Provider Manual - Show Me Healthy Women (SMHW)

Patient Navigation

The CDC’s National Breast and Cervical Cancer Early Detection Program (NBCCEDP), defines Patient Navigation as individualized assistance provided to women to overcome barriers and facilitate timely access to quality screening and diagnostic services, as well as initiation of timely treatment for those diagnosed with cancer.

Navigation focuses on clients who otherwise would not complete recommended screening or diagnostic testing because of personal barriers, limited access to health services and other significant barriers to completing screening and diagnostic services. For clinic guidance on navigation services see Patient Navigation Services Guidance later in this section.

All women enrolled in the SMHW program must be assessed for their need for patient navigation services and provided with such services accordingly. SMHW providers complete the MOHSAIC Patient Navigation form for women enrolled in the SMHW program to reflect the assessment of barriers and actions taken for barrier reduction to achieve completed screenings.

Patient navigation must meet the CDC’s following six (6) requirements:

1. Written assessment of individual patient barriers to cancer screening diagnostics/initiation of treatment
2. Provision of education and support for the patient
3. Resolution of barriers to obtaining cancer screening/diagnostics/initiation of treatment
4. Tracking of the patient to assure completed screening/diagnostics/initiation of treatment
5. A minimum of two (2), preferably more, patient contacts
6. Data collection and data review in aggregate to evaluate outcomes of patient navigation (the delivery of cancer screening and/or diagnostic testing, final diagnosis and treatment initiation if needed).

CDC considers case management for women with abnormal screening results a type of patient navigation, as long as the aforementioned activities are performed.

Patient Navigation services are not limited to enrolled SMHW clients. Women who meet age and income requirements who have insurance to pay for screening and diagnostic services but need assistance with resolving barriers to completing screening or diagnostic services can be enrolled.

Navigation Service Eligibility

Patients with Navigation Service Eligibility

This additional enrollment status within SMHW is called ‘Navigation-Only’.

‘Navigation-Only’ Enrollment Status

SMHW’s enrollment status for Non-SMHW eligible women in MOHSAIC is called ‘Navigation-Only’. The enrollment status of ‘Navigation-Only’ allows payment to SMHW providers for navigation services provided to a woman who meets age and income requirements and has group or private insurance to pay for the screening and diagnostic services. ‘Navigation-Only’ enrollment is prioritized for populations that are predominantly low-income (<250% FPL) and are of appropriate age per screening guidelines. Women receiving ‘Navigation-Only’ services will be included in CDC’s reporting of women served through NBCCEDP.

Payer Sources Eligible for ‘Navigation Only’ Services

MDE data are required for women who receive NBCCEDP-funded ‘Navigation-Only’. The abbreviated record will include data on patient demographics, screening test type, date of test, test results, and final diagnosis.

The ‘Navigation-Only’ client abbreviated record includes the SMHW Patient History form (green) and the Patient Navigation Form (gray) and a Screening Report Form or Diagnostic form as applicable. Select Visit Type ‘Navigation-Only’ and ‘Reporting Only’ on the screening or diagnostic forms as applicable.

SMHW providers complete the Patient ‘Navigation-Only’ form for women in order to reflect the assessment of barriers and actions taken for barrier reduction to achieve completed screenings.

To qualify for enrollment into ‘Navigation-Only’ with an SMHW abbreviated record, the following six (6) requirements must be met.

1. Assessment of individual patient barriers to cancer screening/diagnostics/initiation of treatment
2. Provision of education and support for the patient
3. Resolution of barriers to obtaining cancer screening/diagnostics/initiation of treatment
4. Tracking of the patient to ensure completed screening/diagnostics/initiation of treatment
5. A minimum of two (2), preferably more, patient contacts
6. Data collection and data review in aggregate to evaluate outcomes of patient navigation (the delivery of cancer screening and/or diagnostic testing, final diagnosis and treatment initiation if needed).

