Over the past few decades, patient navigation in oncology care has become established as an evidence-based approach to address cancer disparities. Numerous collaborative initiatives have been launched to ensure the professionalization of oncology navigation, including professional standards, role delineation, competencies and workforce training, and evaluation metrics.1 In fact, the evidence has mounted showing the positive impact of oncology navigation and is a recommended intervention by professional organizations, including The Community Guide.2,3
With all these advances, the stability and sustainability of these programs are now the critical focal points to move the field forward.3,4 Concerted advocacy for local, state, and federal funding has shown great promise to address the need for ongoing financial reimbursement and is perhaps the tipping point for payers and others to reimburse this essential oncology service.5-7 However, there are many factors beyond funding that impact sustainability, including, but not limited to, communication, role delineation, and evaluation data demonstrating outcomes.7,8 Navigators and the organizations where they work offer diverse perspectives and authority to address those factors. Understanding the perspectives of those in the field is essential to develop strategies and approaches for sustainability. Equally important are collaborations across leading organizations to collect and understand that these perspectives support broad representation.
With over 3 decades of program implementation and research, establishment of a professional society (eg, Academy of Oncology Nurse & Patient Navigators [AONN+]) and coalitions (eg, American Cancer Society National Navigation Roundtable [ACS NNRT]), research (eg, at the University of Colorado), and the support at local, regional, and national levels from various organizations, the field is at the tipping point to ensure that navigation programs are sustainable.
The ACS NNRT9 is a coalition dedicated to advancing health equity and ensuring access to quality care throughout the cancer journey through proven and professional patient navigation. The 5-year goal of the ACS NNRT, through its over 100 organizations and individuals, focuses on supporting sustainable navigation programs across the country. The AONN+ is the professional home for navigators to advance the role of patient navigation in cancer care across the care continuum by providing a network for collaboration, leadership, and development of best practices for the improvement of patient access to care, evidence-based cancer treatment, and quality of life. The Colorado Cancer Screening Program (CCSP) created the Patient Navigation Sustainability Assessment Tool (PNSAT) to evaluate sustainability capacity of patient navigation programs and practices.10 The PNSAT has been adopted by the ACS NNRT and AONN+ and is foundational to the aims of each of these organizations. This tool was adapted from the 2018 versions of the Program Sustainability Assessment Tool (PSAT)11 and Clinical Sustainability Assessment Tool (CSAT)12 developed by Washington University in St. Louis. These sustainability tools describe a robust set of internal and external factors, called domains, that affect the likelihood that a public health program or clinical practice will be sustained. The PNSAT is a hybrid tool that primarily encompasses elements of the CSAT along with components of the Funding Stability and Communications domains of the PSAT. The sustainability capacity assessment is paired with an approach to developing and implementing a sustainability plan.13 This tool can be used by clinic systems and organizations to assess the current capacity, including strengths and areas for improvement, to sustain their patient navigation practices. The PNSAT was originally developed for use with cancer screening patient navigation but was updated by CCSP in 2023 to be applicable to all patient navigation practices.
In 2023, the ACS NNRT and the AONN+ collaboratively conducted a series of activities to gather insights from those working in the patient navigation field about the challenges and opportunities to strengthen sustainability capacity. These included hosting discussion groups at the AONN+ Midyear Conference in May 2023, pilot testing the PNSAT with the discussion group participants, and administering a short pulse survey at one of the plenary sessions on program sustainability at the AONN+ Annual Conference in November 2023. The goal of these activities was to gather insights from navigators and administrators about the challenges they faced in sustaining their programs, aspects of sustainability they perceived to have some influence over, and recommendations to both NNRT and AONN+ on their roles in this advocacy.
This article examines the critical issue of sustainability capacity within patient navigation programs based on the domains of the Patient Navigation Sustainability Framework (Figure). The objectives of this project were to gather perspectives from patient navigators and patient navigation program administrators on challenges, needs, and best practices with building sustainability capacity within the context of the sustainability domains.
We utilized the opportunity to gather insights from the field at 2 AONN+ conferences in 2023. The PNSAT served as the guiding framework for these activities, including in-person discussion groups with navigators and administrators participating in the Midyear AONN+ Conference held in May 2023 in Orlando, FL, piloting the PNSAT survey with those participating in the discussion groups, as well as a pulse survey conducted at the AONN+ Annual Conference held in November 2023 in San Antonio, TX. The methods for each of these activities are described in detail below.
