The founding of patient navigation is commonly attributed to Harold P. Freeman, MD, and his concerns of health care disparities, in particular, correlations between poverty, culture, social injustice, and disease outcomes.1 In 1990, Freeman created the first navigation program in Harlem, New York, which consisted of outreach community education and access to free mammography screening for low-income women paired with trained navigators who assisted women in traversing the health care system, eliminating barriers to care, and thereby improving the timeliness of care between abnormal finding, diagnostic resolution, and treatment initiation.2 Throughout the two decades following these pioneering efforts, oncology care continues to be transformed through the widespread adoption and expansion of patient navigation programs along with a continued focus on eliminating health care disparities and improving the patient experience.
IMPORTANCE OF PATIENT NAVIGATION
Oncology care has become increasingly complex as preventive care, early detection screening approaches, and oncology treatments continue to evolve. Understanding and navigating cancer care delivery system structures, interfaces, and inner workings can be challenging and problematic for even the most savvy of health care consumers. As such, patient navigators are increasingly recognized as an essential component of comprehensive cancer care serving as the lynchpin for facilitating a coordinated and seamless experience for cancer patients and their families. While specific responsibilities of oncology patient navigators vary based on unique program needs, common fundamentals among navigation roles are found, such as a focus on the identification and resolution of barriers to care, coordination of efficient evidence-based and patient-centered care, facilitating open communication and smooth transitions between the multidisciplinary team, and the provision of anticipatory guidance, education, and emotional support.
Significant contributions are documented throughout the oncology literature to demonstrate the impact navigation programs are making to improve not only clinical outcomes but also the overall patient experience. Wells and colleagues conducted a review and qualitative synthesis of 16 oncology patient navigation research articles published through October 2007.3 Paskett, Harrop, and Wells provided an update to this synthesis by summarizing new oncology patient navigation findings published November 2007 through July 2010.4 Some general themes among program outcomes include improvements in access to screening, time to diagnostic resolution and treatment initiation, patient and provider satisfaction, avoidable health care costs, and access to community resources.
WHAT’S IN A NAME/TITLE?
One challenge currently surrounding patient navigation pertains to the various titles, required qualifications, and subsequent role definitions that exist. A few examples of role titles that are often closely associated, if not assumed to be synonymous, with that of a patient navigator include care coordinator, case manager, and patient liaison. While distinct differences are found between navigators and each of these examples, common responsibilities and interventions can be found and tend to center around enhancing timely access to care and minimizing health care barriers. Building on the original navigation definition set forth by C-Change, the Oncology Nursing Society (ONS), the Association of Oncology Social Work (AOSW), and the National Association of Social Workers (NASW) collaboratively issued a joint position statement defining navigation as “individualized assistance offered to patients, families, and caregivers to help overcome healthcare system barriers and facilitate timely access to quality health and psychosocial care from prediagnosis through all phases of the cancer experience.”5
GROWTH AND EVOLUTION OF PATIENT NAVIGATION
Cantril and Haylock summarized the historical achievements that have paved the way for the development and advancement of oncology patient navigation.6 While identified milestones date as far back as the 1971 National Cancer Act, the majority of accomplishments have occurred since the signing of the 2005 Patient Navigation and Chronic Disease Act and subsequent allocation of competitive funding to create sustainable navigation models. In addition, numerous professional organizations have recognized and endorsed efforts to advance the field of oncology navigation including C-Change, the Academy of Oncology Nurse and Patient Navigators (AONN+), the Association of Community Cancer Centers (ACCC), ONS, AOSW, NASW, and the American College of Surgeons (ACoS) Commission on Cancer (CoC).
