Population-Based Patient Navigation

24-Hour Personalized Cancer Care for the Entire Cancer Continuum

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OVERVIEWCancer. One word that bears immense significance for so manyindividuals. For some, it is the word that took them by surprise,imposing new routines and adjustments to daily life as quicklyand succinctly as it rolls off the tongue. For others, the wordevokes complex and multifaceted emotions - fear, strength,apathy, gratitude, anger, hope, grief, determination – the list isendless and ever changing. The impact of this diagnosis extendsfar beyond the patient to their family, their care team, theircommunity and more.

In 2017, there will be an estimated 1,688,780 new cancer casesdiagnosed in the United States.1 Of those diagnosed, everycancer journey will be unique. Standard differences in cancersite, stage, treatment modalities and outcomes, coupled withvariances in patient age, receptivity to treatments, and patientpreference of therapies compels oncologists and cancer careteams to design treatment plans patient-by-patient, providing avastly individualized and intricate approach to the treatment of

cancer.

With the complexities involved across the cancer carecontinuum, the need emerged for trained individuals uniquelyqualified to assist patients, providers, and families navigate thisexpounded realm of cancer care. From this need arose the fieldof patient navigation.

Jenna Cowan, BSJennifer Kerkvliet, MA, LPC, NCC

College of Nursing staff of the Office of Nursing Research at South Dakota State University were supported by an interagency agreement from the South Dakota Department of Health to conduct this evaluation and report, using flow-through funds awarded through cooperative agreement number DP006114 to the South Dakota Department of Health funded by the Centers for Disease Control and Prevention. The contents of this report are solely the responsibility of the authors and do not necessarily represent the official view of the Centers for Disease Control and Prevention or the Department of Health and Human Services.

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Patient Navigation: Expanding Cancer Care Services from Prevention through Survivorship

The concept of patient navigation was founded

and pioneered by Harold P. Freeman in 1990 forthe purpose of eliminating barriers to timelycancer screening, diagnosis, treatment, andsupportive care. He initiated and developed thefirst program of its type in order to reducedisparities in access to diagnosis and treatmentof cancer, particularly among disparatepopulations. The original program focused on thewindow of time between a suspicious finding andthe resolution of the finding by further diagnosisand treatment.

Cancer patients may experience considerablebarriers from diagnosis through active treatment.Commonly reported barriers include the financialbarriers of medical costs or loss of wages;communication barriers including language andcultural blocks or lack of understanding; medicalsystem barriers such as missed appointments,lost results, or a fragmented medical system;psychological barriers including fear, distress, oranxiety; and the list of barriers continues withmany others including transportation, need forchild care, and general questions.

Patient navigation programs aim to identify andresolve patient barriers to care, link patients andfamilies to primary care services, specialist care,and community-based health and social services,all in an effort to provide more holistic, patient-centered care.

While patient-centric care has developed andexpanded for the cancer patient, a report from theInstitute of Medicine (IOM) in 2005 “From CancerPatient to Cancer Survivor: Lost in Transition”exposed an urgency to recognize and address theburden that remains after treatment for cancersurvivors.2

The term “survivor” or “survivorship” has beenused in assorted ways, but in the sphere ofoncology it encompasses “the process of livingwith, through and beyond cancer.”3 As of January1, 2016, there were more than 15.5 millionAmericans alive with a personal history of cancer,all of whom are considered cancer survivors.1

Some of these individuals were diagnosedrecently and are still undergoing treatment, whilemost were diagnosed many years ago and have nocurrent evidence of cancer.

Cancer survivors may face numerous barriersfollowing primary treatment. Potential long-termand late effects (some permanent and disabling)from cancer and its treatment includepsychological distress, sexual dysfunction,infertility, impaired organ function, cosmeticchanges, and limitation in mobility,communication, and cognition are among theissues faced in this cohort.2 The 2005 IOM Reportrendered awareness of the medical, functional,and psychosocial impact of cancer and itstreatment and advanced the movement ofsurvivorship care.

