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Patient Navigation in Cancer Care
Guiding patients to quality outcomes
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AOU00157B.1 © 2007 Pfizer Inc. All rights reserved. Printed in USA/November 2007
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Patient Navigation in Cancer Care
Tool Kit
The Patient Navigation in Cancer Care multimedia tool
kit was:
– Designed to be an essential tool for health care
organizations to use in the development of patient
navigation programs
– Developed as a cooperative effort between Pfizer Inc
and the Healthcare Association of New York State
(HANYS)
• In consultation with Dr. Harold P. Freeman
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Components of the Patient Navigation
in Cancer Care Tool Kit
The Patient Navigation in Cancer Care tool kit consists
of 3 modules:
– Establishing a Patient Navigation
Program: An Implementation
Guide for the Program Champion
– Navigation Pathways: The Patient
Navigator Training Manual
– Breast Cancer Pathways:
A Resource Guide for the
Patient Navigator
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Patient Navigation in Cancer Care
Tool Kit Expansions
Additional manuals have since been added to the core
program
– Colorectal Cancer Pathways:
A Resource Guide for the
Patient Navigator
– Recent Management
Strategies in Breast
Cancer
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Presentation Contents
Introduction to Patient Navigation
A Model Program: Application & Adaptability
Results of Successful Programs
Implementation at [Add Name of Organization]:
Establishing a Need
Moving Toward Implementation
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Introduction to
Patient Navigation
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What Is Patient Navigation?
Patient navigation:
– Supports patients in need of assistance with
one-on-one contact
– Ensures that all patients with suspicious findings
receive a resolution to those findings
– Utilizes a patient navigator who moves patients
through the health care system
– Works within the organization and through external
services to eliminate barriers to health care
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Freeman HP. Oncol Issues. 2004;5:44-46.
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The Origins of Patient Navigation
Report to the Nation on Cancer in the Poor (1989)
Harlem Cancer Education and Demonstration Project
at Harlem Hospital (1990)
Voices of a Broken System (2001)
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Freeman HP, et al. Cancer Pract. 1995;3:19-30.
Freeman HP. Oncol Issues. 2004;5:44-46.
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Patient Navigator, Outreach, and
Chronic Disease Prevention Act of 2005
The Patient Navigator, Outreach, and Chronic Disease
Prevention Act of 2005
– Signed into law by President George W. Bush
on June 29, 2005
– Recognizes the challenges facing many Americans
in obtaining the health care they need
– Established a 5-year, $25 million demonstration program
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GOP.gov. H.R. 1812—Patient Navigation Outreach and Chronic Disease Prevention Act of 2005.
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Breast Health Patient Navigator
Program Resource Kit
First navigator resource tool kit
Designed under the guidance of the Healthcare Association
of New York State Breast Cancer Demonstration Project®
Published in 2002 (Copyright 2002)
Disseminated to hospital systems throughout New York State
Used in development of Patient Navigation in Cancer Care
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Goals of a Patient Navigation Program
The main goals of patient navigation are:
– To save lives from cancer
– To eliminate barriers to care
– To ensure timely delivery of services
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Freeman HP. Oncol Issues. 2004;5:44-46.
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Potential Barriers to
Receiving Timely Health Care
Barriers interfere with appropriate and timely care
– Delays of 3 to 6 months in initiating breast cancer treatment
were associated with lower survival rates
– Strong connection found between African American race and
delay in breast cancer screening and treatment
Patient navigation originally targeted the poor who:
– Endure greater pain and suffering than other Americans
– Feel cancer education and outreach efforts are irrelevant to
them
Elderly experience discrimination
– Health care professionals may have limited training in geriatrics
– Less likely to receive preventive care or screening
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Freeman HP, et al. Cancer Pract. 1995;3:19-30.
Richards MA, et al. Lancet. 1999;353:1119-1126.
Sheinfeld Gorin SN, et al. Presented at: 41st Annual Meeting of the ASCO; May 13-17, 2005; Orlando, Fla.
Alliance for Aging Research. Washington, DC; 2003.
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Potential Barriers to
Receiving Timely Health Care (cont’d)
Barrier
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Examples
Financial and economic
Lack of or inadequate insurance
Transportation
Difficulty arranging transportation
Cultural
Cultural beliefs regarding treatment
Communication and language
Difficulty telling desires/needs
Health care system
Fragmentation of care
Bias based on race/age
Fear and mistrust by patients;
inadequate screening of the elderly
Fear
Delay or refusal of care
Freeman HP, Reuben SH. Voices of a Broken System. Bethesda, Md: NIH, NCI; 2001.
