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HCI-670-OncologySouthIntakeForm2.pdf

Oncology South: Oncology Navigator Intake Form Name: MRN: D.O.B.:

ONCOLOGY NURSE NAVIGATION NEW PATIENT BARRIERS TO CARE and PSYCHOSOCIAL ASSESSMENT

The Oncology Nurse Navigator (ONN) introduced self to the patient and gave a brief explanation of the nurse navigator role. Contact information was provided. The ONN obtained a verbal consent for navigation assessment and follow-up.

Tell me about yourself:

▪ Who does your family consist of? ▪ What is your marital status? ▪ With whom do you live? ▪ What is your occupation? ▪ Are you in school? ▪ What do you enjoy doing in your spare time?

Chief complaint: Tell me what you know about your diagnosis so far… (Use direct quotes when possible) Family History of Cancer: Smoking History: Exposure History:

ACCESS TO CARE ASSESSMENT

Was it difficult for you to schedule your first appointment at UACC? NO YES ▪ Tell me more about how the process was difficult for you…

What is the name of your PCP? Who referred you to UACC?

Lack of a PCP is a barrier to cancer care. YES ▪ Refer to MERCK Resource Navigators to help patient obtain a PCP

NUTRITIONAL ASSESSMENT

Is Nutritional Status a barrier to care? NO YES

Malnutrition Screening Tool (MST): (If indicated)

Weight loss:

1. Have you recently lost weight without trying?

Yes or No?

0 = No

2 = I am not sure

2. If yes, how much have you lost? 1 = 2 to 13 lb. 2 = 14 to 23 lb. 3 = 24 to 33 lb. 4 = 34 lb. or more

Appetite:

3. Have you been eating poorly because of decreased appetite?

0 = No

1 = Yes

4. MST Score (weight loss + appetite)

Total score ______. Referral to Nutritionist should be made with a score of 2 or greater.

LEARNING ASSESSMENT – Document in Cerner

Do you have any Communication /Language barriers? NO YES

▪ In what language do you want to get your medical information? Any barriers to learning? NO YES

▪ Memory issues ▪ Dyslexia ▪ Impairment: hearing, eye site ▪ Cognitive Deficits ▪ Cultural Barrier ▪ Difficulty concentrating ▪ Emotional state ▪ Financial concerns ▪ Health Literacy ▪ Desire/Motivation

Preferred Learning Style: Demonstration, Printed materials, Verbal explanation, Video, Internet

PHYSICAL BARRIERS ASSESSMENT

Do you have any challenges accomplishing your Activities of Daily Living? NO YES

▪ Do you have any problems with mobility (walking/getting around)? ▪ Do mobility challenges make it difficult for you to get out of the house for errands or

appointments? ▪ Do you need any assistive devices? ▪ Self-care: bathing, dressing, cooking, etc.

Do you have family care responsibilities that limit your ability to be away from home for several hours at a time? NO YES

▪ How many dependents (children, older adults) do you care for? Ages? ▪ Are you the primary caretaker? ▪ What support do you have for caring for your dependents?

Do you expect to have difficulties obtaining transportation to your appointments? NO YES

▪ What is your primary mode of transportation? ▪ Is your transportation reliable? ▪ Do you expect there to be any transportation difficulties for your appointments? ▪ Is there someone who can drive you to your appointments if necessary?

Is housing/lodging a barrier? NO YES

▪ Do you have safe place to live? ▪ If you come from out of town, do you need a place to stay while you are in Tucson? ▪ If you were to need radiation therapy every day for some weeks, would you need a

place to stay close by?

Would you say that your current financial situation including your insurance coverage will be a barrier to your receiving medical care for your cancer diagnosis? NO YES

▪ Do you have difficulty affording your current bills? ▪ Who provides the main source of income for your household? ▪ Do you have health insurance? Name? ▪ Are you worried about your health insurance being adequate to cover cancer-related

services?

