Building Sustainable Navigation, SDOH Support in Cancer Care: Hope Krebill, MSW, BSN, RN

Patient navigation is increasingly recognized as a cornerstone of equitable cancer care, but sustaining these programs requires demonstrating both patient and financial impact.

In an interview with The American Journal of Managed Care^® (AJMC^®), Hope Krebill, MSW, BSN, RN, executive director of the Masonic Cancer Alliance at the University of Kansas Medical Center, described how hospitals that tie navigation to measurable benefits can maintain and expand services.

She also highlighted innovative approaches, including survivorship navigation for adolescents transitioning out of pediatric care. On the topic of social determinants of health (SDOH), Krebill emphasized that screening must be paired with clear workflows, referral processes, and patient advisory input to ensure it leads to meaningful support rather than becoming a paperwork exercise.

AJMC: Patient navigation is often cited as key to equitable care. What models of sustainable navigation support have you seen work best in practice?

Krebill: One of the challenges is that we have seen patient navigation really move forward very quickly in Kansas, and now we're seeing some retraction of some of it—the programs—and it really varies from hospital to hospital. I think the ones that have figured out that the best way to sustain it within their hospital is to really identify the need [and] figure out the return on investment, because we have to like it's a staff person.

Some hospitals say we really need to make sure when patients come to that first appointment that they're really ready to go, they have all the resources they need, [and] we've pulled all the data that we need from all the tests that were done in advance. When [hospitals] did that, they found that they had a lot fewer missed appointments. Then they're like, “Okay, so that shows that it's working, and that's actually helping our bottom line.”

Others have looked at it with an eye of financial navigation, so maybe they're doing both patient navigation as well as financial navigation. One hospital figured out that it really helped to have the patient navigation, because they really started looking at where they were losing the money with drugs, and could they have used patient assistant programs, and what are the pieces related to that, while others are connecting it directly. I'm a breast navigator, and they find that just being able to support those patients that have specific needs has really been the piece that has really helped.

Finally, we actually have a patient navigator in our survivorship clinic. It's a unique model, but it has really been effective where we partner with our Children's Hospital. She goes there and navigates the adolescents there as they're aging out of the Children's Hospital. They're at least 2 years since treatment, 5 years since diagnosis, and bringing them into a primary care setting navigation survivorship care at the University of Kansas. We've really looked at different approaches. In the end, what works best is individual hospitals need to really assess what is the patient journey? Where are the patients having trouble? Where are the pieces that are getting missed in the care? And then creating something that addresses those issues and then reassessing it over time.

AJMC: How can cancer programs make SDOH screening not just a checklist, but something that truly guides patient support?

Krebill: Screening for social determinants of health is something that lots of cancer centers are starting to think about. They've been doing it in a lot of ways with the NCCN [National Comprehensive Cancer Network] Distress Thermometer, where they ask [about] the distress, but they may also ask for some specific things that are bothering you. It's not to the level of social determinants of health or social drivers of health, but it is at least beginning that piece. Starting with where they've been is the first step, and then really thinking about the workflow.

We had this problem with survivorship care plans. Everyone had to do survivorship care plans, and all they cared about was getting that plan together. But the plan isn't what the patient needs—the plan needs to be alive and engaged with the patient, and really think about what the next steps are that need to be operationalized. It’s the same with the social determinants of health. If you're screening, then what are the next steps for identifying who's going to make those referrals? Because a cancer center isn't going to be addressing employment properly, but they're going to need to know where to go.

We had to think about that with the Distress Thermometer. If someone says, “I'm at this level of distress,” who's already addressing some of the things that they may have checked off if they're also asking some of those questions? And at what level does it trigger a referral? Right now, we're getting ready to partner with a researcher who is going to walk with patients and work with the cancer center teams to understand who at different cancer centers would address employment issues, because maybe it's not the people that we think it would be.

I think the process is really working through operationalizing the workflow, thinking broadly about who's going to address it, making sure it's just not something that someone completes and it goes into a chart, because if that's what happens, patients will actually feel less engaged. And your patient advisory boards—most cancer centers have patient advisory board—they can really help you with resources. Finally, the social work team can be great. They may have all these resources. They could quickly get overwhelmed, though, so who can help them? And if they don't know the resources, how do we help them identify where those resources are?