Knowing patients’ lived experiences is critical to successful value-based and quality care programs.

My last article outlined the steps to build an Oncology Value-Based or Quality Care Model, starting with nurse-patient care coordination. The first step is to gather as much information as possible about your patients' clinical and psychosocial factors. Those data elements can then be used to design a patient navigation and triage program.

Let's examine a framework in which the data can be utilized. A significant amount of data can be gathered, and we should focus on those elements that can be utilized to enhance patient outcomes, satisfaction, and the effective use of financial resources. Otherwise known as the "triple aim". The goal is to identify which patients require active (high-touch) navigation versus those who can be supported through standard or passive (low-touch) pathways.

Why? The goal is to prevent patients from climbing what I'll call the "severity ladder." Every step up the ladder poses greater risks to meeting the "triple aim."

The Severity Ladder of Healthcare Places of Service illustrates how clinical acuity increases as patients transition from home or clinic settings to hospitalization, intensive care, and ultimately hospice or end-of-life care. The goal of this navigation strategy is to flatten the curve and intervene early to stabilize patients before the condition escalates.

Your strategy should define:

• Which patients qualify for active navigation (e.g., new diagnoses, complex regimens, multiple comorbidities, or psychosocial distress scores above a defined threshold)

• Which team members (nurse vs. lay navigators) manage each risk tier

• What triggers escalation or de-escalation (changes in symptoms, treatment cycles, or social determinants)

• How is success measured, such as reduction in ED visits, timely symptom management, or adherence to treatment pathways

This strategy aligns with the ASCO Oncology Medical Home Standards in Domain D, which require clear delineation of care coordination roles (D.1, D.2) and navigation processes to screen for psychosocial distress, refer to resources, and ensure equitable access to care (D.3, D.4)

You should start by building a risk segmentation framework, ideally tied to data elements already captured in your EHR or care management platform. In future posts, I will outline steps that can be taken at each stage to achieve the "triple aim." Before outlining a comprehensive, evidence-based structure drawn from the ASCO Oncology Medical Home Standards, AONN+ navigation metrics, and demand management principles, I would like to focus on patient factors that can be overlooked, specifically their psychosocial needs.

Healthcare utilization is not driven by symptoms alone. Decades of health services research have shown that people use healthcare based on their perceived needs, the availability of resources, psychological factors, social norms, and system-level barriers.

Two landmark studies—Mechanic (1979) and Berkanovic (1985)—were among the first to empirically demonstrate that patient perceptions, expectations, and social context often predict healthcare usage better than objective illness measures.

Here's an example of how this information is used:

"As an oncology nurse, I've learned that you can't design an effective care strategy unless you truly understand your patient population. That's exactly what ASCO Standard D.4 calls for: recognizing health disparities and having a real process to identify and address the challenges that shape outcomes. At Central Georgia Cancer Care, we know the populations in our two clinics are fundamentally different. In one, more patients need mental health support, while in the other, we see greater needs around housing and utilities. That means we should tailor resources—whether that's connecting appropriate patients to foundation funds (including our own Foundation) or directing other patients to online support groups and behavioral health services. And we can't overlook what patients tell us directly through satisfaction surveys, Patient Support groups and the Patient & Family Advisory Council. Their lived experiences should guide how we show up for them every day."

Melissa Shaw, BSN, RN, OCN

Regional Clinical Quality Manager

American Oncology Network

We'll review other patient demographic data in future posts. When combined with patient psychosocial data, you can begin to develop effective value-based and patient-centered care programs that transition from Population to Priority. Every oncology practice faces the same paradox: more patients, more complexity, same number of nurses. The answer lies in demand management strategy - the ability to segment patients by clinical severity, psychosocial distress, and risk for unplanned care.

🎯 Bottom Line

The patients who need navigation most are those at the intersection of clinical complexity, psychosocial distress, and system fragmentation.

When your model captures those data points and connects them to navigation tiers, you move from reactive care to proactive population management—the essence of value-based oncology.

➡️ Next in the Series

The next article will spotlight the nurse navigator's pivotal role in patient coordination—the link between patient behavior, clinical readiness, and outcomes within a value-based model.