Oncology Nurse Navigators and Community Health Workers: Building Unique Relationships for Cancer Care, Part II of II

Amy Sebastian-Deutsch,

RN, DNP, CNS, APN, AOCNS®

System Cancer Services, Memorial Hermann Hospital System Houston, Texas

In part II of her article, Amy Sebastian-Deutsch continues to describe the potential for a collaborative relationship between Oncology Nurse Navigators (ONNs) and community health workers (CHWs). Sebastian-Deutsch discusses the development and implementation of a practicum through which ONNs would mentor CHWs, with the goal of facilitating improved cancer screening and care within the community. View Part I of the series.

Pitching the Collaboration

The February 2011 meeting with Elizabeth Kelley, PhD, RN, CNS-CH, BC-HSP, (the driving force for the Houston Community College Community Health Worker Program) was behind me, and I had completed additional research to familiarize myself with CHWs and their role.

It was now time to try to “pitch” the idea of an affiliation between my hospital system and the Houston Community College (HCC) for the purposes of providing practicum sites for the college’s CHW students. This would include practicum mentorship provided by our own oncology nurse navigators (ONNs). Knowing the size of our hospital system and the fact that I wanted to be ready to accept our first CHW students in June 2011 (only eight short months after first learning about CHWs), I knew it would not be a small challenge, and yet, I did not think it would be an insurmountable one.

Let me first describe our hospital system. Memorial Hermann Hospital System (MHHS) is the largest not-for-profit healthcare system in Texas, and was recognized this year by Thomson Reuters as one of the top 15 healthcare systems in the United States. We serve the greater Houston community, which has a population of nearly six million. We comprise 21 imaging centers, 19 diagnostic laboratories, 10 surgery centers, 12 hospitals, eight breast-care centers, and seven cancer centers accredited by the American College of Surgeons Commission on Cancer (now recognized as an integrated network cancer program). Our academic campus, Memorial Hermann—Texas Medical Center, is part of the largest medical center in the world, the teaching hospital for the University of Texas Health Science Center (UTHealth) at Houston and the UTHealth Medical School. We are known locally for our Life Flight air ambulance program, which maintains six helicopters (including one strictly for pediatrics) and covers those within a 150-mile radius of Houston. We contribute in excess of $300 million annually for uncompensated care and community benefits.

While I envisioned CHW students being mentored by any of our ONNs across any cancer diagnosis, the existing CHW student cohort was supported in part by the Houston Chapter of Susan G. Komen for the Cure, so the need to present my idea to the ONNs who navigated breast-cancer patients became my prime area of focus. Although I would have liked to have opened all seven of our cancer centers to the program, I knew I needed to first pilot this project at a few sites. Additionally, our breast-care centers are separate from the cancer centers, with separate administrative personnel. Therefore, both entities would have to agree on the pilot practicum program.

It was important for me to approach the ONNs first, because without their approval, the program would not get off the ground. In April 2011, I approached the ONNs to discuss the CHW role and the HCC program, and to see who might be interested in being part of the pilot. Four ONNs expressed interest. I also spoke with both our attorneys and personnel from HCC to learn about the requirements of affiliation agreements and what changes might be necessary; I discovered that we would need to add CHWs to the current agreements. Unfortunately, given the time remaining, we could only get three practicum sites up and running.

It then became necessary for me to confer with the directors of education to find out about our system’s requirements for students in clinical settings. While this would be primarily an observational experience, and CHW students would not be performing any patient chart documentation, it turned out that each student would still be required to complete specific facility orientations (including HIPAA requirements). Prior to that, they would need to obtain required immunizations, a tuberculosis test, a hepatitis B test, a drug screen, and a background check. They would also need to be CPR credentialed, and their school clinical instructors would need to sign off on everything.

