Use of a Digital Navigator to Deliver Patient-Centered Genetic Services in Mammography

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

Patients receiving screening mammograms completed HCRA in the waiting room prior to imaging. Patients who met GT criteria were asked via digital navigator to choose their preferred follow-up mechanism: digital pre-test education, virtual group GC, one-on-one GC, or not interested. The digital pre-test education module was developed by genetic counselors at Nest and UIC and utilized a teach-back approach to ensure understanding of the benefits and limitations of GT, possible GT results, how results impact care, and GT logistics. A GC reviewed completed HCRAs and follow-up preferences. Patients consenting to GT after digital pretest education received a phone call and MyChart message to confirm consent and inform them the test was ordered and a saliva kit shipped. For patients requesting GC services, appointments will be scheduled. GT eligible patients not engaging with the digital navigator received standard referral and GC scheduling.

In a pilot phase from January to early May 2024, 96 patients eligible for GT were sent a link to the digital navigator via text or email to capture GT follow-up preference. Only one third of those invited (n=31, 32%) engaged and only 38 (14%) selected a follow-up preference. To increase engagement, beginning mid-May, the workflow was updated such that patients meeting GT criteria select a follow-up preference immediately after completing the HCRA and only those selecting digital pretest education are sent a link via text or email. Additionally, a Spanish version of the HCRA was added at this time. These changes increased the percent of patients who selected a follow-up preference from 14% to 74%.

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

Pairing post-assessment digital navigation with HCRA allows patients to access education and GT based on individual preferences. Most patients completing digital HCRA and meeting GT criteria opted for digital pre-test education over one-on-one or group GC, allowing them to have a test ordered sooner. This digital solution has the potential to reduce bottlenecks and prioritizes limited GC availability for those who prefer one-on-one or group counseling. Further work to optimize reminders to boost engagement with the digital navigator and to improve return of sample kits to the laboratory is underway.