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A Model Program
Application & Adaptability
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Patient Navigation’s Guiding Principles
Ensure that quality, confidentiality, and professionalism
are threaded throughout all aspects of care and
programming. Inherent in patient navigation is continuous
quality care for patients from screening through diagnosis
and treatment, based on the following tenets:
– Culturally competent care
– Confidentiality
– Respect
– Compassion
– Patient safety
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The Patient Navigation Model
The Cancer Care Continuum
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Freeman HP, et al. Cancer Pract. 1995;3:19-30.
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Suitable for Many Health Care Settings
The navigation program:
– Is adaptable to different settings and needs
– Encourages compassion toward persons who are
being served
– Defines at what point a navigator is engaged and
what a navigator does
– Respects the confidentiality of the patients involved
– Is reliable so that patients and navigators in the
program can trust the information and help received
– Evaluates the effectiveness of the program
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Responsibilities of a Navigator
Meet with patients at point of suspicious finding
Identify any barriers or potential barriers to care
Streamline appointments and paperwork
Maintain open communication with health care providers,
caregivers, and patients
Assist in increasing access to culturally appropriate,
supportive care when and where possible
Link patients, caregivers, and families with appropriate
follow-up services
Maintain personal contact with patients throughout the
health care continuum and follow their progress
HANYS BCDP®. Breast Health Patient Navigator Program Resource Kit. Rensselaer,
NY: HANYS; 2002.
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Long Island College Hospital. Breast Health Navigator Program. Rensselaer, NY: HANYS; 2002.
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Characteristics of a Navigator
Preferably selected from the community of patients
being served
Compassionate with a sincere desire to help people
Understands the issues of financial, cultural, educational,
and social barriers to information and care in the patient
community
Can communicate effectively with patients, their families,
and health care providers
Is organized and can demonstrate creative problem-solving
solutions
Is highly resourceful and able to research resources
for patients
Freeman HP. Oncol Issues. 2004;5:44-46.
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Long Island College Hospital. Breast Health Navigator Program. Rensselaer, NY: HANYS; 2002.
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Patient Navigators and
Other Cancer Support Personnel
• Deliver specific services
• Address individual patients only
Social workers and
case managers
• Seek solutions to
various problems
• Address individual
patients only
Community
outreach
workers
Navigators
• Deliver specific services
• Address individual
patients and health care
system
Advocates
• Address individual patients
and health care system
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Dohan D, Schrag D. Cancer. 2005;104:848-855.
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Where Should Navigation
Be Implemented?
Organizations providing care within the cancer continuum
– Hospitals
– Clinics
– Screening centers
– Community not-for-profits
– Oncology and radiology offices
Organizations with an underserved population
Organizations wishing to provide a premier cancer care
center delivery model
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Making a Patient Navigation Program Work
Organizational buy-in and support
Dedicated resources
Supportive leadership
An established alliance between the navigator and highly
connected, key decision makers in the organization,
especially those involved in financial decisions
A patient navigator dedicated to expediting patient access
and improving continuity and coordination of care
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Results of
Successful Programs
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Harlem Hospital Center: Improved Access
to Screening and Patient Navigation
100
90
After access to screening
and patient navigation
program (1995–2000)
80
Patients (%)
70
60
50
Before access
to screening
and patient navigation
program (1964–1986)
70%
40
30
39%
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n=457
n=74
5-Year Survival Rate
Freeman HP. Oncol Issues. 2004;5:44-46.
Oluwole SF, et al. J Am Coll Surg. 2003;196:180-188.
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Freeman HP, et al. Cancer. 1989;63:2562-2569.
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Navigated Patients Were More Likely
to Complete Biopsies
100
90
80
85.7%
Patients (%)
70
60
Had Biopsies
Biopsies Completed
Within 4 Weeks
71.4%
50
56.5%
40
30
38.5%
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Navigated
Patients
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Freeman HP, et al. Cancer Pract. 1995;3:19-30.
Non-navigated
Patients
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Nova Scotia Breast Screening Program:
Shortened Wait Time to Biopsy
Group
Navigation
Median Wait Time
to Biopsy (days)
Screening (n=97)
Yes
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Referral (n=144)
No
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Screening (n=133)
Yes
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Referral (n=162)
Yes
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1999
2000
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Psooy BJ, et al. Can Assoc Radiol J. 2004;55:145-150.
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Long Island College Hospital:
Self-Reported Positive Findings
Positive results after instituting a breast health navigator
program at Long Island College Hospital:
– 99% of all clinic patients had follow-up appointments
scheduled before leaving the hospital vs 25% previously
– Attendance at breast cancer support groups
increased 20%
– Reasons for missed mammograms were tracked
and addressed
– 28% of patients referred for physical therapy following
breast cancer surgery vs 6% prior to the program
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Long Island College Hospital. Breast Health Navigator Program. Rensselaer, NY: HANYS; 2002.