The scope of patient navigation has since evolvedand expanded to include survivorship and is nowemployed across the entire healthcare continuum,including prevention, early detection, diagnosis,treatment, post treatment, quality of life andsupportive care, and survivorship.

As of January 1, 2016, there were more than 15.5 million Americans alive with a

personal history of cancer.1

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Required Standards for Cancer Program Accreditation

Patient navigation has quickly become a central component to cancer care in health systemsnationwide. Evidence-based research demonstrates the value of patient navigation in terms of reducingor removing many of the common barriers associated with cancer care. 4 These findings have ledoncology-related accrediting organizations to integrate patient navigation as a required standard forcancer program accreditation. Survivorship standards have rapidly followed.

In 2005, the Patient Navigator, Outreach, and Chronic Disease Prevention Act of 2005 authorized federal grants to hire and train patient navigators to assist patients with cancer and other serious chronic disease to obtain access to timely diagnostic, treatment, and follow-up care.

In 2009, the National Accreditation Program for Breast Centers (NAPBC) instituted standard 2.2 requiring that a patient navigation process be in place to guide the patient with a breast abnormality through provided or referred services.

In 2012, the Commission on Cancer (CoC) of the American College of Surgeons initiated standard 3.1 that emphasized the need and importance of navigation services, requiring the phase-in and documentation of navigation services by 2015.

In 2015, the CoC of the American College of Surgeons implemented standard 3.3 requiring cancer survivors be provided with a comprehensive treatment summary and survivorship care plan. By 2018 and beyond, 75% of eligible cancer survivors are required to receive a treatment summary and survivorship care plan.

In 2016, the NAPBC instituted standard 2.20 for breast cancer survivorship care. This standard requires that a survivorship care plan and treatment summary be provided to 100% of eligible breast cancer survivors.

As the value of patient navigation and survivorshipprograms becomes more evident, medicalinstitutions are looking for program models that fitthe needs of their facility. Numerous models ofpatient navigation programs exist. Some areclinically-based with nurses or nurse practitioners,social workers, health educators, or clinic staffmembers practicing in a disease-specific orgeneralist role, others are community-basedprograms with intervention by lay navigators orother licensed staff. Still other models existincluding case management and patient advocatemodels. While all program models focus onreducing or eliminating the common barriers

associated with cancer care, the most successfulmodel is one tailored to the needs of thepopulation being served. However, implementinga sustainable navigation program model with theflexibility to adapt to the ever-changing standardswhile staying grounded in patient-centered carepresents a challenge to health systemsnationwide. This paper highlights one example ofan innovative, community-driven yet healthsystem based model of patient navigation that issuccessfully adapting to meet all of theaforementioned needs through 24-hourpersonalized cancer care providing resources,support, and access to expertise.

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Personalizing Cancer Care: Development of a 24-hour Patient Navigation Center within a Cancer Treatment Center in a Rural State

Nobody should face cancer alone. That’s thephilosophy behind the newly developed AveraCancer Institute Navigation Center (ACINC).The ACINC is dedicated to being an around-the-clock source of comfort and support foranyone whose life has been touched bycancer.5 Opening in March 2016, the centeroffers a unique model of patient navigation asa free community service. The model wasthoughtfully developed based on the needs ofthe rural population the health system serves,with the ultimate goal of removing barriers tocare and reducing the burdens related tocancer. The narrative below showcases how“out of the box” thinking can lead to valuablepopulation-based care that extends beyondtreatment.

“Cancer is so complex. You have so manyproviders involved with one patient. You haveso many medications and so many treatmentregimens. You have such a high volume ofpeople traveling from very rural areas to any ofthe six Avera Cancer Institutes. All of thetraditional burdens and barriers that fall intohealthcare tend to be exacerbated foroncology,” said Jamie Arens, Director of theACINC.