The purpose of the discussion groups was to better understand best practices in patient navigation and to gather input on program sustainability, including payment models for patient navigation services. Participants were recruited through the registration list for the Midyear Conference. All conference registrants were sent information about the discussion groups and were able to sign up through AONN+. For those who registered for the discussion group, the PNSAT survey was sent 3 weeks before the AONN+ Midyear Conference.
Since the goal was to explore the issue of sustainability from the perspective of 2 stakeholder groups, navigators and administrators of navigation programs, 2 separate groups were held to explore how they see their roles and responsibilities in terms of sustainability within their institution, and more broadly, as a profession.
In addition, we wanted to explore what the ACS NNRT and AONN+ could do to support long-term sustainability. The Box shows the discussion group outline that was developed by the authors and used to guide the discussion in both groups. During the discussion group, each of the 2 groups were asked to identify the primary barrier to patient navigation sustainability and then respond to 6 discussion questions posed by the facilitator. These guided discussions lasted about 90 minutes and were facilitated by 2 members (LF, MC) of the ACS NNRT leadership with experience in facilitating discussion groups and group discussions. The discussion groups were recorded to create and review transcripts for analysis.
Setting the Stage and Introductions
Review PNSAT Domains and High-Level Survey Results
Review the High-Level Efforts for Financial Sustainability
Abbreviations: AONN+, Academy of Oncology Nurse & Patient Navigators; NNRT, National Navigation Roundtable; PNSAT, Patient Navigation Sustainability Assessment Tool.
Prior to the in-person discussion group, a link to the PNSAT Version 2 – Short Version website and assessment was sent to the 23 AONN+ members who had registered to participate in 1 of 2 discussion groups via email. The registrants were given 3 weeks to complete the assessment through Google Forms prior to the conference and the discussion group. The PNSAT Version 2 – Short Version assesses the 8 domains (Engaged Staff & Leadership; Organizational Context & Capacity; Funding Stability; Engaged Community; Communication, Planning, & Implementation; Workflow Integration; Monitoring & Evaluation; and Outcomes & Effectiveness.) from the perspective of the respondent. Each domain includes a number of statements describing factors relevant to that domain, and the statements are rated on a Likert-scale from 1 (little to no extent) to 7 (a very great extent), as well as 3 optional open-ended guiding questions per domain to provide additional contextual information. See website for specific questions and response categories.
After completion, a score report that summarized the respondent’s answers and average scores for each domain was automatically emailed to each individual through the Autocrat software tool. CCSP staff (ES) then calculated the average scores for each rating question, domain, and overall among the respondents of each of the 2 discussion groups and the full group of respondents using Microsoft Excel. The open-ended questions were not scored.
A 3-question pulse survey using an audience response system and online polling was administered at the 2023 AONN+ Annual Conference following a plenary session focused on the PNSAT framework and the 8 domains of sustainability, led by ACS NNRT and AONN+ leadership. Meeting participants were asked to select the 2 most important PNSAT domains to be addressed for sustainability from 3 levels—their own role, their organization, and national organizations such as AONN+ and ACS NNRT. The poll responses were imported into Microsoft Excel for analysis of descriptive statistics.
Two discussion groups were held with a total of 19 participants (7 navigators and 12 administrators/supervisors). Although 23 had registered for the discussion groups, a total of 19 attended. The participants represented a broad range of organizations (community hospitals, academic, and advocacy) and geographic areas (Northeast, South, and Midwest). Discussions within each stakeholder group raised issues such as the need for reimbursement and standardization of workforce, including equitable pay, job titles and descriptions, training and certification, program evaluation (metrics, return on investment [ROI]), and integration with multidisciplinary patient care.
The discussion groups were recorded and transcribed. Three of the authors (LF, MC, SG) with experience in qualitative methods separately reviewed the transcripts and identified key themes. These themes were reviewed with all the authors to ensure consensus. As shown in Table 1, 4 key themes emerged and were crosscutting the 8 domains of the PNSAT, including Funding Stability, Multidisciplinary Collaboration, Role Clarity, and Workforce Development. Although these key themes emerged in both groups, the administrators and navigators identified unique perspectives and subthemes tied to their specific roles, as well as common challenges and needs. Each of these themes and examples of respondent responses are provided.