My next task was to develop a PowerPoint teleconference presentation to provide an overview of the proposed pilot practicum. Personnel from the respective institutes—including the ONNs, directors of education, cancer service-line administrators, and breast-care center administrators—were invited to participate. The proposed pilot was also presented during cancer committee meetings at the respective facilities. My objectives for these presentations were to describe the CHW role, the HCC CHW student program, how students would be mentored by the ONNs, and how the practicum would be rolled out at the chosen sites. I also hoped to gain the agreement of all parties to participate in the pilot.

The following key points were presented:

• ONNs would not be obligated to take any students.
• Interested candidates would contact me via phone and briefly present themselves and their interests as well as their first, second, and third choices for practicum locations. They would be told there was no guarantee they would be offered a practicum.
• Selected potential candidates would then be referred to respective ONNs so they could be interviewed for “fit” with the facility and the populations being served. (Note: Some of the most positive outcomes have been achieved by CHWs who have worked within their own residential communities.)
• Summer practicum would begin in June 2011.
• Students would need to fulfill 224 hours over 12 weeks.
• If selected, students would be mentored by ONNs.
• Students would be rotated through multiple activities: clinic, exams, support groups, cancer treatments, and some of our community resource partner locations.
• Students would be required to complete a project deemed beneficial to themselves and their site’s ONN.

Table. MHHS CHW Practicum Requirements (Based on DSHS Core Competencies for CHWs)

Objective/Competency

Learning Activities

Affirmation Process

General Orientation

Attend practicum "kick-off" meeting.

Attend facility orientation.

Meeting with APN, ONN, and instructors; signatures of APN and ONN/facility educator

Advocacy

Visit with city/state government official(s). Send birthday card (if applicable).

Signature of legislative aide; copy of birthday card

Capacity Building

Identify patient in need of support (eg, newly diagnosed patient). Provide information/invite patient to support group.

Survivor attends support group; confirmed by social worker or ONN signature

Communication

Observe ONN/PT/MD interaction. Attend support group.

Name of MD/signature of ONN; signature of ONN

Interpersonal Relations

Follow patient across care continuum.

Dates of attendance; signature of ONN

Knowledge Base on Specific Health Issues

Observe screening mammogram, diagnostic mammogram, breast biopsy, lumpectomy/mastectomy, XRT, and chemotherapy administration.

Signatures of oncology nurses, mammography technicians, MDs, and ONN

Organization

Complete project as discussed with ONN.

Project completed; signature of ONN

Service Coordination

Observe with CanCare, ACS, Project Mammogram, Breast Health Collaborative of Texas, and The Rose

Signatures of agency representatives

Teaching

Deliver topic presentation: "What is a CHW?"

Topic presented and witnessed by ONN; signature obtained

ACS indicates American Cancer Society; APN, advanced practice nurse; CHW, community health worker; DSHS, Texas Department of State Health Services; MD, medical doctor; MHHS, Memorial Hermann Hospital System; ONN, oncology nurse navigator; PT, physical therapist; XRT, x-ray therapy.

It’s a Go!

With a general consensus obtained to move forward with the pilot practicum program, I contacted Dr Kelley and indicated that we were a “go.” I informed her of the requirements CHW students would need to complete prior to attending facility orientations, and sent the required form on for completion by the school instructor. My perception was that this process was something new for the school; it seemed we were the first practicum site to require immunizations, CPR, drug screens, TB/hepatitis B tests, and background checks.

Dr Kelley informed me that students interested in completing the practicum portion of the program would be told in the latter half of May that our site was an option. That allowed a short four to six weeks for us to interview students, offer them a practicum, have them complete the pre-orientation requirements, and schedule them to attend the required MHHS “kick-off” session and hospital facility orientations. We received five to six queries and accepted three students. It was at that point that things started to happen even more rapidly. I contacted the accepted students, ONNs, and instructors and conveyed the date of the “kick-off” session. They were informed of the need to wear lab jackets and school ID badges, and a copy of our dress code was e-mailed to them. This provided the impetus for me to complete our system’s CHW practicum template based on the core competencies for CHWs developed by the Texas Department of State Health Services (Table).

