Patient Navigator-RN - Main Chemotherapy - Part Time - Days

Patient Navigation refers to individualized assistance offered to patients, their families, and caregivers to help overcome health care system barriers and facilitate timely access to quality medical and psychosocial care from diagnosis through all phases of the disease experience.  

The primary goals of the Patient Navigator role are to:  (1)   improve patient outcomes;   (2)  support, educate, guide and empower the patient / family; (3)  bridge gaps in communication and promote timely transition between service providers along the healthcare continuum;  (4)  provide seamless and efficient patient care;  (5)  remove barriers to care and minimize fragmentation of care for the patient / family;   and (6) provide a consistent contact person and advocate for the patient / family, in order to improve the patient / family experience and satisfaction.

Assessment 

Reviews baseline data related to patient:  medical, psychosocial, spiritual, financial, and other patient needs.  (This includes review of pathology and test results.)

Assesses educational needs of patient/ family related to disease, treatment, side effect management, resources, etc.

Conducts ongoing assessments of patient / family at specific identified time periods (e.g., diagnosis, beginning and end of treatment, recurrence, etc.)

Assesses barriers to care for the patient / family, including health disparities,  cognitive, psychosocial, financial, transportation, childcare, etc.

Assesses community resources that are appropriate for the patient / family.  

 

Diagnosis and Planning –

Collaborates with multidisciplinary team to create and/or update patient’s plan of care, which is feasible and understandable to the patient / family.

Assists the patient and family in the treatment planning process:      

(1) provides education on resources available to support the patient/family during and after treatment                                   

(2)  helps the patient identify and implement short and long term goals.

Communicates the plan of care with the multidisciplinary team.  

 

Implementation / Coordination of Care –

Provides Services:

-  Provides services for a select patient case load. 

-  Serves as a clinical resource for patients / families at specific points of access (e.g., Imaging, clinics, hospital, palliative care, etc.) 

-  Maintains communication with patient / family members at defined timeframes in patient’s disease trajectory (e.g., screening, diagnosis, treatment, survivorship / palliative care). 

-  Serves as a liaison with the multidisciplinary team members and various departments / specialties (both inside and outside of TCH) in order to integrate pertinent patient information for the seamless continuum of care.

-  Collaborates with the health care team to communicate with the patient and family regarding referral, treatment, symptom management and follow-up (survivorship or palliative care).

-  Uses technologies (e.g., EMR,  My Chart, etc.)  to enhance communication among patients and health care providers.

-  Serves as a professional resource to the team members in the Service Line regarding current trends in care, disease management, side effect management, and community resources. 

-  Participates regularly in onsite multidisciplinary patient conferences, consultations,   and/or committee meetings (e.g., Tumor Board, etc.)

-  Promotes evidenced based practice related to area of specialization and applies findings to policies and procedures.

-  Plans, implements, and evaluates educational and/or supportive programs for patients / families, staff, and the community on appropriate topics. 

-  Participates in Community Activities, such as providing education at Health Fairs, church groups, etc. 

Remove Barriers:

-  Assists patients to overcome barriers to care:  financial, transportation, childcare

-  Refers patients to supportive services, including financial counselors, dietitians,  social workers, and community agencies

-  Reaches out to underserved or rural populations.    

 

Evaluation / Outcomes related to Quality Measurements   

Identify outcomes related to quality measurements for the Patient Navigation program, such as patient / family/ physician satisfaction, accurac