Why Today’s Topic Matters: Navigation Is Becoming a Strategic Imperative

As we head into Thanksgiving, I want to begin with a heartfelt thank-you to every oncology nurse, navigator, physician, APP, scheduler, social worker, financial counselor, administrator, and care coordinator who shows up for patients every single day.

Your work, often unseen but always essential, is what makes timely, safe, and equitable cancer care possible. You lift barriers, restore clarity, and carry patients through some of the hardest moments of their lives.

Thank you.

Over the past few months, I’ve been outlining the building blocks of a modern oncology

operating model. Today’s focus, Oncology Navigation & Care Coordination, is quickly

becoming one of the most important capabilities in value-based and clinical quality oncology.

Navigation is no longer a “nice to have.”

It is a strategic lever that directly impacts:

• Timeliness of diagnosis and treatment

• Avoidable ED visits and admissions

• Adherence to clinical pathways

• Patient experience and satisfaction

• Equity in access and outcomes

Yet many programs still wrestle with the same questions:

➡️ Who should receive active navigation?

➡️ How do we define the scope of navigation?

➡️ How is navigation different from triage?

➡️ What does a true navigation strategy look like?

🔎 What Navigation Is, and What It Isn’t

Navigation is a longitudinal, proactive model that removes barriers and guides patients across

the full cancer care continuum.

Triage, by contrast, is episodic and symptom-driven, a rapid clinical process that determines

urgency and directs next steps.

Navigation includes triage.

Triage is not navigation.

And as value-based oncology expands, that distinction matters more than ever.

🎯 Identifying Patients Who Need Active Navigation

High-performing programs use four categories of data:

1️⃣ Clinical Complexity

Cancer type, stage, treatment modality, comorbidities, symptom burden, oral oncolytic risk.

2️⃣ Utilization Risk

Recent ED visits, admissions, no-show patterns, adherence concerns.

3️⃣ Psychosocial & SDOH

Transportation, housing, utilities, food access, mental health, caregiver support, financial

toxicity, health literacy.

4️⃣ Engagement Signals

Portal use, responsiveness, self-management capacity.

This is the foundation for an acuity model that assigns patients to high-, medium-, or low-

intensity navigation.

“Clinical Complexity” might be easy to define but what do you do with that data once you have

it? That’s an easy answer: Navigate your high complexity patients because:

• You don’t have the resources to navigate all patients, and

• It’s obvious that a high complexity patient is the most at risk to climb the “severity

ladder” and experience all the negative outcomes that are a result of that climb.

But are they really?

Here’s what I found working with a client to reduce avoidable emergency department visits:

The client had the OCM HCC scores of about 450 beneficiaries. I set out to prove that focus was

needed for patients with the highest scores: some ranging up to 12. I created a correlation

between the HCC score and the number of ED visits and found just the opposite: almost a perfect

negative correlation. The number of ED visits decreased as the HCC score increased! That

observation took me several days of mental exercises to form ideas and then it made sense

(some!). What goes into the HCC score?

The five biggest contributors are:

1. Demographics (age, sex, disability, Medicaid status)

2. Chronic disease diagnoses that map to HCC categories

3. Severity level within disease groupings

4. Interactions between conditions

5. Pharmacy-related HCCs (if included)

   
   

Patients who score high in these categories often have learned self-management skills and have

some amount of a support network. On the other hand, a newly diagnosed cancer patient with no

chronic or comorbid conditions can understandably experience severe anxiety when they have

symptoms of nausea, diarrhea, dizziness, etc. after their first treatment.

The takeaway in this example is the importance of a timely and comprehensive patient intake process so that a holistic view of a patient is formulated. This allows navigation resources and processes to be applied effectively across a patient population.

📈 What Navigation Actually Does

Well-structured navigation programs define a consistent scope of practice that includes:

• Barrier assessment & mitigation

• Care coordination & referrals

• Symptom monitoring & escalation pathways

• Education, expectation-setting & shared decision-making support

• Financial/benefits navigation handoffs

• Transitions of care (clinic → ED →inpatient → post-acute)

• Survivorship progression and supportive care alignment

  
  

Navigation is at its best when it is predictable, measurable, and integrated across disciplines.

🏨 Navigation Across the Continuum

High-performing programs embed navigation into every stage of care:

• Telehealth & digital touch points

• Physician office & infusion services

• ED avoidance workflows & same-day access

• Observation units

• Inpatient & ICU episodes

• Post-acute care transitions

• Survivorship & palliative care

Navigation adapts as patient acuity rises and falls.

📊 Measuring Navigation: What Matters

ASCO Certified, AONN+ and other value-based care and clinical quality models prioritize the

same indicators:

• Timeliness of care milestones

• Barriers identified and resolved

• Avoidable ED visits and admissions

• Navigator caseload and acuity mix

• Patient experience metrics

• Equity in access, timeliness, and outcomes

  
  

What gets measured gets improved, and navigation metrics are quickly becoming essential to

oncology performance. Drawing from quantum theory, “Observation changes behavior.”

🖼️ The Navigation Strategy Framework

Every strong navigation strategy answers five questions:

1. Who do we serve?

   Defined patient populations and triggers.

2. How do we classify acuity?

   A consistent model using clinical + psychosocial + utilization data.

3. What does navigation do?

   A defined scope of practice and workflows.

4. Where does navigation engage?

   Integration across the full continuum, not just the clinic.

5. How is success measured?

   Value, timeliness, experience, and equity.

This is how navigation becomes a scalable capability instead of an individual effort.

If your organization is redesigning or implementing value-based care, clinical quality or

patient navigation feel free to message me. I can assist you with:

✔ Acuity models

✔ Patient identification criteria

✔ Scope of navigation

✔ Continuum workflows

✔ Metrics aligned with ASCO Certified, AONN+ and value-based care programs.