With patient navigation now established as a valuable component of cancer care, most providers understand what “navigation” means, but fresh insights such as those provided by a veteran of navigation, Lillie D. Shockney, RN, BS, MAS, are welcomed.
Ms Shockney, herself a 2-time cancer survivor, is the University Distinguished Service Professor of Breast Cancer, Johns Hopkins School of Medicine, Baltimore, MD.
As Ms Shockney described in her talk at the 2016 ASCO Annual Meeting—“The Cancer Navigator: It’s All About the Patient”—navigation has evolved from a community-based concept aimed at increasing access to mammography to a structured process for guiding patients along the cancer continuum. In step with these changes, Ms Shockney shared the following observations at ASCO.
Definition of Navigation Varies
Navigation is “not a person but a process” by which the patient is given individualized support across the continuum of care. This begins with community awareness of the need for cancer screening and continues through diagnosis, treatment, survivorship, and end of life. The primary aims are to identify and eliminate barriers to high-quality and timely care, incorporating education and psychosocial support for the patient and family.
Although these functions may be carried out by nurses, physician assistants, social workers, and other allied health professionals, Ms Shockney emphasized, “Everyone involved in taking care of the patient has some role in navigation. It should not be seen as an isolated process or an add-on to care delivery.”
Navigators can come from several disciplines, but 75% of oncology nurse navigators came from the oncology nursing setting after approximately 15 years of nursing. Oncology nurses, therefore, bring a wealth of experience to patient navigation, she pointed out.
Although navigation first aimed to enhance the care of underserved populations, its scope has broadened in the past 5 years based on the understanding that “any patient may well benefit from being navigated,” she said. With this in mind, she advised patient navigators to never make assumptions about what patients need. “Give all patients the full complement of your resources,” she said.
Especially today, patients need help “circumnavigating” a fragmented healthcare system, and coordination of services—optimizing timing—is a critical task. “We underestimate how complicated our facilities are, in terms of access,” she said. “Because of the complexity of the system, we have to look for built-in delays to care.”
Throughout the process, Ms Shockney added, “It’s important to maintain personal contact with the patient, so the patient has a touchstone.”
Navigators need to advocate for their patients, especially in situations where patients tend to be “passive,” and, most importantly, they must strive to empower patients to directly participate in their own care. “As navigators, we should not be doing things to them, but with them,” she commented.
Navigators Knock Down Barriers
Barriers to the delivery of quality care remain numerous. Financial barriers are particularly formidable, and although navigators must help patients with economic distress, they should not spend their time “on hold with insurance companies,” Ms Shockney advised. “This should be the role of lay navigators.”
With a society that is increasingly multicultural, language and cultural barriers continue to be challenging for patients and healthcare providers alike. “The navigation process must factor in cultural competency care, which means that confidentiality is maintained and we respect the patient and the family at all times, delivering compassionate care and services and being mindful of patient safety,” she commented.
Before implementing a navigation program, she suggested assessing patient flow. “How does the patient currently travel through the system? Make no assumptions! Go alongside a patient and observe. I think you’ll be seriously disappointed with what you witness,” she offered.
Navigators should identify the points at which patients “can fall through the cracks,” where there are delays, and work to correct those factors. They should also participate in community needs assessment “so we understand who we need to take care of within our local communities,” she said.
Throughout the navigation system, the goals should remain clear: elimination of barriers to help patients achieve timely diagnosis and treatment, mindfulness of the patient’s individual needs and preferences, and respect and facilitation of patients’ “desired life goals,” she emphasized.