Administrators and navigators both discussed the importance and challenge of showing the value of patient navigation on patient outcomes through data and making those data come to life.
Administrators and navigators both discussed the importance and challenge of showing the value of patient navigation on patient outcomes through data and making those data come to life. To make the business case for institutional support and funding for navigation to organizational leadership and other stakeholders, participants in the patient navigation administrator group discussed the importance of demonstrating ROI in the form of cost savings and cost-effectiveness in order to staff the navigation team appropriately, as well as a lack of understanding among organizational leadership about the evidence of navigation.
“There’s a finite amount of money. And for us to have navigation, being part of what is chosen, we need to convince the rest of healthcare administration across the country that we are going to be the drivers of those outcomes that are the future of decreasing the cost [and] improving the quality. And that’s a big roadblock, and I’ve tried everything to help them see.”
“I found the one time I really got through and got a huge influx of FTE [full-time employee] allowances was when we had several members of our board diagnosed with cancer. That got navigators, and it was overnight….It was a priority for a hot second, and then it dwindled away. But I took advantage of that. And we got something out of it.”
“I wish the conversation was reframed more about, hey, how much is the cost?…what’s the ROI and…if you build it, the people will come and the quality and the access will be there. And it’s demonstrated through the literature, right? I don’t think we need to reinvent the wheel for one site for one practice at one hospital just to show that we can do what other people are doing all over the country.”
The navigator group also discussed the challenges with proving the value of the navigation position to maintain funding because of variability in their roles and responsibilities (see below for additional discussion of role delineation).
Another component of funding stability is data on patient outcomes and reach, which are needed to demonstrate the impact of the practice to leadership and funders, as well as to identify patients eligible for care and navigation services. Although consensus metrics exist, they are not widely integrated into the electronic medical record [EMR] and may be cumbersome for navigators to extract.
“Talking about funding, it is very difficult to prove everything that we are doing, because it doesn’t go in a linear form, we go outside of our processes, whatever is thrown at us, we will take care of it. So that is the piece that is very difficult to justify when you are trying to justify the benefit of your program.”
“It’s the monitoring [and] evaluation because right now, I have 5 different electronical medical records to try and find out what’s going on with the patient. I have to go into different medical records to find out what’s on the face sheet and what type of insurance they have. And then I have to go into another medical record to see what the doc says. And then I have to go into another medical record to see the radiology, and some data are on Excel spreadsheets. And I’m not able to collect how many patients I get to go to MRIs. Just 5 EMRs is enough make your head spin.”
“We’ve went to a different EMR in the last 9 months. And it’s proved to be a struggle to get the metrics that I historically collected. We had had a navigation software and moving to the new EMR, we were promised the moon and here we are 9 months later. So, it’s just that struggle to recalibrate. We ran pretty well from a metrics perspective before, and I just feel very handicapped for the last 9 months because I don’t have a fraction of what I had before.”
“I’m with some other people with our EMR changing is…feeling like I’m losing patients or not finding them soon enough. And it’s not how navigation in my mind is supposed to work. We’re supposed to be in the up-front and be there early and not picking up pieces. And that’s what I feel like I’m doing.”
“I had a meeting about how hard it is to capture the metrics that leadership wants me to catch. And I brought that up that there’s just no way because of the multiple EMRs. And the [other] person told me about another EMR that [I] didn’t know about. Wouldn’t it be nice if somebody created some dashboards or something that could mean there are ways to bring different data sources together?”
“How about we look at standardizing the data collection points? Because we’re scrutinizing them asking them to collect everything under the sun, why don’t we work with the…disease-specific organizations? To tell us what are quite honestly the minimal amount of data? Because we need to be out there with the patient and not be the data collectors of the world. My sense of collecting everything under the sun was to prove our value. And maybe we’re at a place where we have that proof. Now, what’s the minimal viable data collection to continue monitoring and evaluation?”
Lastly, the discussion groups discussed their perspectives on emerging opportunities from the Centers for Medicare & Medicaid Services (CMS) for reimbursement of patient navigation services for oncology navigation. The criteria for reimbursement were a concern among navigators, and the need for multidisciplinary collaboration across departments was a concern for administrators.
