BCCCP
Patient Navigation
Debbie Webster, BSN, RN, LMSW
May 3, 2011
Patient Navigation Defined

Timely movement of an individual through the
health care continuum from prevention,
detection, diagnosis, treatment support and end
of life care


www.patientnavigation.com
Individualized assistance offered to patients to
help overcome barriers to care, whether through
the health care system or the environment

American College of Surgeons – Cancer Program Standards 2011
Harold P. Freeman
“Disease always occurs within a context
of human circumstances including
economic status, social position, culture
and environment. These human
circumstances can determine the length
and quality of survival. ”
Navigation vs. Case Management

One of Navigation’s primary purposes is to
decrease cancer disparities.

The focus on disparities is a major
distinguishing factor between Patient
Navigation and Case Management.
Disparities in Cancer Care

The 5-year survival rate after a 1st
diagnosis of breast cancer is 90% for
white women and 77% for African women.

Racial/ethnic differences in:

Stage at diagnosis (Robinson-White, et. al. 2010)
 Mammography utilization (Battaglia, et. al., 2007)
 Follow-up after abnormal breast screening
 Racial/ethnic minority women often have the
longest delays (Battaglia, et. al., 2007)
 Early termination of treatment (Ell et. al., 2009)
Barriers to Care

Financial barriers (insurance)

Communication barriers (language)

Lack of information or misinformation

Missed appointments (might be due to
work, child care or transportation issues)

Medical system (lost medical reports)

Fear & emotional barriers
Cancer Burden

A patient without health insurance who has
a diagnosis of cancer can expect a 15%
lower 5-year survival than one who is
insured.

Survival rates for those on Medicaid are
essentially the same.
Navigation’s History

1st program – 1990

Harlem, NY
 Population
predominantly African American
and Hispanic
 Most residents live in poverty
 Most residents have a low educational level

The Goal - Increase 5-year survival rates
of cancer by helping patients move
through the diagnostic and treatment
Does Navigation Work?
1st program outcomes

1964-1986 the 5-year
survival rate at Harlem
Hospital = 39 %


(60% for white women)
1995-2000 the 5-year
survival rate at Harlem
Hospital = 70%
Stage
0
Stage
I
Stage
II
Stage
III
Stage
IV
19641986
19952000
0%
12%
6%
29%
45%
38%
39%
14%
10%
7%
Does Navigation Work?
Additional Outcomes

Earlier diagnosis

Stage 0 diagnosis went from 12.4% to 25.8%
 Stage IV diagnosis went from 16.7% to 9.4%
 Gabram et. al. (2008)

Diagnostic resolution

90% of navigated Hispanic women followed
through to diagnostic resolution compared to
66% of non-navigated women
 Ell et.al. (2007)
More Outcomes

Battaglia et. al. (2006) reported that
women were 39% more likely to have
timely follow up on a diagnostic evaluation
after implementation of Patient Navigation.

Fang et. al. (2007) reported that the
cervical cancer screening rate increased
from 17% to 83% in Korean women after
the introduction of cervical cancer
education and bilingual patient navigation.
Navigation in Cancer Care

Research consistently shows Navigation
to be effective at moving patients across
the Cancer Care Continuum

Identifying & bringing patients into screening
 Walking them through the steps of detection
and diagnosis when necessary
 Facilitating complete and timely treatment

An individualized needs assessment is key
Key components of Patient
Navigation:

Removing barriers to care for individual
patients

Documenting these barriers

Implementation of a feedback system
regarding barriers aimed at system level
change (requires administrative support)
 Vargas et. al. (2008)
Cancer Continuum
Prevention
Detection
Diagnosis
Treatment
Survivorship
Prevention Navigation

Primary prevention

Targeted outreach
HPV vaccinations
 Colorectal cancer screening & polyp removal


Secondary Prevention

Targeted outreach to identifying cancer at an
earlier, more treatable stage

Increasing the % of enrolled patients who are up to
date on breast and cervical cancer screenings
Navigation and Outreach

CDC recommends the following:

Client reminders

Small media

One-on-one education

Reducing structural barriers

The Community Guide
 www.thecommunityguide.org
Outreach - Client reminders

Effective with print or telephone communication.


Can include things like:




Reminding people they are due (or late) for
screening.
Information about screening
Benefits of screening
Ways to overcome barriers to screening
 The Community Guide
It is important to have a feedback system in
place to determine if the client followed-up on
the reminder.
Outreach – Small Media

Videos & printed communications (letters,
brochures, flyers, newsletters)

Convey educational or motivational information




Describe screening tests and procedures
Provide reasons for and benefits of screening
Suggest ways to overcome barriers to screening
Can address a general population or tailored to
a specific population

The Community Guide
Outreach –
One-on-one Education

Can be by telephone or face-to-face

Nurse, health educator, lay health advisor,
volunteer

Education can be general or targeted to
the specific circumstances of the individual

The Community Guide
Outreach –
Reducing Structural Barriers

Activities that make it easier for people to
access preventive services:

Modifying hours of service to meet client
needs (evening and weekend hours)
 Offering services in alternative nonclinical
settings (mobile vans)
 Transportation assistance
 Translation services

The Community Guide
Navigation and Detection

Navigation increases the percentage of
patients who complete their screening or
diagnostic test

Decreasing missed appointments
 Increasing the timeliness of screening
completion
 Decreasing the number of patients who are
lost to follow-up
Navigation & Screening
Education on importance of cancer
screening
 Explaining cancer screening process
 Reminders of appointments
 Assistance in rescheduling if appointments
are missed
 Emotional support – addressing fears
 Assistance with transportation, child care
or other barriers to screening