A steering committee made up of Avera leaders,caregivers and patients was formed in order toaddress and lessen the exacerbated burdens ofoncology. A collaborative and coordinatedapproach was pursued to design a system-widepatient navigation program that would beaccessible for all of their patients, regardless oftheir primary treatment location. Conversationsbegan in 2015 to assess the variety of patientnavigation program models currently in useacross the six cancer center’s service line.Discussions centered on how the six cancercenters could collaborate to utilize best practices,streamline services, and evaluate options forcreating navigation services with the greatestimpact on their largely rural population.

While discussions on streamlining servicesoccurred, Avera Cancer Institute also launched aRural Cancer Advisory Board, a group ofstakeholders providing input on how to betterunderstand the barriers to cancer treatment forrural populations. Navigation, or how to connectpatients and families to resources, particularlyafter hours, was a key issue for the AdvisoryBoard. “How can you incorporate people to fillgaps, to reduce burdens, to remove barriers, tostreamline things, and to really be there whensomebody needs it?” This question, asked withinthe Rural Cancer Advisory Board, led the group toinsightful discussions about the burdens thatpatients encounter throughout their cancerjourney and the services that could addressthem.

Located in the Upper Midwest, Avera Cancer

Institute serves patients from six regional cancercenters and 40 outreach sites across a 72,000mile footprint in South Dakota and surroundingstates. The demographic served by these centersis largely rural, with 32% of patients at the urbancancer center location traveling more than 100miles to receive care. The system sees more than2,000 new cancer patients come through itsdoors each year, every one with unique needs,questions and concerns related to their care.

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Current and former patients, rural communitymembers, and the steering committee identified acritical need for a resource that, 1) would extendbeyond the normal office hours, 2) could provideaccess to a navigator for anyone affected by cancer,and 3) would create a centralized process for allpatients and caregivers at their time of need. Fromthese discussions, the design of the program grewand developed into a 24-hour, primarily phone-based patient navigation center that serves notonly patients receiving care at one of the AveraCancer Institutes, but also providing a communityservice that connects patients, families, andhealthcare providers with information andresources to navigate the cancer journey fromscreening and early detection, to initial diagnosisthroughout survivorship.

The process of developing the ACINC started with areview of existing models, reading journal articles,and understanding what models other healthsystems were implementing. What they found isthat when it comes to oncology navigation, thereisn’t a clear definition or process.

“I always say that navigation is provided basedon the needs of the people you are trying toserve. That’s how I define what navigation shouldbe in place. That’s how we figured out ournavigation model – we are here to removebarriers to care and reduce burdens related tocare. The research helped us understand that it’sokay to design it out-of-the-box and create ourmodel based on what our patients need. That’sprobably going to end up being a better productthan trying to budget for and fit an existingmodel into our system,” Arens said.

The team also used the history of patientnavigation for their design. The founder of patientnavigation, Harold Freeman, simply looked at whatwas needed in his community. By applying a grassroots method and building relationships within thecommunity, the original program was able to make

a significant impact applying a longitudinal modelof navigation that shepherds patients througheach phase of care. Avera Cancer Institute hopesto replicate that impact by having a presence inthe communities they serve and a relationalapproach to patient interaction and support.

To better understand the cancer related needswithin the service area, it was vital for thesteering committee to assess the needs of theregion. This research included an analysis ofexisting community health needs assessments,review of the South Dakota Cancer Control Plan2011-20156 and other state data provided by theSouth Dakota Department of Health, a focusgroup of existing navigation staff within AveraCancer Institute, and a thorough review of bestpractices around patient navigation services.Trends discovered throughout the assessmentrevealed common needs including (in noparticular order): transportation, access to care,mental health services, chronic conditionmanagement, availability of cancer supportservices, navigators, and social workers, timelytreatment, financial/insurance concerns, cancereducation and support. This extensive list alsovalidated the belief that patients rarely presentwith a singular need; rather, almost everyinteraction involves a combination of clinical andpsychosocial needs.