“I think [reimbursement] comes with just as many headaches as not getting reimbursed. And they had very specific guidelines for what constitutes a navigator; you have to have a bachelor’s degree in a health field. So, for example, if you have [nonclinical] patient navigators; like we do at our facility, as well as nurse navigators, some of those people wouldn’t meet the qualifications. And so that is going to complicate things, do we get rid of really good people? Because they don’t have a bachelor’s degree? Or does it help support the program if some of the navigation is covered? And some isn’t? But then that creates a whole other level of management.”
“I think the physicians and providers would need to be educated on what the navigators are doing to be able to submit that bill [for reimbursement], the coders would need to understand what needs to be in that note to submit the bill. And then that goes a bit to role delineation, and then the ability to fund the positions perhaps.”
The second priority theme that emerged from the discussion groups was the importance of multidisciplinary collaboration across the departments of organizations, including internally among navigators, providers, administrative staff, and leadership. Having strong relationships is important for building trust and buy-in for the navigation role among providers as well as for establishing workflows and effective communication channels.
“One of the things that I’ve noticed in this new role is the [value of] communication of what we do to build the trust…[with] the providers to help them and like ‘help me help you.’ So just making sure that they know that we’re here that we’re here to assist the patients [in addition to] them.”
“[In regard to] having the staff buy-in, I said ‘this is our navigator, she’s going to help you with this, this, and this.’ Even if it’s just a just a little snippet of what we do, introducing us, putting a name or putting a badge on us [helps with explaining] this is what they do and building that trust and that sort of thing. I think we still have a long way to go with the education and staff buy-in and just showing our worth.”
“[My organization] is moving forward with an institutional navigation program now. So, what is keeping me up at night with this new project is their workflow integration and the organizational capacity. Because the few [current] navigators are stressing the system. But if we do the whole rollout institutionally, how are the departments involved going to react to that type of care coordination?”
“What keeps me up at night…is integrating the navigators and the navigation program into these clinics spaces that already exist. And some of that sort of push and pull of whose jobs does what and just overall collaboration, the workflow integration and collaboration.”
“My largest headache currently right now is the fact that nobody understands navigation. We are a large enterprise and countrywide have 190 sites. And oncology navigation is something that is completely misunderstood. We don’t have any actual process maps, because we’re running 190 different clinics with different processes and systems in place. And we don’t have a common EMR.”
Challenges with multidisciplinary collaboration also coincide with gaps in defining the navigator role and ensuring the level of staffing aligns with the caseloads of patients. This may lead to burnout among navigators and confusion among providers and patients. Patient navigators discussed that providers and the public are confused about the scope of the navigation role and where it begins and ends, and titles may not be used appropriately.
“…Everybody wants a navigator. But I find that what they want is a personal secretary that they can tell you where to go and who to go to. Everyone’s definition of it is different. Everyone wants it. But how we function and how we support is vastly different. So, I feel like everyone wants it in theory, but they don’t know what we do.”
“In my organization, [there are a] number of very similar names. We have care advocates, patient coordinators, care coordinators. Some of them are at the office level, some of them are at the cancer level, some of them are hospital- based. That’s [confusing] even from a title perspective, so it’s not necessarily just communication and how you’re sharing the stories. But it’s confusing, because you will see the word navigator or coordinator, patient, nurse, etc, any mishmash of words, and it is increasingly confusing to the public. I mean, it has to be in the job description. Because that’s where those titles come from. I mean, I am given titles, I don’t get to make titles.”
“Unfortunately, a lot of that comes down to HR just kind of sharing these job descriptions, and you can just kind of cut and paste it together and it ends up being a little Frankenstein job description that kind of has the name, but totally different roles.”
Several administrators of patient navigation programs have observed burnout among their navigation teams. Burnout can be caused by multiple reasons, including lack of role clarity, lack of sufficient staffing to serve patient caseloads, as well as challenges in obtaining the healthcare services needed for their clients.
“The biggest thing that keeps me up at night is the burnout of the navigators due to systemic internal health structure barriers.”
“Burnout, because if the team dynamics aren’t good, then there’s a lot of burden on the navigator. It makes for a more stressful environment.”
