By Lisa Kennedy Sheldon, PhD, APRN, AOCNP®, FAAN

Well-coordinated care by knowledgeable healthcare providers improves patient-centered care, supports shared decision making, reduces fragmentation of care, and decreases readmissions and emergency room visits. However, patients with complex care needs are often lost in the very systems designed to support them.

What Is Care Coordination?

The four key concepts of care coordination are accountability, patient support, relationships and agreements, and connectivity.

Effective care coordination requires communication throughout the continuum of care to improve the quality and affordability of care and, ultimately, patient outcomes. In July 2017, the National Quality Forum endorsed seven measures to capture care coordination, including advanced care planning, medication reconciliation, and transmission of transition records.

Cancer care coordination broadly addresses process issues relevant to streamlined and appropriate navigation of the care system. Many clinicians are involved from the screening process to the diagnosis of cancer and delivery of treatments, and into survivorship, palliative care, and end-of-life care. Beginning in 2015, the American College of Surgeon Commission on Cancer included the patient navigation process (standard 3.1) as a component of its credentialing system of cancer centers.

Improving Coordination Through Navigation

One role that has evolved to improve cancer care coordination is the oncology nurse navigator. ONS is currently revising the 2013 ONN Competencies to reflect the evolving role of ONNs in cancer care in helping patients and families overcome barriers in the healthcare system. This includes providing patient and family education, assessing psychosocial and financial needs, providing appropriate referrals, measuring patient outcomes (e.g., decreased time to initiation of treatment), decreasing outmigration to other providers, and increasing patient, family, and clinician satisfaction.

Transitioning care: ONNs ensure safe transitions of care by communicating with patients, family members, and other care clinicians across care settings and empowering patients to advocate for themselves. They teach patients about genomic testing and precision oncology care during the diagnostic phase. ONNs are often following patients on oral oncolytics at home.

Survivorship: Another transitional point in cancer care is after treatment is completed and during survivorship. ONNs may create treatment summaries and survivorship care plans and communicate with primary care providers regarding long-term treatment effects and surveillance guidelines during survivorship, especially for pediatric cancer survivors.

Comorbidities: As patients with multiple comorbidities move between care settings, they are at risk for adverse events from poor communication such as incomplete transfer of information, medication errors, or lack of follow-up care. ONNs are the link for their patients back to their primary providers to make sure that care is coordinated and symptoms managed appropriately to reduce preventable hospital admissions and readmissions. ONNs are often involved in obtaining advanced care directives.

ONNs need be involved at the policy level to influence cancer care outcomes, advocating for their role in the system including reimbursement for services. They can teach patients and survivors as well as communities about cancer prevention and risk reduction from preventable causes of cancer (e.g., tobacco). ONNs can assess and refer patients and families for genetic counseling. They should be resources to non-oncology providers about cancer treatments and navigating the oncology care system. Most importantly, ONNs need to advocate for affordable, equitable, accessible cancer care and innovative provider payment models to help improve the overall health of the population.