May 2016 VOL 7, NO 4

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Learning Guide

Basics of Patient Navigation

Kamilah Konrad, LMSW 

Patient navigation addresses barriers to care and enables patients to be screened for cancer and complete cancer-related care as recommended by their healthcare providers.1 Although the details of how patient navigation is implemented in various healthcare and community settings vary based on available services and resources, clientele served, community context, and access point in the cancer continuum, the role of the patient navigator includes navigation assessment, shared decision-making, and identification of barriers and resources.1-3

The Role of the Oncology Patient Navigator

The role of an oncology patient navigator is to improve patients’ timely access to cancer-related care throughout the cancer continuum.1-3 The navigator identifies and addresses real and perceived barriers to cancer screening and care, provides guidance and emotional support, encourages patient empowerment, advocates for patients, coordinates cancer-related care and resources, and provides general information to patients about cancer screening, treatment, and resources to reduce gaps in quality care and improve cancer-related outcomes.1-4 Navigators link patients to health and community programs and services, improve communication between patients and healthcare providers, encourage patients to cope by providing support and addressing fears, and facilitate the problem-solving process and shared decision-making with patients and their families.2,4

Navigation Assessment

To address patients’ logistical, structural, and sociocultural barriers to care, patients’ strengths and needs must be identified through an assessment process.1,2 The patients’ diagnosis and prognosis, personal characteristics, financial status, emotional distress, and physical, spiritual, and social environment should be considered.2,4 Assessments occur by developing rapport with patients, interviewing them empathetically, and communicating openly with patients, their caregivers/family members, and healthcare professionals about the patients’ strengths, assets, values, and needs.2,4,5 Through the assessment process, the patient navigator should identify gaps in services and respond to the patients’ preferences for support, receiving care, communication, decision-making, and disclosure.2,4 An assessment should also address patients’ health literacy levels; need for child care or elder care; understanding of cancer screening, treatment, or side effect management; scheduling challenges or limitations; feelings of fear and fatalism; insurance limitations; limited access to care; lack of transportation, housing, or lodging; linguistic or cultural needs; financial restrictions; physical or psychological comorbidities; mistrust or lack of awareness of the complex healthcare system; and lack of social support.1-4 Barriers may occur at various points in the cancer continuum, from prevention to end of life, and may overlap and repeat.1 Assessment may also reveal patients’ and their family members’ strengths, assets, and interpersonal resources (eg, a strong social support network, organizational skills for managing appointments and medications, reliable transportation, active coping strategies, preparedness for active care, and self-efficacy skills), as well as external resources (eg, established and active community resources and services).2,4

Shared Decision-Making

After assessments and discussions with patients, caregivers, family members, and other healthcare providers, patient navigators should support shared decision-making by encouraging patients to be informed and active partners with the navigator, healthcare team, and family, emphasizing the patient’s importance in the process. Navigators should support a patient’s autonomy in making their primary health decisions; however, caregivers and family members should be included as mutual participants based on the patient’s preferences for privacy or level of caregiver involvement.2,4,5 The navigator should confirm that all conveyed information regarding options is understood by all members of the partnership, limit gaps, correct misconceptions, and explore ambivalence.5 All relevant stakeholders should reach consensus on determining a realistic plan of action, including selecting needs to be addressed and identifying specific tasks and responsibilities to the patient, navigator, or caregiver—which may include completing paperwork, attending appointments, advocating for care or resources, and documenting patients’ treatment choices and care preferences.1-5 Shared decision-making breaks down the many steps of an often lengthy and complex cancer care process, leading to increased knowledge, treatment adherence, and better patient health outcomes.1-3 This process is ongoing with no particular end point and may require reevaluation and changes over time.

