December 2013 VOL 4, NO 6

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Patient Navigation

Development of a Framework for Patient Navigation: Delineating Roles Across Navigator Types

Anne Willis, MA1; Elisabeth Reed, MPA1; Mandi Pratt-Chapman, MA1; Heather Kapp, MPH, LICSW1;
Elizabeth Hatcher, RN, BSN1; Virginia Vaitones, MSW, OSW-C2; Stacy Collins, MSW3;
Jennifer Bires, LICSW, OSW-C4; Etta-Cheri Washington5
1George Washington University Cancer Institute; 2Association of Community Cancer Centers; 3National
Association of Social Workers; 4Association of Oncology Social Work; 5Capital City Area Health Education Center


Background: The profession of patient navigation is rapidly growing: community health workers (CHWs), patient navigators, and clinically licensed navigators (ie, nurse and social work navigators) play critical roles in the continuum of care. As navigators become more integral to the healthcare system, their roles need to be more clearly defined. This project sought to develop a framework to describe the similarities and differences across navigator types with a focus on clarifying the unique roles and responsibilities of patient navigators.

Methods: Leveraging expertise from project partners representing each of the navigator types, the framework was developed in 3 phases: a literature and internet review, mapping of review findings to functional area domains in a draft comprehensive framework, and creation of a simplified framework that delineated the similarities and differences for each domain across the 3 navigator types.

Results: A consensus-based finalized framework was developed that includes 12 functional area domains and indicates areas of commonality and distinction among CHWs, patient navigators, and clinically licensed navigators.

Conclusions: With more clarity regarding the roles and responsibilities of patient navigators, the field of patient navigation can move toward greater standardization of the profession within the healthcare system. The Patient Navigation Framework: Navigator Function Across Domains will serve as a guide for developing patient navigation–specific competencies, which will become the basis for competency-based training and thus inform certification efforts.


Several new healthcare professional roles have emerged to help patients navigate around barriers to accessing care. Though they may fall under the umbrella term of “navigator,” confusion exists about their unique roles and responsibilities. Community health workers (CHWs), patient navigators, and clinically licensed navigators (ie, nurse and social work navigators) are 3 professional types that have overlapping yet distinct roles and responsibilities. For example, they all involve individual or patient education, but the types of information provided can vary. The term patient navigator is used here to encompass professionals who are sometimes referred to as lay navigators. Because the latter term implies that these navigators have not received training or education or are not professionals, the term is used throughout this discussion rather than the term. The purpose of this paper is to clarify the role of the patient navigator who straddles community and healthcare settings vis-à-vis community health workers or clinically licensed navigators operating predominantly within the healthcare system.

Establishing competencies is critical for creating consistency across a profession. CHWs have a defined set of competencies in several states,1 and the Oncology Nursing Society (ONS) recently launched a project to define nurse navigator competencies.2,3 The Association of Oncology Social Work (AOSW) is also in the process of developing social work navigator–specific competencies. Despite these advancements, there is a lack of clarification about the roles of patient navigators and how they differ from the other navigator types.4,5 Identification of core competencies specifically for patient navigators is therefore needed to develop a standard of practice for patient navigators that is distinguishable from other navigator types. Before competencies can be established, however, the roles and responsibilities need to be clearly defined.

To clarify and develop consensus on the roles and responsibilities of patient navigators, the George Washington University (GW) Cancer Institute embarked on a collaborative project with national stakeholders in navigation. This paper describes an effort to create a role-delineation framework for patient navigation to guide the development of patient navigator–specific competencies. Ultimately, the project findings can be used to standardize patient navigation practice through the development of competency-based training.

Methods
To create the framework, we used a collaborative approach that included a steering committee composed of 18 individuals with navigation expertise. Participants included representatives from the Academy of Oncology Nurse & Patient Navigators (AONN+), Association of Community Cancer Centers (ACCC), National Association of Social Workers (NASW), AOSW, and ONS. Patient navigators and CHWs from MAC Inc. (Maintaining Active Citizens), City of Hope, Nueva Vida, Moffitt Cancer Center, Capital City Area Health Education Center, and the University of South Florida were also integral to the effort.

Framework development took place in 3 phases: a literature and internet review, mapping of content to functional area domains in a draft comprehensive framework, and creation of a simplified framework that delineated the similarities and differences for each functional area domain across the 3 navigator types. In phase 1, we conducted a literature review and online search to identify published and/or public patient navigation training curricula, CHW certification competencies, and journal articles on the roles, responsibilities, tasks, competencies and/or activities of the 3 navigator types.

In phase 2, we created a framework outline that included the 3 patient navigator types and functional area domains for each. The common domains across navigation types were mapped vertically while the differing roles, responsibilities, tasks, competencies, or activities of CHWs, patient navigators, and clinically licensed navigators were included to the right of each domain. Functional area domains were established based on domains found in the literature and internet review. One researcher mapped the information identified in phase 1 to the framework. For example, one of the competencies identified by Minnesota for CHWs is the ability to define their scope of practice.1 This was mapped to the framework by identifying the functional area domain (Professional Roles and Responsibilities) and entering the competency statement into the box for CHWs. When this draft comprehensive framework was complete, 3 additional researchers with patient navigation expertise reviewed the framework to attain consensus on the mapping process. The 4 researchers collaboratively reorganized the content by combining similar competencies, moving content to different domains, and collapsing several domains.

The steering committee met by teleconference to review the project and the draft comprehensive framework. Participants discussed the goals and methodology and were asked to provide additional resources to add to the framework. Several new resources were recommended and incorporated into an updated framework that was e-mailed to the partners for final approval for this phase.

