Nurse practitioner care led models care models are evolving. A literature review by  emphasizes the utilization of advanced practice nurses and nurses in the geriatric setting based on the utilization of evidenced-based nursing practices incorporating interprofessional novel approaches across settings ranging from the community, long-term, and acute care.
Likewise, nurse practitioner led models are emerging in the forefront to deliver care to cancer patients across all care settings such as emergency rooms , survivorship , treatment both home , in-house , as well as for palliative care .
The utilization of the oncology nurse practitioner (ONP) in navigation roles is yet another emerging care model that has been shown to be effective in cancer care for ensuring timely care and patient satisfaction . A study was undertaken to answer the question: what processes do oncology nurse practitioner navigators use in care for cancer patients. It consisted of a semi structured interview utilizing grounded theory  of N = 20 oncology nurse practitioners and showed:
The ONP navigation process is a process that is carried out synergistically within the context of the patient, facility, and community, and consists of a barrier focused assessment, triaging, pulling in resources, guiding to the next step, tracking, and program development (p.61)
In this study the carving of the unique role of the ONP navigator involved the development of a navigation system . The question arises as to how to begin to develop a navigation system utilizing this framework?
This paper will briefly focus on preliminary assessment factors to consider in the development of an ONP led navigation program.
If the ONP wanted to begin to develop a program entailing timely work-up of hematology patients with potential blood disorders and hematological malignancies, on the facility level hematologyoncology specialist back-up would be the initial step. It is important to determine the modality of supervision/collaboration set-up that is to be used for ensuring orders leading to an accurate diagnosis. Some models include telemedicine in collaboration with a teaching institution  on-site multi-disciplinary conference (Bovero et al., 2017), or other means.
Timely facility specimen handling is another critical factor that is necessary for a successful program. If the bone marrow biopsy is to be done on site, measures that ensure timely processing of specimen at the diagnostic facility are necessary to avoid treatment delays .
On the community level, navigation assessments along with structured tools are necessary as patient navigation is community driven . The National Cancer Institute Community Cancer Centers Program (NCCCP) has the goal of expanding cancer research and delivering quality care in communities. Its subcommittee the NCCCP Quality of Care (QoC) aimes to develop and improve the quality of multidisciplinary care. It has developed an assessment tool with nine key elements relevant to multidisciplinary structure and operations . Collaboration with programs such as this can assist the navigator to mobilize community resources.
A navigation barrier focused patient assessment must be comprehensive and specific to each patient. For example, molecular testing is an established norm for the diagnosis and treatment prescription for hematological malignancies, and there is evolving and rapid growth following the integration of the next generation sequencing in the patient care pathways. However, understanding specific barriers and challenges for care access pertaining to precision medicine in the underserved population is an ongoing challenge. CMS claims have shown that Medicaid patients are 40 percent less likely to get tested than patients with private health insurance and Medicaid patients are 30 percent less likely to receive targeted therapies after the testing is completed compared to the privately insured (“patient navigation”, 2020). The Association of Community Cancer Centers (ACCC), has a project underway entitled “Eliminating Precision Medicine Disparities” . The focus of the project is to understand the barriers to equal access for the underserved population . Innovative programs that address care disparities such as this are an important avenue for care enhancement and communication on the patient level.
Synergy is a key aspect to operating within this model, as is timely care a key component, as navigation is done synergistically and timely on a patient, facility community, and community levels. For example, on the patient level, the patient going for a bone marrow biopsy may be in good physical, and psychological health, and mentally ready for the procedure. He/she may have very good family support. The facility may do a marvelous job with the procedure, but the specimen is outsourced to an outside community facility that is overburdened with specimens, thus affecting the timeliness of the diagnosis. Even though the patient is well navigated on the patient and facility level, the community level navigation is suboptimal. Since there is synergy amongst the three levels of the navigation process within this framework the timeliness of the care is impeded.
Research pertaining to navigation utilizing this model would take into account studies that focus on improving care on all three spheres of navigation.
In summary, nurse practitioner care led models are evolving. Nurse practitioners in navigator positions have been shown to participate in a navigation processes to overcome barriers to care synergistically on a patient, facility and community and facility level . Deficits in one sphere will affect the overall navigation process. In setting up a ONP led program initial assessment of each sphere and interventions to iron out the factors that impede timely care are important.
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