The National Accreditation Program for BreastCenters (NAPBC) 2024 Standards require implementation of a protocol to identifyand manage patients at increased risk for breast cancer due to personal riskfactors or family history. In response, the University of Illinois Healthpartnered with Nest Genomics to implement a comprehensive digital platform tostreamline and scale genetic services. The Nest Digital Patient Navigator forHereditary Cancer Risk Assessment (HCRA) was introduced into a routine mammographysetting in November 2023. To date, 4153 patients underwent HCRA with 17%meeting genetic testing (GT) criteria. Successful patient identification led toa new challenge: bottlenecks in access to genetic counseling (GC). Tostreamline care and empower patients to select their preferred follow-upapproach, post-assessment digital navigation was implemented in January 2024and offered to GT eligible patients.

Patients receiving screening mammogramscompleted HCRA in the waiting room prior to imaging. Patients who met GTcriteria were asked via digital navigator to choose their preferred follow-upmechanism: digital pre-test education, virtual group GC, one-on-one GC, or notinterested. The digital pre-test education module was developed by geneticcounselors at Nest and UIC and utilized a teach-back approach to ensureunderstanding of the benefits and limitations of GT, possible GT results, howresults impact care, and GT logistics. A GC reviewed completed HCRAs andfollow-up preferences. Patients consenting to GT after digital pretesteducation received a phone call and MyChart message to confirm consent andinform them the test was ordered and a saliva kit shipped. For patientsrequesting GC services, appointments will be scheduled. GT eligible patientsnot engaging with the digital navigator received standard referral and GCscheduling.

In a pilot phase from January to early May2024, 96 patients eligible for GT were sent a link to the digital navigator viatext or email to capture GT follow-up preference. Only one third of thoseinvited (n=31, 32%) engaged and only 38 (14%) selected a follow-up preference.To increase engagement, beginning mid-May, the workflow was updated such thatpatients meeting GT criteria select a follow-up preference immediately aftercompleting the HCRA and only those selecting digital pretest education are senta link via text or email. Additionally, a Spanish version of the HCRA was addedat this time. These changes increased the percent of patients who selected afollow-up preference from 14% to 74%.

In total, from January through June 2024, 156patients selected a follow-up preference via digital navigator, with most(n=98, 63%) opting for digital pre-test education, 4 selecting group GC, and 54selecting one-on-one GC. Of the 73 completing digital pre-test education, 31consented to GT, 7 were not interested in GT, and 19 were unsure about GT. Ofthe 31 who consented, 26 had a test order placed, 2 had prior GT, 2 had GT inprogress, and 1 declined GT after GC outreach. Of the 4 patients requesting groupGC, 1 completed and had GT ordered, 1 missed and has not rescheduled, and 2 arescheduled. Of the 54 patients requesting one-on-one GC, none have beenscheduled yet due to an administrative backlog.

Pairing post-assessment digital navigationwith HCRA allows patients to access education and GT based on individualpreferences. Most patients completing digital HCRA and meeting GT criteriaopted for digital pre-test education over one-on-one or group GC, allowing themto have a test ordered sooner. This digital solution has the potential toreduce bottlenecks and prioritizes limited GC availability for those who preferone-on-one or group counseling. Further work to optimize reminders to boostengagement with the digital navigator and to improve return of sample kits tothe laboratory is underway.

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