Access to clinical information is necessary to complete the MDE record. MDE data for ‘Navigated-Only’ clients are analyzed separately and included in calculating the NBCCEDP core indicators.

A process for report/result sharing between health care agencies is required, as is informing each patient of their test result. Reporting the results of the screening or diagnostic services on the appropriate forms counts the woman as ‘Served’ by the program. To complete billing for Patient Navigation Services, reporting results of the screening and/or diagnostic test is required in MOHSAIC. The table below outlines the required forms by Navigation Service Type.

Patient Navigation Services

Navigation Service Type

MOHSAIC Navigation Form

The MOHSAIC Navigation form is located in Section 10: Forms. The Navigation Form includes the following sections:

• Personal Data and Client Assessment
• Barrier Identification (e.g. financial, communication)
• Action Plan
• Outcomes

Resources that may assist navigating clients through obtaining healthcare coverage include the Missouri Department of Social Services’ Medicaid Program.

Terminating Patient Navigation

Depending on screening and diagnostic outcomes, patient navigation services terminate when a client:

1. Completes screening and has a normal result,
2. Completes diagnostic testing and has normal results,
3. Initiates cancer treatment, or
4. Refuses treatment.

Case Management

Clients who have abnormal screening results receive follow-up services, up to the point of a final diagnosis and treatment start date. Achieve this through case management. The goal of case management is to ensure clients enrolled in the program receive timely and appropriate diagnostic and treatment services. An abnormal screening result is determined based on nationally recognized screening guidelines identified in the Provider Manual Chapters 5 and 6.

Non-clinical professionals may provide required case management activities, and a qualified health care professional (Registered Nurse, Nurse Practitioner, Physician Assistant or Physician in good standing to provide health care in Missouri) must have oversight. Although case management services vary based on an individual client’s needs, at a minimum, case management must include the following activities:

• Notify the client of an abnormal result within a reasonable period of time (i.e., two (2) weeks from the date the procedure was performed),
• Assessment and resolution of barriers to diagnostics services,
• Assessment and resolution of barriers to initiation of cancer treatment, if treatment is indicated,
• Client education and support,
• Arrange diagnostic appointments on the client’s behalf,
• Clients may not be given a referral list and asked to schedule their appointment,
• Client tracking and follow-up to monitor client progress in completing diagnostics and initiating treatment, and
• A minimum of two contacts with the client over the course of the screening and diagnostic cycle.

Terminating Case Management

When a client concludes cancer treatment, the treating physician releases the client to return to a schedule of routine screening, and the client continues to meet SMHW eligibility requirements, the client may return to the program and receive all services, including patient navigation or case management.

Clients screened through SMHW clinical services who are subsequently insured may continue to receive patient navigation services. In such instances, agencies are encouraged to continue navigating clients to ensure diagnostic procedures are completed, and if a diagnosis of cancer, that treatment is initiated.

Lost to Follow-up Cases

Funding received from the CDC is contingent upon SMHW meeting or exceeding several quality assurance parameters of the CDC Core Performance Indicators. Case managers must ensure and meet the following indicators for all SMHW clients with abnormal screening results:

• Ninety (90) percent or more of SMHW clients with abnormal findings achieve a definitive diagnosis.
• Seventy-five (75) percent or more of SMHW clients with an abnormal finding achieve a definitive diagnosis within 60 days or less.

A SMHW client contact and tracking system must be in place to notify clients of abnormal results. Contacts with a client should be clearly documented in a client’s medical record and should include what type of follow-up is needed, the recommended timeframe for follow-up, and the clinical implications if the follow-up does not occur. Client contact continues until one of the following occurs and is documented in the medical record:

• Recommended follow-up evaluation complete and the client referred for treatment (if indicated),
• Made two documented attempts to contact the client. If the client has a valid address, one of these attempts must either be in writing and sent as a certified letter or sent via the client portal/email with a read receipt confirmation. Use of certified letters or read receipt emails early in the course of follow-up can expedite the notification process,
• Notified the Regional Program Coordinator after no response,
• Documented informed refusal in the client’s medical record, or

• Documented in the client’s medical record at least two contact attempts made (considered lost to follow-up).

  a. This documentation should include the dates, types of contact attempted, and the outcomes.

  b. If the client has a valid address, at least one of the contact attempts should be a certified letter with a return receipt. Keep a copy of the certified letter and the return receipt in the client’s medical record.