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Building upon a community-based generalistmodel of navigation and armed with the data fromthe community needs assessments, the ACINC wasshaped. The navigation center provides services bytelephone at any hour of the day to anyone whoneeds support or referrals. Walk-in services areavailable at the urban cancer center location from8:00 a.m. to 5:00 p.m. A registered nurse navigatoras well as a master’s prepared social worknavigator, both with backgrounds in oncology, areavailable during walk-in hours or by phone until8:00 p.m. Outside of those hours, calls areanswered by the Avera Call Center, and triaged asneeded to the appropriate resource to addressimmediate concerns. A log of all triaged calls isprovided to ACINC staff the next day, who thenfollow up with each caller to provide furtheroncology support. Call volume and staffing needsare continuously monitored in order to adjustservices to match the needs of the community.

Provision of services by phone ensures that care isavailable immediately, alleviating access concernsfor the rural population. Arens stated, “I would saythat our model is unique to any model that I’veseen….you have national support lines, onlineresources, and then you have hospital systemsthat have a clinical piece, all which provideneeded care to cancer patients and their families.But, offering a free community service thatprovides support, connection to resources, triageeducation, and clinical experts…all of that issomething that I haven’t found yet.”

The ACINC is available to anyone whose life hasbeen touched by cancer, including patients andfamilies of all six Avera Cancer Institute centers andoutreach sites, as well as community members andcallers from anywhere in the nation. The staff atthe ACINC work with existing clinical navigatorsand care teams for patients undergoing treatmentat one of their six cancer center sites, providing theafter hours support and connection to resourcesthat may be needed outside of direct clinical care.

“We do a lot of communicating within the careteams, so if it’s somebody that uses the AveraCancer Institutes, we are an extension of all of ourphysicians and staff, so we can pull that patient’schart up from any of the six cancer centerlocations. We are able to read the progress noteof that oncologist or look at their schedule orreview their treatment regimen, so we’re reallyan extension of them. We are also able to keepproviders updated, so whether it’s getting back totheir primary care or the specialist who referredthem – we really look at who on their oncologycare team needs to know this,” Arens said.

One of the key principles of the service however, isthat the ACINC is available to any cancer patient orfamily member, even those who receive careoutside of the Avera system. Additionally, asurprisingly large portion of the calls received inthe ACINC are from medical professionals,including oncology and non-oncology staff.

“We see a lot of medical professionals utilizingthe center as a hub to ask questions, figure outwho to go to, send a patient referral, or whateverit might be. I think the amount of communicatingwith other medical professionals is just a naturalfit with the work that we do, but it wasn’tanticipated. It just naturally happens when we’reworking with somebody and things arise thattheir provider needs to be aware of,” Arens said.

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As services were established in the first year ofoperation (March 1, 2016 – March 1, 2017), theACINC addressed 511 patient concerns across 165unique zip codes. Callers were most commonlyseeking information about cancer treatment ordiagnosis, location or contact information for amedical facility, anxiety or emotional concerns,communication concerns with medical staff, orissues scheduling care. Cancer patients were themost likely to reach out, followed by oncology staffand providers, non-oncology medical staff andproviders, survivors, and the family, friends, andcaregivers of patients.

Approximately 90% of services are provided byphone/remotely, with the remaining 10% of clientsutilizing the walk-in option at the physicalnavigation center location. Staff of the ACINCemphasized the diversity of the needs they’vehelped address.

“We literally never know what’s on the otherline,” said Jordan Fiegen, Social Work Navigator atthe ACINC. “It could be as simple as a transfer, orit could be someone who is going through anemotional breakdown. It could be someone whois vomiting uncontrollably and needs to go to theemergency room immediately. It is just so broad.You never know what you’re going to be doing ona daily basis, or what 10:00 AM is going to looklike in comparison to 7:00 PM. One of the biggeststruggles we face is in working over the phone. Itis not like working in a clinical setting or in anoutpatient setting where you are face-to-facewith a patient and you can pick up on their bodylanguage and physical queues that accompanytheir words. You have to be comfortable allowingthem to cry, or just keep talking, or maybe theyjust need to grieve. If a person is picking up thephone and reaching this number, they really wantsomeone who is going to be able to becomfortable in that setting and take their timewith them,” said Fiegen.

