A Guide to Implementing Best Practices in Person ... - cancerview.ca

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Navigation: A Guide to Implementing Person-Centred Care September 2012CoordinationBrokeringAdvocacyDocumentationSystem-level changeLeadership/Team buildingDesigns care plan within scope of discipline, participatesin interdisciplinary care plan, coordinates care acrosssettings, sets up appointments, explains upcoming appointments/procedures,helps to integrate services; iscentral point of contact and communication with allhealth care team members and service providersthroughout the continuum of care; is a direct link totumour board networks; has access to and can sharemedical records; monitors and evaluates plan of careActively negotiates for service delivery to clients withthe range of professionals and administratorsAdvocates directly for patient with care providers andservices, intervenes regarding problems or barriers,advocates for system changes when gaps andinefficiencies are identifiedMaintains detailed clinical records, integrates withmedical file, monitors care according to professionaland institutional standardsMay identify system barriers (gaps in services, problemswith procedures or policies) in the course of daily interactionswith patients, and intervene to address/improvethem in consultation with interprofessional team and/oradministration; may perform patient advocacy and coordinationacross services and professionals, improvingcare systemsProvides leadership and influences clinical standardsetting,policy development and change management;promotes and facilitates an interdisciplinary team approachto delivery of care and decision-making; providesleadership in the coordination and implementation ofquality improvement activities; facilitates the developmentand implementation of care pathwaysLinks patient to community resources; encourageshelp-seeking from professionals; may facilitatereferrals to health care professionals as neededand within scope of roleEncourages self-advocacy, empowerment ofpersonRecords patient information in some cases,according to defined scope of role and agencyexpectationsMay identify gaps in services, problems withprocedures or policies in the course of daily interactionswith patients, and communicate concernsto appropriate person in the organizationMay act as representative on a team, helping tocreate programs to address identified gaps; offerspeer/lay-based leadership and support to othervolunteers or participates in mentoring62
Navigation: A Guide to Implementing Person-Centred Care September 2012Skills and trainingExpected Outcomes• Health professional – often a nurse or a social worker• Extensive clinical knowledge of oncology and/or subspecialtyin specific cancer site• Specialized training in navigation process and bestpractices• Ability to network and coordinate care among allresources, services and professionals• Interpersonal communication and listening skills• Empathy and sensitivity• Knowledge of psychosocial issues, specific needs,possible barriers to care for diverse populations(e.g., cultural, racial, sexual, religious)• Expert in family dynamics• Conflict resolution skills• Awareness of provincial and community canceragencies, services and resources• Ability to work autonomously• Training in telepractice• The cancer experience is improved for the person andfamily; all are:– well informed– prepared with a tailored care plan, with navigatoras focal point of contact– supported and guided– empowered to make treatment-related decisions– better equipped to manage anxiety and distress• Barriers to care are identified and addressed; gapsacross care path are improved• Disparities are reduced for marginalized groups• Transition points are well managed• Care is timely• Care is appropriate to identified needs (medical,nursing, psychosocial, supportive and palliative)• Service provision is continuous and coordinated• Care team communicates and collaborates well• Service duplication is reduced• Identification of system-related problems is improved• Knowledge of volunteer role and boundaries• Training in navigation process and bestpractices at peer/lay level• Interpersonal communication and listening skills• Empathy and sensitivity• Ability to maintain client confidentiality andprivacy• Knowledge of conflict resolution and incidentreporting process• Awareness of limits to knowledge-sharing andwhen to refer• Knowledge of psychosocial issues, needs,possible barriers to care for diverse populations(e.g., cultural, racial, sexual, religious)• Awareness of provincial and community canceragencies, services and resources• Professional language translation skills in somecases; ability to access translation services• The person and family are:– better informed– supported and guided– empowered to make decisions aboutnon-medical issues– better able to manage anxiety and distress– empowered to communicate better withhealth care providers, family and others• Barriers are identified and addressed, withinscope of program• Disparities are reduced for marginalized groups• Services are more accessible and bettercoordinated, within scope of program63
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A Guide to Implementing Best Practices in Person ... - cancerview.ca

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