HOW IT MIGHT HAVE TO WORK

Some radiology department clinicians feel uncomfortable sending these reports directly to the nurse navigator, citing HIPAA regulations as well as possible Stark Law violations. If this is the case, the nurse navigator must wait for the ordering physician to direct the patient to the program, either by making the referral call themself or by having the patient/family call the program. This step increases the need to educate primary care and specialty physicians. Sometimes, the doctor will call the pulmonary department directly, and they place the patient into the Pulmonary Nodule Program for ongoing follow-up.

Regardless of which way the patient enters the program, the following points then need to occur.


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  • The multidisciplinary team orders the appropriate diagnostic test following the Fleischner guidelines for the patient’s lung condition (eg, pulmonary nodule, pleural effusion, interstitial lung disease).
  • Patient is scheduled for a consult within 1 to 2 weeks.
  • All patients with lung nodules or masses meet with the pulmonary team to discuss biopsy options and determine resulting course of treatment as needed.

Nurse navigators also have a critical role to play in streamlining patients’ access to care. Three tactics for proactively pulling patients into the thoracic program include leverage radiology data, keep an eye on the calendar, and network with pathology.

Leverage radiology data The nurse navigator receives reports of abnormal findings from the Radiology Department weekly, if permissible. The nurse navigator can check with the hospital’s legal department on whether this is permissible.

If the nurse navigator cannot proceed without a formal referral, primary care physicians, emergency department physicians, hospitalists, internal medicine physicians, residents, and fellows, as well as any other clinicians who may be a member of the patient’s nononcology health care team, should be educated on how and why to contact the Pulmonary Nodule Program for appropriate patient follow-up.

The nurse navigator then directly follow-up with the primary care physician for any patients who meet the criteria for treatment in the thoracic center.

Diagnostic work-up is streamlined, as navigators may not require a physician’s approval for every test if the program’s multidisciplinary team has established guidelines for proceeding (Table 1). If no guidelines are established, the nurse navigator continues to work with the ordering physician to ensure appropriate actions take place in a timely manner.

TABLE 1. Diagnostic Work-up for Pulmonary NoduleChest CT

Chest CT
• Chest computed tomography (CT) ordered not more than 45 days prior to Pulmonary Nodule Program office visit
• If previous imaging was only positron emission tomography (PET)/CT, order a separate chest CT per the following
  – IV contrast (if the patient’s blood urea nitrogen/creatinine is within normal limits)
  – Coronal and sagittal reconstructions
PET/CT
• If insurance will not pay for PET/CT without a tissue diagnosis of cancer
  – Review case and CT scan
  – Determine which option is most appropriate
      ▪ Percutaneous biopsy by IR
      ▪ Surgical biopsy
      ▪ Proceed without a PET/CT
Pulmonary function test
• Within last 6 months

Keep an eye on the calendar Pulmonary Nodule Program nurse navigators may have access to the pulmonary and thoracic surgery calendar. If they do not, frequent and open communication with the Pulmonology and Thoracic Surgery office staff is key to ensuring appropriate and timely follow-up.

Network with Pathology Department Pathology reports may be printed directly in nurse navigator’s office. The nurse navigator reviews the reports, identifies those with positive thoracic findings, and alerts the pulmonologist. The nurse navigator then reaches out to treatment physicians of those patients.

Effective and efficient communication between physicians and nurse navigators is paramount to streamlining patient care, particularly during the diagnostic phase of patient care. All too often, patients experience significant delays because the diagnostic tests needed to determine their treatment plan require physician approval.

As this health care system is COC accredited, we utilized the development of this program to meet programmatic metrics for ongoing accreditation. We created metrics for the program using the SMART methodology, and these metrics are currently being collected.2

  • Development of marketing tools for the program;
  • Collection of data regarding total number of patients in the program, number of cancers detected, and stage of cancer at detection;
  • Timely appointments with pulmonologist postinitial incidental identification of pulmonary nodule (within 5 to 10 working days).