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

Navigation: A Guide to Implementing Person-Centred Care September 2012Appendix H: Professional Navigation Conceptual FrameworkReprinted from Guide to Navigation, Cancer Journey Action Group (2010)Dimension Concepts Process/Functions OutcomesInformation continuity • Having access to, and understand, high level of informationUse of information, diseaseon the cancer patients and their careor person focused, to • Providing timely and tailored information and advicemake current care appropriateto the interdisciplinary team and cancer patientsfor each individual. (patient centered information)Information is relevant to • Working closely with the interdisciplinary team tolink care from one providerimprove continuity of the information and knowledgeto another and from of family/patients’ needs and changesone healthcare event to • Using communication tools and strategies to increaseanother.continuity of information(Haggerty et al., 2003)FACILITATINGContinuity of care(experience of care as coherent and connected)(Organizational functions of the role)(Dimension health-system-oriented)Management continuityA consistent and coherentapproach to the managementof cancer that isresponsive to a patient’schanging needs. Providinga sense of predictabilityand security in futurecare for both patients andproviders.(Haggerty et al., 2003)Relational continuityOngoing therapeutic relationshipbetween a patientand one provider.Bridges past to currentcare. Provides a link tofuture care.(Haggerty et al., 2003)• Conducting comprehensive screening and needs assessment(initial and ongoing)• Matching unmet needs with services, resources availableand support systems within the cancer care organizationand the community• Identifying lack of resources, finding temporary solutionsand reporting the system gaps• Mapping continuum of care; explaining care plan;minimizing uncertainty (patient orientation); decreasingbarriers to cancer care adherence• Referring and communicating with hospital andcommunity teams• Doing prompt liaison• Facilitating coordination and organization of medical/psychosocialcare (using care pathways)• Contributing to the elaboration and application ofthe interdisciplinary care plan• Facilitating interprofessional collaboration (hospitaland community settings)• Maintaining an ongoing relationship• Being easily accessible through the cancer continuum• Mapping on the cancer trajectory how the professionalnavigator is involved and until when• Being part of an oncology team• Being trusted by health providers and team members• Effectiveness in which coherent information is transferredand understood (information on medical condition, patient’spreferences, values, and context):– among providers (e.g., SECON)– between institution (discharge plans, transfer of dischargeinformation, referral data inventory)– between primary and specialty care (referral documents)(e.g., PCAT)– from patient perception(e.g., PCCQ; Experienced continuity) Accumulated knowledge: patients can be asked if they knowtheir providers at earlier steps of the care trajectory; howwell they know their providers, or providers can be askedhow well they know their patient Satisfaction about information exchange in the team(e.g., EORTC-SAT32)• Coherent and timely coordination of services (shared careplan+ facilitate access to a broad range of services) Longitudinal follow-up- completion rates of recommendedtreatment for cancer specific diseases or for "gaps" in carefor chronic diseases (especially in transition) Perception of continuity of care (e.g., PCCQ; Experiencecontinuity)• Participation of patient in care (flexibility in adapting careto individual’s needs and circumstances) Consistency in care: adherence to cancer care. Applied fromprimary care, a measure of compliance in preventive carefor cancer survivors Satisfaction with coordination of care (EORTC-SAT32) Delays/waiting time Symptoms relapse; worsening conditions Hospitalizations; emergency visits• Effective professional navigator / patient communication(bridges not only past to current care ; a link to future care) Extent to which the same provider sees the patient in differentsettings Strength of patient-provider affiliation (e.g., PCAT; satisfactionwith providers)81