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Table 2 Thematic EPIS constructs

From: Implementation factors for patient navigation program success: a qualitative study

EPIS construct Example quotation
Outer context
 Funding, guidelines, and service environment: OCM bundled payments and CoC accreditation requirements [O]ur participation in our oncology care model and the fact that they require navigation, it has definitely given both financial support and cultural support to continue to grow our navigation program, which has expanded substantially during the past few years.
-Navigation Supervisor
“[W]e have to present for the American College of Surgeons and that’s the standard [for] PN… [S]ince we already had this in place it’s been a benefit to the hospital.”
-Navigation Supervisor
 External networks: community partnerships and philanthropy As a community, we work with the city, we work with the councilmen, we work with the pastors, the barbershops, the beauty shops. The navigators get in there and as we identify patients, they’re the ones that bring them in… You can look at the data: patients do not show up unless they’re navigated through the system.
-Administrator
Because we’ve been able to show how we’ve helped patients, my chairman...has created a push towards philanthropic dollars to help support some of my activities.
-Administrator
 Patient characteristics and advocacy: demonstrated need for services [B]ased on previous research…looking at minority, underserved, English as a second language ’cause those [are] shown to be the people who benefit most from navigation. Yes… we’ve seen a decrease in time to diagnosis, a decrease in time to treatment within the breast center…[W] e are looking at screening adherence and then again time to diagnosis or whether or definitive resolution if it’s not cancer.
-Navigation Supervisor
They want to be able to provide a cost of the patient’s estimated services…to prevent them from having kind of a shell shock of getting a large bill on the back end…[I]t all ties into just the patient need. I think that that’s a part of the overall care of a patient. It’s not just getting well physically, but just mentally knowing that the bills are being taken care of and that someone is on their side to help maneuver through the billing aspect of it all and insurance aspect of it all.
-Patient Navigator
[O]ur patients were showing up…with late stage disease…[They] had a lack of education and fear regarding the health systems and trying to get their cancer screenings. So we created our first Navigation Program to help the community improve cancer outcomes and late stage disease presentation.
-Administrator
Inner context
 Alignment with organizational priorities: strategic priorities and leadership support [The program] is embedded in our cancer service line strategic initiative to expand and enhance our care coordination services. So we are actually looking to expand and enhance the nurse [and] lay navigation program.
-Administrator
From the very beginning it was high, high level, highest level leadership that was saying, “This is what’s going to happen, and this is how we’re going to do it”, and so our reporting structure is at the highest levels.
-Navigation Supervisor
 Organizational support: Training [W]e can’t just do PowerPoints and recorded classes, because it’s hard for them to get everything they need from that…[O]ur onboarding program…is a combination of… class work that they’re doing with us, online courses, [and] on the job training.
-Administrator
 Appropriate staffing levels We are a team of seven…The way that everything is split and divided, I think we have pretty good coverage
-Patient Navigator
 Relative advantage It’s helpful in showing the positive impact that we have and just the volume of our work. [Leadership] can actually see, basically, how many patients we’ve interacted with, individual patients that we’ve interacted with over the year...it helps justify the need for [additional] navigator[s].
-Administrator
[W]e looked at patients who were navigated versus patients who weren’t navigated, in terms of their retention within the health system, the percentage of patients who went to and received chemotherapy, those who received radiation… [T]his was actually the most profitable program we’ve ever had within the health system.
-Navigation Supervisor
Innovation factors
 Innovation developers I hire the navigators, supervise the navigators on a day-to-day basis….Most all of our navigators now are currently grant funded so a lot of the grants are written by me.
-Navigation Supervisor
 Navigator role and scope of practice We are all lay navigation, but we partner with nurse navigation programs in the clinic… [W]e’re…at about 250 patients per navigator…for the lay navigators, the clinical navigators [have] a much lower…number. We take first line for them, so they’re doing clinical escalations.
-Administrator
 Clear protocols [I]f one of our patients goes to the emergency room, we get a notification...[T]he day after they get back from the emergency room, we’re going to call and find out: What did you go to an emergency room for? Did you call the clinic?…Do you have a follow up appointment scheduled with your doctor? Did you build your scripts? Did they take care of everything? So we don’t want that emergency room visit to result in a hospitalization or another ER visit.
-Administrator
 Strong communication channels [W]e have coordinated care between different specialties, and that’s when the navigators come in and talk to the patients about the complexity of care and the need to be seen by multiple providers, and helping us coordinate the tests. So, they have access to the tumor boards.
-Medical Oncologist
 Innovation fit [W]hen we start a project or hire a navigator working with the clinic...[W]e meet with the managers and sort of see how is the best way for the navigator to fit in. We make them a part of the team. They meet with social work. And we make it very clear that we have lay navigators. They practice within their scope. They’re not doing any psychosocial sort of thing, but are there to sort of support the social workers.
-Navigation Supervisor
Sustainability
 Community-academic partnerships [O]ur researchers are able to say, “Okay, I know that she’s tracking this in head, and neck. She has some information that I would like to look at, and I think it can fund a proposal for a grant.”
-Navigation Supervisor
 Funding stability [W]hen somebody says the service is amazing and the doctors want it but the free money runs out and nobody’s running around to try to get more money, that doesn’t make it feel like navigation is an important asset to the organization as a whole.
-Patient Navigator