BCCCPBCCCPPatient NavigationPatient Navigation
Debbie Webster, BSN, RN, LMSW
May 3, 2011
Patient Navigation DefinedPatient 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. FreemanHarold 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 ManagementNavigation 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 CareDisparities 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 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 BurdenCancer 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 Navigation’s History 1st program – 1990
Harlem, NYPopulation predominantly African American and
HispanicMost 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 processes.
Does Navigation Work?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%
1964-1986
1995-2000
Stage 0
0% 12%
Stage
I6% 29%
Stage II
45% 38%
Stage III
39% 14%
Stage IV
10% 7%
Does Navigation Work?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 OutcomesMore 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 CareNavigation 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 Key components of Patient Navigation: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 ContinuumCancer Continuum
Prevention Detection Diagnosis Treatment Survivorship
Prevention NavigationPrevention 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 OutreachNavigation 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 remindersOutreach - Client reminders Effective with print or telephone communication.
Reminding people they are due (or late) for screening.
Can include things like: 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 MediaOutreach – 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 –Outreach –One-on-one EducationOne-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 –Outreach –Reducing Structural BarriersReducing 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 DetectionNavigation 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 & ScreeningNavigation & 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 ScreeningNavigation’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 DiagnosisNavigation 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 DiagnosisNavigation and Diagnosis Easy and timely access to surgical
consultations post-abnormal finding is essential to a woman’s emotional well-being Increasing the timeliness (decreasing number
of days) between abnormal screening result and diagnostic completion
Navigate through health care setting
A patient’s perspectiveA 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 ProblemsCare Coordination ProblemsA 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%
~ USA Today
Navigation and TreatmentNavigation 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 TreatmentNavigation and Treatment Decrease disparities by improving access
Ensure unrestricted access to all services
Build awareness of all available services Help clarify choices
Dispel fears so patient seeks appropriate care options Dispelling fear can increase compliance with treatment care
recommendations
Education on the treatment phase Understand and manage side effects
“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 SurvivorshipNavigation 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 SurvivorshipNavigation 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 NavigatorWe 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?Questions?
Illustration: Guy Billout
ReferencesReferences
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); 359-366.
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.
ReferencesReferences
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.
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