Due to the variability of calls, the combination of

nursing staff and social work staff has been anenormous benefit to the center and to theindividual callers.

Arens stated, “It was clear from everybody’sperspective on the steering committee and therural cancer advisory board that almost everyinteraction is never just a clinical need or apsychosocial need. It is just intertwined. It is greatto have a master’s level social work navigator aswell as a registered nurse navigator who knowand live and breathe oncology to be able to teamapproach any need that comes in.”

Funding for the ACINC was fairly organicallyderived as well. The very first navigator position forthe Avera Cancer Institute was philanthropicallyfunded through a donation to the AveraFoundation. With a philanthropic tie to patientnavigation from the beginning, it was clear that theAvera Foundation would be a valued voice to haveon the steering committee for the development ofthe ACINC. Support of the Avera Foundation,through contributions from donors and communityorganizations, opened the door of possibilityprompting conversations of providing the ACINC asa free community benefit. With three years ofdonor funding in place, plans could be verbalizedfor the center and fundraising events were hostedin many of the six cancer center communities. Thecombination of donor support and fiscalresponsibility allowed the ACINC to provideservices free of charge to the community.Additionally, grant opportunities were sought outto complement existing avenues of support.

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“We’ve never had a conversation with anybodywho has utilized our service about giving back tous. It has never entered the conversation. I thinkthe benefit of operating from donor funding is itmakes it very meaningful. You have moreopportunity to think outside of the box anddevelop something that you, at the end of theday, can say is for the people who are funding it.You don’t have quite as much constraint tonormal healthcare system practices. But, thebiggest benefit is just that the center was able toopen. If we wouldn’t have had the donor support,I don’t know what it would look like. We wouldn’texist in the manner that we do,” said Arens.

Arens stated, “The drawback or fear whensomething is philanthropically funded is whathappens if funding runs out. Realistically, that isthe downfall of having something funded thisway. I am not concerned about that. I think thereis downstream revenue that is generated fromsomething like this, but there are also successmetrics that reflect the impact we’re making onour communities. Hopefully that data can reflectthe center’s impact when we apply for grants.We’ve been afforded the opportunity to proveourselves, and I think that has allowed us to besustainable.”

Marketing of services follows inline with the grassroots approach of the center. Promotion occurs viaspeaking engagements and vendor tables atcommunity events. The ACINC also partners withhealthcare systems to make sure information isavailable to nurses and providers, as well as in thewaiting rooms within community healthcarefacilities so that community members are informedof the service at diagnosis. The ACINC service isalso promoted to current oncology patients as anextended resource, available in addition to thesupport from their care team.

As the navigation center grows, expansion ofservices is planned using outbound phone calls toreach patients at intentional points in their cancerjourney, such as after their initial diagnosis, aftertheir first round of chemo, or following theirsurvivorship visit at the end of active treatment.Through experience, the center has learned thatthese pivotal points in the cancer journey arecommonly filled with questions, fear, resistance inmoving forward or other matters which thenavigation center could help patients address.

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Survivor Navigation:An Innovative Model for Survivorship Care

With the goal of providing support in a pivotal timepoint, a Survivorship Program was piloted at theACINC in August of 2016. An outbound call isplaced to a survivor roughly two weeks followingthe survivorship visit as an additional means toprovide resources, assess remaining patient needs,and offer continued support and encouragementto survivors.

Rita Sanem, registered nurse navigator at theACINC stated, “The survivorship outbound call letsthe patient know that they are not just cut offfrom care once their treatment ends. We wantthem to know that we are always here for them.We want to remind them that they can call us forany reason at any time….it’s a free call. Followingthe survivorship outbound calls, we send outresources and information that they might needdown the road. For survivors, one of their biggestfears is that they’ve lost control. Their whole lifehas been given over to their care team duringtreatment. Sending them resources andinformation gives them back control, or at leastthey have it when they are ready.”