In phase 3, the framework was refined to focus on the similarities and differences across navigator types. The focus was on the patient navigator’s unique role compared with the other navigator types because the others have already been defined or are being defined. Based on the draft comprehensive framework, the 4 researchers drafted definitions for each functional area domain to encompass the similarities across navigator types. These definitions were based on existing definitions when possible as well as group consensus. The researchers also created short, high-level summary statements that described the distinctive role of each navigator type. These summary statements were based on the information in the draft comprehensive framework as well as the researchers’ expert opinion.

This simplified framework was e-mailed to the steering committee and reviewed by teleconference. Participants were then assigned to 1 of the 3 subgroups, each of which included a CHW, 1 or 2 patient navigators, a nursing representative, and a social work representative. Facilitated by a GW Cancer Institute research team lead, the groups were assigned 4 functional area domains and met by teleconference to provide feedback on the similarities and differences presented in the simplified framework. Each team lead compiled the subgroup’s feedback and sent an updated version of the group’s selected functional area domains back to their subgroup for review and finalization.

With the final feedback from each subgroup incorporated, a fifth researcher reviewed the framework for coherence and identified remaining gaps. An updated simplified framework was e-mailed to the whole group. Participants met by teleconference to review any further feedback or seek clarification. The revised framework was e-mailed again to the group, and participants were asked to provide additional edits or comments by e-mail. Consensus was reached through this final round of feedback.



Results
In phase 1, we identified 4 patient navigator training programs (GW Cancer Institute Patient Navigation Training,6 Patient Navigator Training Collaborative Level 17 and Level 28 Training, Patient Navigation Research Program Training Curricula,9 Ho`okele i ke Ola (Navigating to Health) Patient Navigation Training,10 and Cancer Disparities Research Program11). We also reviewed 5 programs with published or publicly available information on CHW training objectives or curricula (Boston,17 Minnesota,1 New Mexico,18 New York,18 Ohio,19 and Texas20) as well as 5 journal articles referencing roles and responsibilities across navigator types.2,21-24 Project partners recommended inclusion of the AOSW/NASW/ONS joint statement on patient navigation,25 the AOSW scope of work,26 and the ACCC Cancer Program Guidelines on patient navigation services.27 In phase 2, the original draft comprehensive framework was developed with 23 functional area domains. These domains were then collapsed into 12 domains as the roles, responsibilities, tasks, competencies, and/or activities were moved and combined.

The finalized framework includes 12 functional area domains: professional roles and responsibilities, community resources, patient empowerment, communication, barriers to care/health disparities, education/prevention and health promotion, ethics and professional conduct, cultural competency, outreach, care coordination, psychosocial support services/assessment, and advocacy. Differences between CHWs, patient navigators, and clinically licensed navigators are described to the right of each domain.

For example, in the domain “Professional Roles and Responsibilities,” regardless of navigator type, one must have a knowledge base and the skills needed to perform job-related duties and tasks, including understanding one’s scope of practice, supporting evaluation efforts, and identifying and exercising self-care strategies. Critical skills include organizational skills, office skills, interpersonal skills, time management, problem-solving, multitasking, and critical thinking. While CHWs should have general knowledge on health issues such as cancer, diabetes, obesity, heart disease, stroke, HIV/AIDs, and other chronic diseases, the oncology patient navigator should have a knowledge of cancer screening guidelines, diagnostic processes, treatment options, survivorship issues, and related physical, psychological, and social issues that might arise for cancer patients. In contrast, a social worker or nurse navigator should have knowledge of cancer clinical impacts and the ability to intervene to manage symptoms and assess functional status or psychosocial health. CHWs should document their activities within a client record, while patient navigators may document patient encounters, barriers to care, and resources or referrals within a client or medical record. Clinically licensed navigators should provide active documentation in the medical record. Finally, CHWs should focus evaluation on the community’s needs and health behaviors. Patient navigators should conduct evaluation based on barriers to care, health disparities, and quality indicators. And the evaluation focus for clinically licensed navigators should be clinical outcomes and quality indicators.

The Table illustrates the finalized Patient Navigation Framework: Navigator Function Across Domains, inclusive of all 12 domains and comparisons across navigator types.

Conclusion
This framework helps to fill a critical gap in the field of patient navigation. The goal of the framework is to begin to clarify similarities and differences across patient navigator types, with a focus on better defining the unique role of patient navigators in the continuum of care. Aligned with the success of CHWs in creating certification programs at the state level, this project is the first step in a concerted effort to move toward creating a set of common competencies for patient navigators that can be used to create training and certification programs and ensure consistency across the profession. Next steps include refining the framework based on feedback from a larger group of patient navigators, creating competency domains and statements based on functional area, and validating the competency statements with a larger group of patient navigators and their supervisors through a national survey. A free training program will be developed around these competencies. Standardization across the profession will facilitate research on the efficacy and value of patient navigators to continue to advance the field.

Acknowledgments
We would like to acknowledge all of the contributors to the project: Susan Bowman, RN, OCN, CBCN, MSW, Oncology Nursing Society; Margaret Darling, Nueva Vida; Leigh Ann Eagle, MAC Inc.; Lorena Gaytan, City of Hope; Linda Paige, Moffitt Cancer Center; Ana Quijada, Nueva Vida; Fedra Sánchez, Nueva Vida; Lillie Shockney, RN, BS, MAS, Academy of Oncology Nurse & Patient Navigators; David Trejo, City of Hope; Coni Williams, MS, University of South Florida. Partial support for this project was provided by the Avon Foundation for Women.

Disclosures
All authors report nothing to disclose.

Corresponding author
Anne Willis, MA
George Washington University Cancer Institute
2030 M Street, Suite 4069
Washington, DC 20036

References
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