April 2016 VOL 7, NO 3

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Learning Guide

Basics of Healthcare

Mandi Pratt-Chapman, MA1; Linda Fleisher, PhD, MPH2; Andrea Dwyer, BS3; Monica Dean4 

Although the role and scope of practice for a patient navigator does not require a clinical license or advanced medical or healthcare degree, patient navigators need to have certain medical knowledge to interact with the healthcare team, and ensure that patients are successfully navigated through a difficult time and complex system.

For example, patient navigators need to understand at a basic level how the healthcare system functions, as well as how it is financed. They should know who the various members of the healthcare team are, in addition to their roles; the major therapeutic modalities for cancer, and available support services for patients with cancer; how insurance is structured, and the types of cost-sharing required by patients; who is eligible for Medicare and Medicaid in your state, and what the various parts of Medicare (Parts A through D) cover; how to explain to a patient when they should seek emergency, primary, or specialty care; and what type of care (ie, inpatient or outpatient) the patient is receiving.

Patient navigators will also need to understand what the physicians and nurses are saying, which requires a basic understanding of cancer and general medical terminology. It is helpful to understand the challenges patients face, determinants of compliance, what health behaviors can reduce cancer risk and facilitate treatment, diagnostic procedures for various tumors, major modalities of cancer treatment, and the importance of clinical trials. Although it is not the job of patient navigators to convince patients to participate in a trial—that decision is theirs alone—raising awareness about the role of clinical trials in advancing cancer therapies is a way patient navigators can contribute.1 In addition, to provide support to patients, they should understand the physical, psychosocial, economic, and spiritual impact cancer may have on patients and their families.

Case Study

Javier owns a construction business, and has historically paid out-of-pocket for any medical services he needed. He was happily surprised to find out that he could afford coverage through the new health insurance marketplaces rolled out as a result of the Affordable Care Act, and signed up for a plan that requires a monthly premium of $300 after rebates, and coinsurance of 20% for any healthcare services he receives after a $50 copay and $1000 deductible.

Javier is at high risk for prostate cancer. During his annual physical, Javier’s primary care physician screens him for prostate cancer with a digital rectal examination (DRE) and prostate-specific antigen test, and refers him for a biopsy when the tests come back with suspicious findings. Javier has the biopsy at a local hospital, and is, unfortunately, diagnosed with prostate cancer. When he meets with the oncologist, his prostate cancer is confirmed, and Javier is offered the opportunity to participate in a clinical trial. He does not want to participate in a clinical trial, however, because he thinks the physicians will experiment on him. Javier heard the physician say something to another doctor about TNM, and did not clearly understand the kind of treatments he would need, or what his physician expects from him as a patient.

Check Your Knowledge

1. What does 20% coinsurance mean?

a. Javier must pay 100% of his deductible, and then 20% of any remaining healthcare costs for care he receives

b. Javier must pay his deductible and 20% of his premium, and the government will pay 80%

c. Javier must pay 20% of his deductible, and the government will pay for the remaining 80%

d. Javier is covered for ≤120% of the cost of standard-of-care treatment, as long as he keeps his premiums current

2. What does TNM refer to?

a. The time it will take Javier to complete treatment

b. A system used to stage and grade cancer

c. A special screening process to diagnose prostate cancer

d. Specialized care centers where men can receive treatment

3. What would be a navigator’s best response to Javier’s concerns about clinical trials?

a. Tell him it is his decision, it is fine for him not to participate, and that many patients do not want to be involved in trials, so he is not alone

b. Tell him the physician will be disappointed if he does not participate, and that he should listen to the experts

c. Explain to him that it is important for him to talk to his physician to better understand what is being offered in the trial, and reassure him that his care will be at least equal to standard treatment (ie, he would not receive a placebo but rather standard treatment plus what is being included in the trial)

d. Explain to him that all patients at the cancer center have to participate in a trial to qualify to receive care

4. What does DRE refer to?

a. An examination where a physician or nurse inserts a gloved, lubricated finger into the rectum to evaluate the prostate size and feel for lumps or abnormalities

b. A blood test analyzed for a substance naturally produced in the body, to see whether instance of this substance is higher than usual

c. An imaging test using x-rays

d. An ultrasound test using sound waves

5. Which of the following is not used as a treatment for prostate cancer?

a. Radiation therapy

b. Imatinib

c. Prostatectomy

d. Orchiectomy

Acknowledgment: The authors are grateful to Angela Patterson, Vice President, Georgia Center for Oncology Research and Education, Atlanta, for her work on this component of the Oncology Patient Navigator−Certified Generalist examination.

Answers

1, A; 2, B; 3, C; 4, A; 5, B.

Reference

  1. Willis A, Reed E, Pratt-Chapman M, et al. Development of a framework for patient navigation: delineating roles across navigator types. Journal of Oncology Navigation & Survivorship. 2013;4:20-26.
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