“There’s this level of sustainability, beyond just financial of overburdening navigators as you work them into an integrated workflow and the community.”
“So think these programs, I’m sure all of you agree, we’re reactive, instead of proactive when it comes to staffing, I have to prove the volume has increased before I can hire my FTE and train them over 6 months. And by then we need another because we are drowning from that person who was already established having to train that other person plus that other person’s not fully up, ramped up.”
The final theme that emerged from both discussion groups was the importance of workforce development to foster the value of the navigation workforce through elements such as equitable salaries, resources available to the workforce, and professional development opportunities.
Furthermore, navigators expressed the need for advocacy of role delineation within their organizations as well as by other groups to ensure that the roles and responsibilities of navigators are clearly defined to prevent scope creep.
“What keeps me up at night is true voice representation for the patient navigator in collaboration with nurse navigators, financial navigators and social work navigators, [as well as] salary transparency. I believe equitable health also has a lot to do with where we all stand in our role delineation but also in our salaries.”
“And I think that’s a really important point that, you know, isn’t just the funding, it’s what are those structures? And are you paying attention? And is your administration also paying attention to these other issues around workforce development, workforce maintenance, and viewing this as a workforce, a specific, professional workforce?”
“You have to be your own leader, in addition to being the navigator. And that’s a really difficult thing to do. Where is that leadership, that you have someone who’s going to be advocating for what that role is? And isn’t?”
“Everybody wants to navigate so if I call this position a navigator isn’t that good? And we have to keep working against this, because it does diminish the role of navigation. This is a profession and we have to protect that.”
The PNSAT was completed by 10 out of 23 discussion group registrants (43%), including 7 of 14 individuals (50%) from discussion group 1 (patient navigation administrators/supervisors) and 3 of 9 individuals (33%) from discussion group 2 (patient navigators). Respondents represented 8 states across the United States and a mix of roles, including nurse/patient navigators (n=3; 30%), navigation/clinical management (n=5; 50%), and other roles (n=2; 20%).
The overall average score of the 10 respondents was 5.1, with a range of 4.1 to 6.4 on the 7-point scale. Domains with the highest average scores were Engaged Staff & Leadership (5.8) and Communication, Planning, & Implementation (5.8). The domains with the lowest average scores were Funding Stability (4.0) and Workflow Integration (4.6). The average scores of discussion group 1 were similar to the overall averages. Discussion group 2 had lower average scores for Monitoring & Evaluation and higher average scores for Workflow Integration and Engaged Community.
Table 2 illustrates the overall average scores of all domains for the full group of respondents and by discussion group.
Responses to the pulse survey were received from 413 attendees at the AONN+ Annual Conference during one of the plenary sessions. From the questions posed in the automated response system (Table 3), the top 2 PNSAT domains that individuals (N=413) felt they had the ability to address in their current role were Engaged Staff & Leadership (n=86; 20.82%) as well as Communication, Planning, & Implementation (n=67; 16.22%), while the domains the fewest number of people were prepared to address were Organizational Context & Capacity (n=20; 4.84%) and Funding Stability (n=22; 5.33%). In terms of the areas that their organization could address (N=361), the top 2 domains were Workflow Integration (n=75; 20.78%) and Engaged Staff & Leadership (n=67; 18.56%), while the least selected domains were Engaged Community (n=17; 4.71%) and Monitoring & Evaluation (n=24; 6.65%). When asked about what national organizations such as AONN+ and ACS NNRT could address (N=375), the top 2 domains were Outcomes & Effectiveness (n=97; 25.87%) and Communication, Planning, & Implementation (n=61; 16.27%), while the lowest 2 domains were Organizational Context & Capacity (n=26; 6.93%) and Engaged Community (n=32; 8.53%).
The PNSAT considers both elements of clinical practices, such as workflow integration and outcomes and effectiveness, as well as elements key to public health implementation initiatives, such as funding stability and strategic planning. It has been adopted by various organizations, such as ACS NNRT and AONN+, to guide the ongoing work to ensure that oncology navigation is sustainable. Through this lens, we had the opportunity to gather insights from the field to better understand what aspects of sustainability they felt were important, those elements they could influence based on their role, and what their organization, as well as national-level organizations, could address.