The process for survivorship outbound calls wasarranged in a linear fashion. Using existing clinicalprocesses, a survivorship care plan (SCP) is createdfor eligible patients and delivered during asurvivorship visit with an advanced practiceprovider. During that visit, the provider completesan assessment in the patient’s electronic medicalrecord (EMR) which covers physical activity,nutrition, body mass index, tobacco cessation,colorectal cancer screening status, anxiety anddepression screening, physical rehabilitationneeds, and also gathers information about thepatient’s primary care provider. When theassessment is reviewed and approved in the EMR,a notification is automatically sent to thenavigation center to follow-up with the survivor byphone, within 2-4 weeks following the survivorshipvisit.

Sam Gaster, Survivorship Program Manager atAvera Cancer Institutes stated, “The whole processis set up like a series of dominos. One of the sidebenefits of a domino process is that while everyindividual may perceive one domino or onecomponent as being especially valuable, everycomponent in the process needs to be completedfor the final component to occur. Let’s say aprovider really loves the survivorship outboundcalls; well, the only way that can happen is if aperson gets a survivorship care plan. So, theprovider must deliver a SCP. Or, if a provider saysthey really love the assessment that was createdbecause it helps guide the patient conversation;well, the provider has to deliver a SCP, whichtriggers the assessment, which then triggers theoutbound call. So everything has to happen in acertain sequence.”

When staff at the ACINC receive a survivorshipnotification for a patient, they know that thepatient has received a SCP, had an assessmentcompleted during a survivorship visit, and in 2-4weeks an outbound survivorship follow-up call canbe made from the navigation center. Staff of theACINC can access the patient’s information then toreview and learn a little about the survivor beforethey place that outbound call, which allows themto personalize and tailor the call to achieve thehighest patient benefit and prepare for a verymeaningful call. They can review the completedassessment from the last visit and, based onpatient needs, can prepare further resources tooffer to the survivor and discuss potential concernsduring the outbound call.

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“It was important for us when we first started theoutbound survivorship calls to know whichspecific documents to review prior to calling. Wereview the patient’s SCP and are now comfortablewith the patient’s charts that are in the EMR, sowe know where to look for notes from their careteam, their social worker, or their nursepractitioner. Collectively, that information is agreat connection piece. When we call the survivorthen, we can make it a conversation and let themknow that we are calling to care about them, notto take a survey or get these tasks done. We arecalling as a courtesy to care about them and toask How are you doing?, How is your familydoing?, Have you done these things?, and if not,we are going to take the opportunity to remindthem,” said Fiegen.

The content of the calls is primarily patient-driven.Staff ask standard questions for assessment oftobacco use, physical activity and nutrition, andassessment for colonoscopy screening, but theremainder of the call is open-ended to allow thepatient to determine the course of theconversation.

“The call is really quite open-ended based onwhat the navigator sees in the patient’s chart andwhat that assessment during the visit tells aboutthe needs, so it was designed to be very patient-centered. The content of the call is up to thepatient. That’s the goal. We know there are goingto be some very important things to always coverwith everybody, but we want it to be as muchdriven by the patient as humanly possible,”Gaster stated.

In the first year of survivorship outbound callimplementation (August 1, 2016 – July 31, 2017),299 survivors were successfully contacted for thisadditional service, representing an estimated one-fifth of the health system’s total eligible survivorpopulation in a one year period.

Initial planning is underway for the next step inassisting survivors in their journey, which istransition of care back to the patient’s primary careprovider. “We are planning to structurecommunication between the ACINC and primarycare providers. For survivors that have gonethrough our center, we have their SCP, asurvivorship assessment, and a follow-upassessment completed during the survivorshipoutbound call. We have a record that says here’severything about the patient and their care,here’s what’s concerning them right now, here’swhat we’ve done to address those concerns, andhere are the concerns that remain unaddressed. Iwould love to have the ACINC staff standardlyprovide a document that encapsulates all of thatinformation to the patient’s primary careprovider,” said Gaster.