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Improving Follow-up to Abnormal Breast
Cancer Screening via Patient Navigation
Timely Follow-Up
100
Follow-up Within 120 Days (%)
90
80
78%
70
60
50
64%
40
30
20
10
Preintervention
Group
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Battaglia TA, et al. Cancer. 2007;109 (2 suppl):359-367.
Intervention
Group
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Screening Adherence Follow-up
Program (SAFe)
Reducing Barriers to Follow-up and Treatment
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First Treatment
Within 30 Days of
Diagnosis
Median Time From
Diagnosis to
Treatment
Woman in
SAFe Program
62%
24 Days
Women Not in
SAFe Program
40%
29 Days
Ell K et al. Cancer Pract. 2002;10:130-138.
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Possible Benefits of
Patient Navigation Programs
Improved coordination of high-quality care
Enhanced access to services for all populations
Removal of barriers to care
More efficient delivery of care
Improved outcomes
Improved sharing of resources
Enhanced relationships with the community
Increased patient satisfaction
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Implementation at
[your organization name]
Establishing a Need
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NOTE TO CHAMPION:
Customize the following slides with data specific to your organization .
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Patient Navigation Is Appropriate
for [Your Organization]
Patient demographics
Statistics concerning patient populations
Outcomes
Number of patients who complete a treatment
plan to resolution
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NOTE TO CHAMPION:
Customize the following slides with data specific to your organization .
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Patient Population Likely
to Benefit From Program
Insurance level
– Percentage uninsured
– Percentage underinsured
Cancer stage at intake
– Percentage in stages 0–I (early)
– Percentage in stage II
– Percentage in stages III–IV & recurrent
Percentage of patients speaking a primary language
other than English
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NOTE TO CHAMPION:
Customize the following slides with data specific to your organization .
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Barriers That Inhibit Optimal Health Care
Appointments missed per week
Percentage of patients lost to follow-up
Average time from suspicious finding to follow-up
appointment
Average time from suspicious finding to diagnosis
and/or treatment
Lack of coordination between departments
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NOTE TO CHAMPION:
Customize the following slides with data specific to your organization .
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Moving Toward
Implementation
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Action Plan:
Setting Goals for Success
Step 1
Define program goals, objectives,
budget, evaluation mechanisms,
and time frame
Step 2
Formulate a patient
navigator role description
Step 3
Develop tools from provided templates:
Intake Form and Tracking Tool
Promotional materials
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Action Plan:
Promote Awareness of the Program
Step 4
Identify other departments involved in overseeing
care (eg, radiology, radiation oncology, patient
billing, social work)
Step 5
Formulate outreach
and educational strategies
Step 6
Work with the public relations department
to promote and publicize program, both
internally and externally
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Action Plan:
Demonstrate Program Success
Data should be gathered at the start of the program and
tracked throughout to:
– Identify system changes that need to be made
– Determine resources that are lacking
– Track success of interventions
– Assure that the intended audience is being served
Choice and complexity of evaluation measurements:
– Should be determined based on the resources available
– Will vary from program to program
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Budgetary Considerations for the
Program
Patient navigator selection, salary, benefits, and training
Supplies, materials, and office space with computer
access for the navigator
Program promotion for patients and professionals
Outreach incentives to patients to use navigation
Evaluation costs in implementing tracking systems,
if not already incorporated into the existing structure
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Implementing a Navigation Program
Step 1:
Assess need for implementation
Step 2:
Enlist internal support
Step 3a:
Evaluate potential obstacles to
implementation; brainstorm
for solutions
Step 3b:
Step 3c:
Determine program scope, cost, and
implementation strategy
Collect baseline data for needs
assessment and evaluation
Step 4:
Implement program and identify
a patient navigator
Task:
Coordinate program planning
with appropriate departments
Task: Prepare documents
(eg, posters, brochures, policies,
procedures, forms)
Task:
Implement support systems,
referral processes, outreach
strategies
Task:
Track responses, appointments,
and other relevant data
Step 5:
Assess program effectiveness
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HANYS BCDP®. Breast Health Patient Navigator Program Resource Kit. Rensselaer,
NY: HANYS; 2002.
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Conclusion
Patient navigation eliminates barriers to enable individuals
with a suspicious finding to receive timely diagnosis
and treatment
Patient navigation keeps patients from falling through
the cracks
Patient navigation programs exist across the United States
and Canada
US legislation signed into law in support of patient navigation
programs
Patient navigation can be of great benefit to [Name of
our organization]
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