient Baylor Charles A. Sammons Cancer Center at Dallas in late 2011 and the inpatient Baylor Cancer Hospital in February 2012. Combined into a single campus, the two facilities are meant to position Baylor's cancer services as a destination center for those in North Texas and elsewhere. John McWhorter, president of Baylor University Medical Center at Dallas, says for that goal to be reached, service and coordination have to be at the forefront.

"Embarrassingly enough, hospitals generally don't do a good job of helping the patient and family navigate through all these options," McWhorter says. "I think that's why our patient navigation office has been such a hit."

The six full-time cancer navigators have several roles. The first, as a facilitator, is to help patients manage appointments or referrals so that, for example, they can see a team of specialists in a single day rather than spread out over a week or two. For instance, a patient with a renal mass might need to see as many as four specialists: a urologist, a surgeon, a medical oncologist, and a radiation oncologist, Robinson-Hawkins says.

"Why can't we get those initial appointments scheduled all on the same day?" Robinson-Hawkins says. "That patient makes one trip down here. He may see the urologist at 8:00. He will see the oncologist at 11:00, and he will see the radiation doctor at 2:00. A patient's time is not wasted. Gas is not wasted. We're coordinating the care of the patient to make sure we're all on the same wavelength. And then the navigators will get everything that that physician needs to make an informed medical decision—from medical records to CT scans to x-rays to a patient's pathology slides."

Facilitation comes with familiarity, which is why the staff navigators are divided into focus areas: one handles breast cancer; another lung, head, and neck; a third takes on skin cancer; and Robinson-Hawkins handles the rest.

"We broke them up by disease and disease processes because I want each navigator to become close with that physician and close with that physician's team," Robinson-Hawkins says. That closeness had an unintended consequence: Some of the physician office nursing staff thought the navigators were there to take over their responsibilities. Once the navigators were able to demonstrate that their role was coordinating care, not providing it, the office nursing staff saw the value, she says.

An equally important role for the navigator is as an educator. After the initial diagnosis or referral, the navigator will work with the patient to research the condition and suggest where to find trusted sources for reference and education about what to expect in treatment, Robinson-Hawkins says.

"We are there to educate the patient to make sure they're making the right decision for them and their family," she says. "Every patient is different. Nobody is the same. You know, when you have cancer people like to tell you their aunt had the same kind of cancer and they did this or that. What worked for their aunt may not work for them. So if you educate the patient on the disease, the treatment, and what can and what is going to happen, they have a better outcome."

Cancer's nature as a life-threatening disease means that compassion has to ride along with navigation. Robinson-Hawkins stresses that the navigators are not counselors, but they are there to recognize the signs that a patient may have a social or behavioral issue that could affect his or her outcome, and to connect that patient with a broader support team of social workers, chaplains, and psychologists. Robinson-Hawkins recalls a cancer patient who was about to be discharged, but started talking about suicide. With the intervention of a social worker, it was clear that the patient was not suicidal, but alone.

"The social worker figured out there's nobody there to help him along," she says. "So then we have all of these community resources that you can utilize. And you've just got to keep a closer eye on him because he is by himself." Another patient who had head and neck cancer was not responding well to treatment at another hospital and had become withered and lost his voice. One of the navigators was able to find a physician with a new course of treatment, and the therapists and nutritional counselors to help him recover, Robinson-Hawkins says. Navigators at their best can intervene to put patients in the right place, but the rest is up to the patient.

"It's very important for patients to understand that if they're not participatory in their care, it's not going to work," Robinson-Hawkins says. "We do all we can to make sure that they're involved. But while we can tell patients all day what to do, they've got to be willing to participate and be involved in it."

Too often the missing piece in service is hardest to measure: compassion. "There is no question that we don't get to have a bad day," McWhorter says. "Our staff cannot have a bad day, because these patients just received news that is the worst news they've ever received. So, no question, service has to be at the forefront of everything we do."

Reprint HLR1012-10

This article appears in the October 2012 issue of HealthLeaders magazine.