1. BREAST CANCER ONCOLOGY NAVIGATION SERVICE
Identification/
referral
Coordination
Diagnostic
phase
Staging/ treatment
phase
Longitudinal
Follow-up
Coordination
with primary care
Mammogram referral
BI-RADS 4 or 5 (needs biopsy)
Patient gets imaging
Receptor status, molecular subtypes
Hand-off to “navigator”
eReferral to referring (sporadic)
Patient gets mammogram
PCP referral to case management
Post-diagnosis evaluation
Navigator documents on “navigator notes”
or phone call communication
Patient gets biopsy
Radiology interpretation; f/u recommendation
Case details and intake written into a binder
Call patient to apprise and/or arrange visit
Imaging, additional labs, bone scans
Schedules f/u studies and/ or procedures
Mammogram service apprises referring provider
Order additional diagnostics studies as necessary
Present case at breast tumor board (every 2 weeks)
Surgery, oncology, radiation oncology,
treatments
eReferral to referring provider
Outcome entered into binder
Post surgical assessments
Particular “pain point”
Patient contact and ensure that appointments are kept (phone calls, s, letters)

2. PULMONARY NODULE JOURNEY MAP
Identification/
referral
Coordination (Pulmonary nurse)
Coordination
(Pulmonary service)
Diagnosis and
staging
Longitudinal f-u
Coordination
with primary care
Places on Word document
F/u imaging schedule
Place schedule on Word document
Receive f/u plan from pulmonary
Abnormal imaging
Biopsy with chest radiology
eReferral to pulmonary service
Alert pulmonary service
Schedule f/u imaging
Follow f/u
imaging plan
Staging: PET CT (external referral)
bronchoscopy/ surgery
eReferral attending reviews consultation
Check insurance status (refer to eligibility)
Consultation
with chest radiology
Schedule f/u studies and/ or procedures
Risk assessment:
pulmonary function test, cardiology studies, exercise testing
Pulmonary outpatient diagnostic service referral
Make recommendations: imaging f/u vs. procedure
Establishes PCP if none
Notify patient of plan
Notify referring provider
Patient to surgery, medical oncology, radiation oncology
Particular “pain point”
Patient contact and ensure that appointments are kept (phone calls, s, letters)

3. PROSTATE CANCER JOURNEY MAP
Identification/
referral
Coordination (Urology team)
Consultation
(Urology Attending)
Care Pathway
(“Active surveillance”)
Care Pathway
Longitudinal f-u/ coordination with PCP
Elevated PSA
> 4 ng/ml
Patient comes in for urology f/u
Adjudicate need for biopsy
Add patient to “registry” (list)
Intermediate-high risk/ metastatic
Resident on 4- month block
DRE and informed decision-making
regarding need for biopsy
Resident fills in tracking “book” (binder)
Assign risk categories and assign f/u pathway
PSA f/u with option for biopsy (every 1-2 years)
Patient assigned
to treatment pathway
Requisitions, lab orders, lab “book”, EHR documents
Patient scheduled for biopsy
Referral to Radiation Oncology
Communicate plan to PCP
Back to PCP if "watchful waiting"
Assigned "Active surveillance" pathway
Referral to Medical Oncology
Surgical intervention
Patient contact and ensure that appointments are kept (phone calls, s, letters)
Particular “pain point”