If you were to need cancer treatment, would you anticipate there being any problems getting time off from work or school? NO YES

▪ Does your job allow for time off for being sick? ▪ FMLA? Other programs? ▪ Will you get a pay check if you cannot work?

SOCIAL HABITS ASSESSMENT

Let me ask you about social habits: Do you smoke?

▪ Never ▪ Quit; How many years ago? ▪ Yes; How many PPD? How many years? ▪ Are you interested in quitting? ▪ Do you know about ASHLine? 1-800-55-66-222

Are you in the habit of using recreational drugs or drinking alcohol? And if so, have you had any problems as a result? NO YES

▪ Have you ever been stopped for driving under the influence? ▪ Do you have difficulty keeping a schedule after drinking/using recreational drugs?

PSYCHOSOCIAL BARRIERS ASSESSMENT

Do you worry about having enough social support to help you during stressful times? NO YES

▪ Who can you rely on to help you at home or outside of your home?

▪ Is there someone that can attend appointments with you? Who?

Do you have any religious and/or spiritual beliefs or cultural practices that may impact your health care decisions and that your health care team should be aware of? NO YES Would you say that you have difficulty trusting the medical system or medical providers? NO YES

Learning that you have a cancer diagnosis can certainly be frightening. Do you anticipate that fear of cancer or its treatment might affect your willingness to get care? NO YES Have you ever been diagnosed with anxiety, depression or other mental health condition? NO YES

▪ What was the specific diagnosis? ▪ Are you currently under a doctor’s care? ▪ Do you take any medications? What are they? ▪ How long ago were you diagnosed?

Would you say that you are having difficulty coping with your diagnosis at this time? NO YES

▪ How have you coped with stressors in the past? ▪ Would you find it helpful to speak to a counselor who can help with coping strategies?

DISTRESS THERMOMETER: On a scale of 0-10, with 10 being “extreme”, how much distress have you been experiencing in the past week including today? ____ Is there anything else that you want to share with me that you think might make it difficult for you to get access to care or is a barrier for you? NO YES

Distress Thermometer Score: ________________ Number of Barriers: _________________ Patient Acuity Score: _________________

NAVIGATION PLAN

1. Referrals:

2. Patient Education Plan: : At her initial visit, this patient will receive the ASCO Guide to Lung

Cancer and an orientation packet containing the UACC Living with Cancer Guide book. If a

decision to go to surgery is made, she will receive a surgical education packet. At subsequent

visits, she will receive Krames or Chemocare Handouts on any systemic antineoplastic agents

prescribed.

3. Navigation Follow-up Plan for Barrier Resolution (based on Acuity Score): Per the GREEN

YELLOW ORANGE RED protocol, I will make future contact to reassess and offer further

navigation as needed.

4. Hand-off: This note was routed to the Clinical Nurse Coordinator for Dr. who will take

over care during the treatment phase.

Barrier and Distress Resolution Protocol 1. GREEN (Normal) Within 5 business days of MD visit, ONN will call to assess understanding of the plan of care and reassess acuity. If patient remains at this acuity, no additional calls will be made unless new issues develop. If acuity increases, the number of FU calls will increase to that acuity level protocol. 2. YELLOW (Low) Within 5 business days of MD visit, ONN will call to assess understanding of the plan of care and reassess acuity. If patient remains at this acuity, at least one additional FU call will be made. If acuity increases, the number of FU calls will increase to that acuity level protocol. If acuity decreases, the number of FU calls will decrease to that acuity level protocol. 3. ORANGE (Medium) Within 5 business days of MD visit, ONN will call to assess understanding of the plan of care and reassess acuity. If patient remains at this acuity, at least two additional FU calls will be made. If acuity increases, the number of FU calls will increase to that acuity level protocol. If acuity decreases, the number of FU calls will decrease to that acuity level protocol. 4. RED (High) Within 5 business days of MD visit, ONN will call to assess understanding of the plan of care. If patient remains at this acuity, at least three additional FU calls will be made. If acuity decreases, the number of FU calls will decrease to that acuity level protocol.