The themes that emerged from the discussion groups focused on funding, collaboration, role clarity, and workforce development and mapped to a number of PSNAT domains. There was consistency between navigators and program administrators in these themes, yet some nuances about elements of each domain existed. For example, administrators focused on the need for ROI data to garner support, while the navigators focused on the need for data on the impact of their efforts on patient care. Both are critical to ensuring funding but suggest that the focus may be different based on role and responsibilities. The PSNAT survey provided additional insight with support from internal leadership and champions (Engaged Staff & Leadership). Multidisciplinary collaboration and engagement across teams and among the wider community (Communication, Planning, & Implementation and Engaged Community) and Outcomes & Effectiveness as highly rated domains of sustainability.
The pulse survey allowed us to explore where the individual, their organization, and national organizations can have influence in sustainability. Navigators and navigation program administrators identified Engaged Staff & Leadership and Communication, Planning, & Implementation as their top-rated domains to influence, and Organizational Context & Capacity and Funding Stability as the least likely to influence. At the organizational level, Workflow Integration and Engaged Staff & Leadership were ranked the highest. The role of national organizations leading efforts for Outcomes & Effectiveness and Communication, Planning, & Implementation were ranked highest, with Funding Stability close behind.
Engagement includes buy-in from all multiprofessional team members, higher-level leadership ongoing support, and strong clinical champions and is based on collaboration and infrastructure.
Research has shown that engagement of internal champions is essential to the longevity and growth of patient navigation programs because of their ability to advocate and promote the practice among other stakeholders while fostering a collaborative environment, which in turn can support growth within other sustainability domains.10,14,15 Engagement includes buy-in from all multiprofessional team members, higher-level leadership ongoing support, and strong clinical champions and is based on collaboration and infrastructure. Building that support and engagement takes considerable effort, communication, and the ability to show program effectiveness and impact.
Communication, Planning, & Implementation encompasses communication about the value of the patient navigator role and also incorporates feedback from partners and patients into the practices of patient navigation programs. Navigators and other members of navigation programs have first-hand knowledge of best practices and impacts of patient navigation on patient outcomes, which can add context to data on outcomes and effectiveness. Outcomes & Effectiveness emerged as a key area to be addressed by professional organizations such as the ACS NNRT9 and AONN+ through the pulse survey and had the third lowest PNSAT scores on average. The discussion groups agreed that evaluation data on navigation are being collected, but there is a need for standardized evaluation metrics across navigation programs and best practices to efficiently utilize evaluation data to demonstrate value. To further support efforts by navigation programs to demonstrate value through data and case studies, the ACS NNRT and AONN+ can provide roadmaps to success for evaluation of patient navigation, including recommended metrics, case study examples, and summaries of available data on impacts of navigation. AONN+ currently features a CATCH (Catching & Addressing Threats to Care & Health) Initiative16 that shares navigators’ everyday practice interventions with positive outcomes to further highlight navigation value and efficiency. The reporting system details the incidence, intervention, and outcome, as well as the metric it is aligned with for value support.
When comparing the sustainability challenges identified by patient navigators versus patient navigation program administrators in the PNSAT results and discussion groups, the domains with the lowest scores of sustainability capacity by both groups were Funding Stability and Workflow Integration. In the area of Funding Stability, the need for stable, diversified funding beyond grants to support appropriate FTEs based on patient volumes and equitable wages, including access to reimbursement mechanisms, were raised as key needs by the patient navigator discussion group. In the administrator discussion group, access to data, such as ROI and patient testimonials that can be used to demonstrate outcomes and effectiveness of navigation services and justify funding of navigator positions, was identified as a critical need.
Funding stability, while a critical domain for sustainability capacity as identified through the discussion groups, is a domain that the patient navigation programs felt less equipped to address directly as individuals or through their organizations. This has been echoed by other patient navigation and public health programs.10 However, the sustainability domains do not function in silos, and there is value in building capacity among the domains that sustainability programs feel equipped to strengthen. As expressed by a participant of the patient navigator discussion group, “I always feel like, if you’ve got the other pieces your funding will take…because you if you don’t have the other pieces, even if your funding is good, you probably won’t have it very long.”
After decades of funding primarily supported by grants, community health worker and patient navigation services are beginning to be eligible for reimbursement through insurance payers.
