For the nurse navigators at UNC Lineberger’s PFRC to shift navigation services to the virtual setting, they needed to create a standardized method by which patients could be referred to see a volunteer or nurse navigator virtually. Implementing a standardized virtual referral-based system instead of ad-hoc in-person assessments had the added benefit of allowing patients to decide on the most convenient time to speak with a navigator, increasing the likelihood that patients would be engaged during the conversation. It also served as an opportunity to improve the provider referral pathway, as cancer care team members had historically been inconsistent about referring patients to PFRC navigators.

First, the PFRC nurse navigators analyzed over 100 interviews they had conducted with patients and families before the pandemic and reviewed literature to identify the factors most associated with high barriers to care. Then, they used their findings to develop guidelines on which patients would benefit most from navigation and educated the hospital clinicians and staff on referring eligible patients.

Under the new guidelines, clinicians and staff are encouraged to refer patients to navigation if they have at least one of the following risk factors (though all referrals are accepted):

• Are sixty-five years or older
• Live alone
• Live over one hour from the cancer center
• Need complex care (based on treatment modality, disease stage, and comorbidities)
• Have a malignant hematological diagnosis
• Started a new treatment within the previous 30 days
• Were newly discharged within the previous 14 days
• Require interpreter services (non-English speaker)

To virtualize the referral process, the nurse navigators set up a system where patient referrals are submitted through EHR in-basket messages that are routed to an EHR in-basket pool created specifically for the PFRC navigation program. Referrals can be sent by hospital clinicians, staff, and tumor site-specific clinical nurse navigators or by the PFRC nurse navigators themselves, who review the daily records for scheduled treatments to identify eligible patients.

The PFRC nurse navigators assess the complexity of all referred patients and complete referral forms within the EHR to assign patients to PFRC navigation team members accordingly. The PFRC nurse navigators work with complex patients that may require more advanced education services, while the volunteer patient navigators are responsible for helping address barriers, such as transportation needs and food insecurity. The PFRC also employs a Spanish Liaison who works with all Spanish-speaking patients referred to the PFRC navigation program. In anticipation that Spanish-speaking patients would benefit from additional education and support services during the pandemic, the PFRC nurse navigators recruited three bilingual navigators to support the work of the onsite PFRC Spanish Liaison and conduct proactive outreach to Spanish-speaking patients who have scheduled in-person or virtual appointments.

Concurrently, the oncologists at UNC Lineberger were developing a separate risk stratification algorithm to aid in referrals for navigation at the same time as the PFRC nurse navigators were redesigning their operations. The physician work group automated an algorithm, adapted from the PROACCT score created by researchers in Ontario, which generates a score that is predictive of early acute care use based on a patient’s age, treatment regimen, and whether they have had a recent hospital discharge. They first piloted the algorithm among UNC Lineberger’s hematology patients and published the results in Supportive Care in Cancer. As of August 2020, the algorithm has been adapted for use among the cancer program’s gastrointestinal, thoracic, and malignant hematology patients and incorporated into the PFRC’s standardized referral system, which is used for all other patients. The PFRC nurse navigators triage patients with eligible cancer types to the navigation program based on their risk scores; tumor site-specific clinical nurse navigators call patients with risk scores of 8 or greater, while PFRC nurse or volunteer navigators call patients with scores between 4 and 7. Patients with scores below 4 are not currently referred to any navigator. This streamlined referral process ensures that the appropriate navigators reach the patients most at risk for needing acute care in an organized fashion.

As part of the transition to a virtual navigation program, the PFRC standardized its patient interactions to ensure that all PFRC navigators not only feel comfortable engaging with patients by video and phone but are also delivering consistent support to patients. To do so, the PFRC nurse navigators created a script for themselves and the volunteer navigators to use when performing virtual barrier assessments or education activities (see the Supporting artifacts section in the PDF for the full script).

The script includes instructions on introducing themselves, providing Covid-19 education, and conducting a 15-minute assessment that identifies financial, logistical, medical, emotional, and social barriers to care. It also has guidelines for leaving messages and scripting for unexpected situations, such as if a patient is in extreme distress, has a major complaint, or is sexually explicit. The script was vetted by leaders from UNC Lineberger’s Comprehensive Cancer Support Program, the hospital’s Volunteer Services, and other hospital divisions, as well as members of the cancer center’s Patient and Family Advisory Council. A Spanish version of the script was culturally and linguistically tailored for the Spanish Liaisons to use with their patients.

The script also standardizes the intervention process. It outlines which interventions PFRC navigators should use to address specific unmet patient needs identified in the barrier assessment. These are the same interventions they would have used during in-person navigation. Potential interventions include education (e.g., instructions on using MyChart), referrals to internal resources (e.g., social workers and dieticians), and referrals to vetted external resources (e.g., transportation funding and food resources). While the PFRC nurse and volunteer navigators use the same script, the PFRC nurse navigators also provide more in-depth disease education and symptom management support to patients with complex needs.

In addition to standardizing the barrier assessment and intervention processes, the PFRC nurse navigators designed a standardized follow-up process. They created a digital report form that all PFRC navigators are responsible for filling out after each patient interaction, which includes detailed patient information, the results of the barrier assessment, and any interventions provided or referrals made (see the Supporting artifacts section in the PDF for the report form). After the PFRC navigators complete the report, they file it at the PFRC and upload a summary into the EHR so the whole care team can see it. The PFRC navigators also alert the clinical care team about any urgent needs by calling them directly or sending an in-basket message, depending on urgency. When necessary, they schedule follow-up visits with patients to ensure all interventions are completed.

Before they could begin providing navigation services virtually, the PFRC nurse navigators trained the volunteer navigators and Spanish Liaisons to implement the new standardized virtual navigation process. The volunteer navigators and Spanish Liaisons participated in weekly group meetings for two months to help them prepare for the change. In the meetings, they were taught to conduct virtual visits through the Doximity app, a networking platform for medical professionals that offers telehealth capabilities, and were given UNC domain accounts so they could access limited patient information securely from their homes. The PFRC nurse navigators also trained the volunteer navigators and Spanish Liaisons on using the script they had created and on properly documenting calls.

As the volunteer navigators and Spanish Liaisons became more comfortable with the new processes, the group meetings were shifted to a monthly basis, though they still receive informational newsletters weekly. In addition to the group meetings, the Spanish Liaisons participated in meetings with stakeholders, including a Latinx physician, a social worker, and a representative from Volunteer Services, to help the Spanish Liaisons understand the unique cultural and linguistic needs of the patients they would be serving.