Navigation’s Impact on
Screening

Research shows that any type of
navigation aimed at increasing screening
has an impact

Detrich (2006) tested telephone navigation
and found that it impacted screening rates of
mammography, pap tests and colorectal
cancer screening
Navigation and Diagnosis

Patient Education

Importance of diagnostic follow-up
 Explaining cancer diagnostic test process

Patient Support

Emotional support – addressing fears
Reduce Barriers
 Appointment Reminders

Navigation and Diagnosis

Easy and timely access to surgical
consultations post-abnormal finding is
essential to a woman’s emotional wellbeing


Increasing the timeliness (decreasing number
of days) between abnormal screening result
and diagnostic completion
Navigate through health care setting
A patient’s perspective
"Sara feels like an angel sent to me. It’s
unbelievable to have someone within the
medical system come alongside you,
anticipate your needs, hear your concerns,
and offer help.“
~ Breast cancer patient
Steelquist, 2009
Care Coordination Problems
A 2006 survey :

Half of cancer patients say that care was
uncoordinated at times. The sickest patients and
those with the deadliest tumors were most likely to
encounter a problem.






Records or test results did not reach doctor in time for
appointment - 13%
Left a doctor's office with critical question unanswered 15%
Confused about prescription medication - 20%
Sent for duplicate tests - 21%
Given conflicting information from doctors or nurses - 25%
Any of these coordination problems - 50%
Navigation and Treatment
 Continued
assistance with navigating the
health care setting

Tracking patients diagnosed with cancer into the
start of treatment

Increasing timeliness (decreasing number of
days) between diagnosis and initiation of cancer
treatment

Coordinating care among different providers

Have medical records available at appointments

Assist in scheduling of follow-up appointments
and their reminders
Navigation and Treatment

Decrease disparities by improving access
 Ensure

Build awareness of all available services
 Help

unrestricted access to all services
clarify choices
Dispel fears so patient seeks appropriate
care options
 Dispelling
fear can increase compliance with
treatment care recommendations

Education on the treatment phase
“Even more than the cancer fears, the
financial worries were eating me alive. I
knew treatment was going to be expensive
and I didn’t want to burden my kids. But I
wanted to live”
~ A breast cancer patient
Steelquist, 2009
Navigation and Survivorship

Transitional care

Proactive management of health
Long-term (Survivorship) Care Plan
 Maintain appropriate follow-up
 Symptom management
 Wellness/nutrition


Emotional concerns
Support groups
 Stress management

Navigation and Survivorship

Few models on this type of navigation

No research has been done

Many hospital Nurse Navigators add
survivorship issues into their plan of care
for patients

Follow up calls on HRT therapy
We can’t hire a Navigator

Patient Navigation Team

In many programs, the roles of the Navigator
is divided among multiple staff

Unmet needs are identified and then split
based on the skills of each team member
“Poverty should not be an offense
punishable by death.”
~ Harold Freeman, MD
cancerpatientnavigation.org
Questions?
Illustration: Guy Billout
References
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American College of Surgeons Commission on Cancer. (2011) Working draft:
Cancer program standards 2012: Ensuring patient-centered care. Retrieved on
February 7, 2011 from http://www.facs.org/cancer/coc/cps2012draft.pdf
Battaglia, T., Roloff, K., Posner, M., & Freund, K. (2007) Improving follow-up to
abnormal breast cancer screening in an urban population. Cancer. 109(2); 359366.
Center for Disease Control. (2010) Using evidence for public health decision
making: Screening for breast, cervical and colorectal cancer. The Guide to
Community Preventative Services.
Dillon, T. (2006) Cancer care often uncoordinated. Retrieved on April 7, 2011 from
http://www.usatoday.com/news/health/2006-11-19-cancer-care_x.htm
Ell, K., Vourlekis, B., Xie, B., Nedjat-Halem, F., Lee, P., Muderspach, L., Russell,
C., & Palinkas, L. (2009) Cancer treatment adherence among low-income women
with breast or gynecologic cancer. Cancer. (October); 4606-4615.
Ell, K., Vourlekis, B., Lee, P., & Xie, B. (2007) Patient navigation and case
management following an abnormal mammogram: A randomized clinical trial.
Preventative Medicine. (44); 26-33.
References
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Fang, C., Ma, G., Tan, Y., & Chi, N. (2007) A multifaceted intervention to increase
cervical cancer screening among underserved Korean women. Cancer Epidemilogy,
Biomarkers & Prevention. 16(6); 1298-1302.
Freeman, H. (2004) A model patient navigation program. Oncology Issues
(September/October); 44-46.
Freeman, H. (2008) Patient navigation: Community centered approach to reduce
cancer mortality. Retrieved on January 20, 2011 from
http://georgiacancer.org/treat/pat.nav.pdf
Gabram, S., Lund, M., Hatchett, N., Bumpers, H., Okoli, J., Johnson, B., Kirkpatrick,
G., Brawley, O. (2008) Effects of an outreach and internal navigation program on
breast cancer diagnosis in an urban center with a large African-American population.
Cancer. 113(3); 602-607.
Pfizer. Cancer patient navigation overview. Retrieved on February 14, 2011 from
http://www.cancerpatientnavigation.org
Robinson-White, S., Conroy, B., Slavish, K., & Rosenzweig, M. (2010) Patient
navigation in breast cancer: a systematic review. Cancer Nurse. 33(2); 127-140.
Steelquist, C. (2009) On the right path. Retrieved on February 11, 2011 from
http://www.fhcrcorg/about/pubs/quest/articles/2009/path.html.