Every client has the right to elect or refuse treatment. A client is considered to have refused service when one of the following has been carefully documented in the client’s medical record:

• Client has verbally refused the follow-up care recommended.
• Client has refused in writing the follow-up care recommended.

Keep documentation of the informed refusal in the client’s medical record. Include refused service or treatment and when the client was informed of the risks involved if recommended follow-up is not completed.

Quality Assurance/Quality Improvement

Documentation of Patient Navigation Services will be reviewed during the regular monitoring visits every two years and as necessary. Verification of eligibility for navigation services will be assessed. Notation of the assessment and appropriate interventions to assist with barrier reduction will be reviewed. Please refer to Section 8, Quality Assurance, for more information.

Patient Navigation Services Guidance

Patient navigation assists a patient so they can move through health care promptly without the road stops of a complex healthcare environment. This includes moving the patient through distinct healthcare settings such as primary care (clinic) and tertiary care (hospital). The goal is to eliminate barriers to timely health care through a one-to-one relationship between a navigator and the patient. No matter what phase of health care, the patient should benefit from an appropriately trained navigator at the phase of health care.

A patient navigator works with patients to reduce real and perceived barriers to health care. The services provided depend on barriers identified and actions taken to alleviate the barriers. Common barriers include:

• the inability to schedule and keep appointments,
• English as a second language,
• confusing medical information,
• lack of insurance,
• limited finances, and
• lack of or limited transportation to and from home.

Other barriers may emerge and must be recognized and addressed as the navigation plan develops.

Navigation is an early phase of health care and includes education about cancer prevention, cancer risk factors and the need for screening for those patients not engaged with obtaining health care or not a part of a health care system. It may also include educating patients already within a healthcare organization who have not received screening services. For patients already engaged with a healthcare organization, navigation may include education regarding timely follow-up appointments for further studies or beginning treatment.

Healthcare organizations must assess their capacity to support increased patient activity and anticipate an increase in screening rates.

Healthcare organizations with patient navigation involving medical record review and required documentation know exactly who is due for breast or cervical cancer screening and subsequently, contact those patients to encourage them to come in for the screening.

In managing navigation services, the organization asks the following in their capacity assessment:

• What setting -- primary care clinic, community-based affiliate, or regional-based tertiary care?
• Who is the target audience and priority population?
• How to provide services – in person, by phone, or both?
• Who will serve as navigator—lay person, nurse, or other?
• Who will all the partners be and how will they work together?

These organizations dedicate staff time to the appropriate phase of healthcare navigation for their patients.

Effectiveness evaluation components are “no-show” rates, completion of screening exams, and timely follow-up.

A successful navigation program will see a reduction in “no-show” rates, an increase in the completion of screening exams, and consistent timely follow-up of abnormal test results.

Navigation Services Tasks

Assigning responsibility for specific tasks increases an organization’s accountability for patient navigation. Consider these tasks for patient navigation:

The elimination of cancer disparities is critically important for lessening the burden of cancer. Patient navigator programs improve clinical outcomes.

In response to Missouri women and providers reaching out to SMHW to inquire about additional cancer navigational resources, SMHW developed a list of Cancer Navigational Resources to assist in filling a gap in the current healthcare system. The following pages contain the SMHW Cancer Resources to help navigate Missouri women and families to help at many points along the health care journey: insurance problems, identification of available cancer screening programs, medication assistance, financial assistance, housing assistance during travels, etc.

Show Me Healthy Women Cancer Resources

View resources