According to Gaster, plans are underway to trialdelivery of a document such as this to primary careproviders on a small scale, with hopes to expandthe practice to the larger scale.

In summarizing the ACINC, he stated “Eachcomponent of the Survivorship Program is just adrop in the bucket. It is one document, or onephone call, or one person transitioning care, andso I don’t know if [the survivorship outbound call]makes the critical difference in a person’s care atall times. But, it’s the additional service and Ithink that’s how the ACINC is always described –it’s an additional service to provide furthersupport to patients and staff. So you just needdrops in the bucket. And when we can startmaking connections back with primary care, thenit becomes a splash because then you’re trulybridging silos.”

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As the ACINC continues to grow and expand, thecenter hopes to add further standardized outreachservices at pivotal time points in the cancerjourney. Currently, staff only conduct outboundcalls for the Survivorship Program, or at therequest of care team members. The center alsohopes to sustain and expand communityconnections and outreach to stay consistent withtheir grassroots mission and to continue to tailorservices to meet the needs of the community.Growth is also anticipated in terms oftelemedicine, especially with the high demandfrom the center’s rural population.

“As far as the services we want to provide, we’regoing to keep molding and adding to meet theneeds of our community,” said Arens.

REFERENCES:1. American Cancer Society. Cancer Facts & Figures 2017. Atlanta:

American Cancer Society; 2017.2. Institute of Medicine and National Research Council. 2006. From

Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC:The National Academies Press. https://doi.org/10.17226/11468.

3. About Survivorship. (2016, July 18). Retrieved August 15, 2017, fromhttp://www.cancer.net/survivorship/about-survivorship

4. Wells KJ, et al. Patient navigation: state of the art or is it science?Cancer. 2008;1999-2010

5. Avera Health. (2016). Avera Cancer Institute Navigation Center[Pamphlet].

6. South Dakota Comprehensive Cancer Control Program. (2011). SouthDakota Comprehensive Cancer Control Plan 2011-2015. Pierre, SD:South Dakota Department of Health. Available at:https://apps.sd.gov/ph18publications/secure/Publications/SD-CompCancerPlan.pdf.

Executive SummaryLaunched in 2016, the Avera Cancer InstituteNavigation Center (ACINC) was developed as acommunity-based model of patient navigationadapted to meet the needs of the highly ruralpopulation in the region. The 24-hour, 7 day aweek phone based delivery model provides thesame level of service to patients and families at allsix cancer centers within the system in acentralized manner by staff specialized in oncologynavigation. With the model in place, the ACINCquickly became a resource not only for cancerpatients undergoing treatment in the healthsystem, but also to health care providers, survivors,caregivers and the community inside and outsideof the health system.

Building on the initial success of the ACINC andliterature demonstrating the medical, functionaland psychosocial barriers patients face followingprimary treatment of cancer, a SurvivorshipProgram was added in 2016. The SurvivorshipProgram provides outbound phone calls to cancersurvivors a few weeks after they’ve received asurvivorship care plan. This outbound survivorshipcall occurs at a pivotal time point in the transitionout of treatment, adding another opportunity toensure that patients’ needs are addressed, andpreventative and rehabilitative health needs areassessed with referrals provided as needed. Allservices of the ACINC are provided at no cost tothe patient or provider, which is a key aspect of theservice. To accomplish this, the center is fundedthrough both philanthropic gifts and grant funding.

The ACINC model provides the opportunity to scaleservices to better meet the needs of both patientsand health care providers. Future components ofthe center include expansion of the servicesprovided to survivors, as well as additional workwith primary care providers as survivors transitionback to care in their community settings. The rapidrate of growth at the ACINC demonstrates that theservice is filling a critical gap for the ruralpopulation in the region.