It was also now time to contact several of our community partner organizations and explain the pilot CHW practicum. This was necessary to pave the way for future contacts by the ONNs/CHW students when they arranged for onsite time to complete the service coordination component of the practicum—an opportunity for them to learn about community resources available for the populations they would serve in the future. Finally, students were also asked to complete logs of their clinical experiences and to touch base with their mentors at least weekly.

Results of the First Practicum

All three students completed their programs. Some were more successful than others in their efforts, perhaps based on personal motivation and passion for the endeavor. Two out of three ONN mentors described positive outcomes by their CHW students and one ONN indicated that her student did not fully deliver on the practicum requirements. One of the CHW students even gained employment in one of our smaller breast centers. While she was not hired specifically as a CHW, she is working in a satellite breast center and is able to utilize her skill base to work with patients. The relationship she built with her ONN mentor during her practicum now provides her the opportunity to refer patients from her remote site on to the ONN for higher-level care and support when required.

Since this had been our first time working with CHW students, we knew we needed to process the experience with both the school faculty and the ONN mentors “at the table.”

The ONNs expressed that they had been unclear about how much they could expect or request of the CHW students and how much they could say if the students did not seem to be delivering on the practicum requirements. Handouts on mentoring were provided by the school. Overall, we believe the first pilot was a success. We decided to continue on to a second pilot practicum; however, we needed to make some minor tweaks to the system’s practicum requirements. We would no longer require students to complete a weekly log, as this was considered a duplication of other school requirements.

The Second Pilot Practicum

After getting the affiliation agreement signed for our academic campus located in the Texas Medical Center and meeting wit h the manager of education, we were now prepared to offer a fourth practicum site. During this cycle, we received about the same number of req uests to participate from CHW students; however, from a geographic perspective, most of the CHW students did not want to be considered for the campus sites we had to offer. Furthermore, during the interviews that did occur, the ONNs indicated that they did not note the same level of desire f or fulfillment of practicum requirements that they saw in the first pilot practicum CHW students.

We accepted only one student for this rotation, at our academic cam pus. Unfortunately, the CHW student elected to quit her rotation after only three weeks (in the beginning of April 2012). We have yet to discuss exactly what occurred, but are scheduling a collaborative meeting with the school instructors and all t he ONNs to perform an analysis of our practicum and discuss how we can continue to build this unique partnership, which is still in its infancy.

Possible Future Collaborative Efforts

While the CHW students have initially been focusing on breast health and breast cancer, I can envision future students focusing on other tumor sites and being mentored by the ONNs who navigate those sites. One example might be lung health and lung cancer wit h a focus on tobacco cessation. Practicum experiences might include observing bronchoscopies and lobectomies, completing Freshstart tobacco cessation training, and participating in the Great American Smokeout. Being able to assist in tobacco-cessation efforts with community members might help to improve quit rates. Another opportunity might be t he head and neck cancer patient population wit h an eventual community focus on nutritional needs and/or body image issues. The possibilities are almost endless.

It is important for CHW students to experience firsthand the entire continuum of cancer care. The benef its are many. Students are able to gain an understanding of the entire care process, from screening and prevention through suspicion, diagnosis, treatment, and survivorship. Successful completion of this type of practicum can also assist the CHWs in working collaboratively with hospital-based ONNs in the future. A common bond can be built, with each understanding the other’s role and how collaboration can be of benef it to their mutual populations.

The ONN/CHW student practicum is a segue for future relationships between CHWs and ONNs. It af fords the opportunity to eventually extend ONN services provided in the hospital setting (when patients have higher level-of-care needs) out to the community, where the college-trained CHW can then manage lower-level needs, thus providing a smoother care transition. By the same token, when members of the community require a higher level of care, t he CHW can transition them back to the ONN. Forging this relationship can only serve to benefit existing cancer patients, and will most assuredly assist future cancer patients.