Access to funding is primarily dictated by the funding mechanisms available at the local, state, and national level. After decades of funding primarily supported by grants, select community health worker and patient navigation services are beginning to be eligible for reimbursement through insurance payers, including reimbursement from CMS for Principal Illness Navigation7 delivered to Medicare beneficiaries with eligible chronic conditions, as well as reimbursement for a variety of community health worker services through Medicaid in 24 states.17 ACS NNRT and AONN+ applaud this step toward stable funding for patient navigation, while acknowledging that currently these payment methods are underutilized and additional efforts are needed to explore the barriers and provide technical assistance for increased adoption. As discussed, teams were not yet utilizing reimbursement mechanisms but expressed that these may add additional administrative burdens that would need to be weighed in their decision to bill Medicare and/or Medicaid for reimbursement.
Within the domain of Workflow Integration, the importance of role delineation and inconsistency in implementation of navigation responsibilities within organizations were identified as challenges by both discussion groups. Workflow Integration was also identified as one of the top 2 domains that should be addressed at the organization level and the third priority domain for the navigators and ACS NNRT9/AONN. The Oncology Navigation Standards of Professional Practice18,19 was developed by the Professional Oncology Navigation Task Force in 2022 to create common definitions and scopes of navigation roles within the field. Additional efforts to disseminate these standards among those working in the navigation field are needed, as the participants in both discussion groups were not yet aware of this resource. These standards can be applied to the development of patient navigator job descriptions and practice workflows and may assist with standardizing processes at the organization level. In 2024, the NNRT Workforce Development Task Group released an article20 that can be used as a resource for administrators in creating job descriptions for the navigator with specific levels of expertise, as well as used as a resource for patient navigators who are striving to attain a higher level of expertise. Furthermore, Casanova et al23 developed a workflow mapping process toolkit that can be used to guide navigation teams in documenting and standardizing workflows. The ACS NNRT11 and AONN+ can assist with uptake of these standards and tools.
A multilevel, multidisciplinary approach is needed to ensure sustainability of the patient navigation field. The ACS NNRT11 encourages navigation teams and programs, as well as the larger organizations that employ and promote patient navigators, to take steps toward sustainability by assessing their sustainability capacity using an assessment such as the PNSAT and implementing a sustainability action plan that addresses at least 1 domain that can be feasibly targeted for change by their internal team. Sustainability Planning for Patient Navigation: Best Practices by Staples and Dwyer provides practical guidance and tips for patient navigation programs to take simple steps to assess and strengthen sustainability capacity using a sustainability framework.24 Examination of internal sustainability capacity can also provide valuable insights about the domains that navigation teams need external support from their wider organizations and professional organizations to successfully address.
It is important to note that these findings have limitations and may not be broadly representative. First, these evaluation activities were cross-sectional and exploratory in nature based on real-world practice data rather than data from a controlled research setting. The results from the discussion groups and PNSAT assessment were obtained from small sample sizes and data from personal experiences with the navigation field; thus, conclusions and recommendations based on these responses should be approached with caution. We conceptualized sustainability based on common domains from the literature for this evaluation. However, the PNSAT is a tool adapted from validated assessments, and additional models of sustainability exist; therefore, other measures of sustainability capacity could be considered in future studies and practice evaluations.
The field of oncology patient navigation has been developing over the past few decades. It has reached the pinnacle of a critical, evidence-based intervention to assist patients across the continuum of care and impact health status, timeliness of care, patient engagement, and health outcomes. Patient navigation has been adopted in many organizations, and it is now imperative that programs become sustainable for the future. The PNSAT framework provides a foundation to explore the domains of sustainability, and the dedicated efforts of many organizations to address workforce standards and roles, metrics and evaluation, and financial models have provided the necessary elements for sustainability. The insights from the field highlight the ongoing challenges to move from theoretical to pragmatic strategies to support sustainability, recognizing that the areas of influence may be different for navigators and their administrators. Ongoing technical support and national-level advocacy is needed to keep the sustainability of oncology navigation moving ahead.
We would like to thank and acknowledge the contribution of the navigators and program administrators who shared their insights in discussion groups and via pulse surveys. We also thank Kelsey Lachow for her assistance in preparing the manuscript for submission.
Institutional support for authors’ time and efforts.
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