Identifying Resources

Patient navigators should identify and provide appropriate resources that address identified barriers to care for patients.2 Resources may be community- or health facility–based, governmental, or within patients’ social networks.1 Navigators should also refer patients to culturally appropriate resources and cancer-related health information from credible sources about cancer screening, treatments, and side effect management.1 They also refer patients to free and low-cost services and programs that may address barriers to accessing care and affordability of care (eg, transportation, lodging, medication assistance, nutritional supplements, support groups, or financial assistance), thereby assisting patients with the use of these services in a timely manner; resources should address patients’ physical, spiritual, and psychosocial needs.1-3

Conclusion

It is the role of the patient navigator to build a strong partnership with patients, their families, and their caregivers that is multidimensional, customized, and patient-centered.4 Through assessment, shared decision-making, and identifying and coordinating resources, patient navigators can make care more accessible and may increase adherence to screening and timely diagnostic follow-up care and cancer treatment.1,3 Navigation can help make care more understandable, accessible, and affordable for patients, in addition to improving their psychological well-being, quality of life, and health outcomes.1-3

Case Study

Malik, aged 54 years, is a construction worker who was recently diagnosed with lung cancer after many years of smoking. He is an uninsured, unmarried, Muslim man who lives 15 miles from the hospital where he was recommended for treatment with radiation and chemotherapy. He does not want to tell his elderly mother with whom he lives about his diagnosis and feels guilty about his diagnosis because of religious restrictions on smoking; however, Malik is motivated to be treated, plans to follow through with treatment recommendations, and would like more information about his treatment options and smoking cessation programs. He is also concerned about how he will pay his bills for treatment and for transportation to and from the hospital, because he will be unable to work.

Check Your Knowledge

1. What role should the oncology navigator play with Malik?
a. Provide information and resources
b. Provide cancer screening locations
c. Provide patches to help him stop smoking
d. Contact his family to explain his diagnosis

2. What questions should be asked of Malik during the assessment process?
a. “Were you unaware that smoking could cause cancer?”
b. “Who do you have in your support network that may be able to help you?”
c. “Why hasn’t your company paid for you to have health insurance?”
d. “Have you been a Muslim your entire life?”

3. Which strengths can be assessed based on what Malik has shared?
a. He has a significant social support network
b. His faith helps him to cope and feel hopeful about the future
c. He is more likely to be familiar with cancer because of his age
d. He is willing to follow treatment recommendations

4. What would encourage Malik to be part of the shared decision-making process?
a. Invite members from his religious community to convince him to accept treatment
b. Assure him that his medical information will be kept confidential and private
c. Recommend that his first step should be choosing a smoking cessation program
d. Present him with information about a patient who has already received the recommended treatment

5. Which of these resources would be appropriate for Malik?
a. Local support groups and services
b. Lodging and housing programs
c. Financial and insurance assistance
d. Brochures for family members

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

Acknowledgments

The author is grateful to Linda Fleisher, PhD, MPH, Senior Scientist, Children’s Hospital of Philadelphia, PA; Associate Research Professor-Adjunct, Department of Pediatrics, University of Pennsylvania; Associate Research Professor/Collaborating Member, Fox Chase Cancer Center, Philadelphia, PA, and Mandi Pratt-Chapman, MA, Director, The George Washington University (GW) Cancer Institute, Washington, DC, for their work on this component of the Oncology Patient Navigator−Certified Generalist examination.

References

  1. Braun KL, Kagawa-Singer M, Holden AE, et al. Cancer patient navigator tasks across the cancer care continuum. J Health Care Poor Underserved. 2012;23:398-413.
  2. Doll R, Barroetavena MC, Ellwood A-L, et al. The cancer care navigator: toward a conceptual framework for a new role in oncology. Oncology Exchange. 2007;6:28-33.
  3. Wells KJ, Battaglia TA, Dudley DJ, et al. Patient navigation: state of the art or is it science? Cancer. 2008;113:1999-2010.
  4. Palos GR, Hare M. Patients, family caregivers, and patient navigators: a partnership approach. Cancer. 2011;117(suppl 15):3592-3602.
  5. 5Butterworth SW. Influencing patient adherence to treatment guidelines. J Manag Care Pharm. 2008;14(suppl B):21-24.
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