In fact, new patient-centered standards from ACoS have been phased in that now require CoC-accredited programs to provide access to patient navigation services as a mechanism to minimize system barriers and improve access to care. This impacts more than 1,500 cancer programs that provide care to more than 70% of patients with newly diagnosed cancer.7 The navigation standard specifies processes must be defined and established based on a community needs assessment and identified health care disparities. Thereafter, navigation services are evaluated, documented, and reported annually to the organization’s cancer committee with subsequent program modifications and enhancements to meet additional needs identified.8
LEARNING GAPS FOR PATIENT NAVIGATORS
As mentioned previously, oncology patient navigators are often viewed as the lynchpin of the cancer care experience. As such, navigators are expected to have current knowledge of standard and emerging treatment options as well as available community and supportive resources so they can appropriately guide and offer interventions based on patient-specific needs. For example, as advances are made in the field of personalized medicine, navigators need access to current information on the use of biomarkers and how these guide treatment decisions so they can appropriately educate and support patients in discussions related to treatment options. Furthermore, navigators need to be well-versed and skilled in side effect management as they are often the first to be contacted when a patient experiences treatment toxicities. Then, once treatment is completed, there are survivorship issues navigators can assist in clarifying, such as late- and long-term effects of treatment, surveillance schedules, and appropriate follow-up care.
Aside from managing the complex patient experience, one of the learning gaps frequently expressed by both navigators and program administrators is the desire to establish and measure meaningful program outcomes. Developing such metrics not only documents program successes, but also provides direction for quality improvements and process enhancements contributing to overall program sustainability.
These learning gaps demonstrate the importance of targeted education for oncology navigators to effectively advocate for and guide patient-centered evidence-based cancer care. Evaluations from the 2014 National Coalition of Oncology Nurse Navigators (NCONN) Annual Conference indicate navigators prefer attending live conferences with networking opportunities as their means for learning. In response to this feedback and the continued learning needs expressed by navigators, Haymarket Media developed the Oncology Nurse Advisor (ONA) Navigation Summit: Bringing Navigation to the Forefront, which will be held in Denver, Colorado, June 26-28, 2015. The intent of ONA Navigation Summit is to provide quality education for oncology patient navigators. This fast-paced and information-packed conference will consist of keynote, general, breakout, and networking sessions, along with access to a wide range of exhibitors.
Karyl Blaseg is interim director of the Billings Clinic Cancer Center, Billings, Montana.
1. Freeman HP. A model patient navigation program. Oncol Issues. 2004;19(5):44-46.
2. Freeman HP, Rodriguez RL. History and principles of patient navigation. Cancer. 2011;117(15 suppl):3539-3542. doi:10.1002/cncr.26262.
3. Wells KJ, Battaglia TA, Dudley DJ, et al; Patient Navigation Research Program. Patient navigation: state of the art or is it science? Cancer. 2008;113(8):1999-2010. doi:10.1002/cncr.23815.
4. Paskett ED, Harrop JP, Wells KJ. Patient navigation: an update on the state of the science. CA Cancer J Clin. 2011;61(4):237-249. doi:10.3322/caac.20111.
5. Oncology Nursing Society; Association of Oncology Social Work; National Association of Social Workers. Oncology Nursing Society, the Association of Oncology Social Work, and the National Association of Social Workers joint position on the role of oncology nursing and oncology social work in patient navigation. Oncol Nurs Forum. 2010;37(3):251-252. http://ons.metapress.com/content/f2830241m137mg1m/fulltext.pdf. Accessed January 14, 2015.
6. Cantril C, Haylock PJ. Patient navigation in the oncology care setting. Semin Oncol Nurs. 2013;29(2):76–90. doi:10.1016/j.soncn.2013.02.003.
7. About CoC accreditation. American College of Surgeons Web site. https://www.facs.org/quality-programs/cancer/accredited/about. Accessed January 14, 2015.
8. American College of Surgeons Commission on Cancer. Cancer Program Standards 2012: Ensuring Patient-Centered Care. v1.2.1. Chicago, IL: American College of Surgeons; 2012. https://www.facs.org/~/media/files/quality%20programs/cancer/coc/programstandards2012.ashx. Accessed January 14, 2015.