Upon receiving a cancer diagnosis, patients are immediately placed in frightening and unfamiliar territory without a map or compass. Although nurses and other healthcare professionals have always helped patients through the bewildering process of diagnosis, treatment, and recovery, formalizing these tasks into a specific role improves outcomes, saves lives, and ultimately decreases costs. And in 1990, navigation pioneer Dr. Harold Freeman did just that—piloting the first navigation program at Harlem Hospital Cancer Center designed to overcome social, cultural, economic, and other barriers to the community’s access to healthcare.
Today, patient navigators are found in hospitals around the country, and the American College of Surgeons (ACOS) Commission on Cancer’s 2012 standards require every hospital to have a navigation program in place by 2015 to receive ACOS accreditation. Currently, most oncology navigation programs take one of two approaches: general cancer navigation or site-specific cancer navigation.
General Cancer Navigation
Jennifer Peagler, RN, BSN, OCN®, is a general oncology navigator, one of three nurse navigators at Lexington Medical Center in West Columbia, SC. She explains that her institution’s first navigation program, breast navigation, began in 1997, with the goal of facilitating diagnosis in five days or less.
Jennifer Peagler, RN, BSN, OCN®
“The program was wonderful, but with so many other types of cancers diagnosed at our hospital, a navigator was needed for these patients as well. And so, in 2010, a general cancer navigator was hired. The general cancer navigation program was so successful that in 2011 we hired a second navigator to meet the growing needs of our patient population,” she explains.
Peagler says that nurse navigators at Lexington Medical Center are oncology-certified RNs who help patients and their families through the cancer diagnosis, treatment, and recovery. They offer information and emotional support and help identify community resources. Her patients are in both inpatient and outpatient settings and are referred by nurses, physicians, and social workers or self-refer. Oncology nurse navigation services are available to all patients at no cost.
“Our approach is unique in that we do not divide up cancers,” Peagler says. “We have a breast cancer navigator and two general cancer navigators. Other hospitals have site-specific navigators, but we feel all patients with cancer should have access to a navigator. Therefore, I see patients with all types of cancers, including hematologic malignancies. I am as involved as each patient would like me to be: some patients want me with them at every doctor’s appointment, whereas others are comfortable just knowing I am a phone call away.”
Site-Specific Navigation
Proposed Evaluation Measures for Patient Navigation Programs
Uniform, core metrics for evaluating patient navigation programs need to include measures that assess reductions in barriers to care, and improvements in the delivery of timely, effective, and equitable cancer services. Following are recommended measures that would allow adequate and reliable comparisons between programs and assist in replicating successful ones.
Diagnosis and Early Management
- Diagnostic confirmation
- Patient education
- Timeliness of care
- Continuity of care
Treatment
- Timeliness of care
- Adherence to treatment plan and guidelines
- Unplanned, emergency use of health services
- Clinical trials participation
- Care coordination
- Clinical outcome
Patient Reported
- Satisfaction
- Functional, health status
- Coping abilities
Survivorship
End of Life
Another approach to patient navigation programs can be found east of the San Francisco Bay area at John Muir Health where Lori Durbin, RN, BSN, MSN, OCN®, is an oncology nurse working as a resource for the thoracic and colorectal patient navigation programs.
In contrast to the generalist approach, Durbin says that John Muir Health’s navigation programs are specialized. The health system has seven site-specific areas, with a nurse navigator to oversee each one: breast health services, thoracic/esophageal, gastrointestinal, gynecologic oncology, brain tumor and neuro-oncology, urology, and survivorship. A palliative care inpatient program is also available.
“At John Muir Health, patient navigators are nurses who are experienced in a specialized field and provide support and education to the patient and family,” Durbin explains. “Nurse navigators provide emotional support, help patients find necessary resources, and assist patients on their journey through the disease process. The navigator works from an interdisciplinary perspective with the community, physicians, and patient care team to ensure continuum of care.
Durbin says that although nurse navigation is most widely used in oncology, John Muir Health uses it in several fields of chronic disease, including gerontology, cardiology, renal, and thoracic.
Additional Roles and Responsibilities
“The nurse navigator has many roles in addition to education and support,” Durbin says. “We advocate for patients and refer them for survivorship planning. We’re also involved in tumor boards: preparing cases, attending the tumor board, writing up their recommendations, and sharing this information with the patient’s managing physicians. We prepare quarterly network cancer committee reports, quality improvement requirements, task force meetings, and outcomes from follow-up action plans. We collaborate with the research department on clinical trials, working with physicians to promote the latest technological advancements in medicine, and finally see that the goals, objectives, and standards for the oncology program are met.”
Identifying and breaking down barriers to health care for communities at risk is another role of the nurse navigator. Durbin’s program is involved in community outreach projects and health fairs. Peagler’s as well; she explains that ACOS’s new standards address health disparities and ensure that the patient navigation process meets the needs of the community. The navigation standard requires each facility to be responsible for evaluating the needs of the community it serves and its population of patients with cancer.
“Our program provided this before it was a standard,” Peagler says. “We developed a community needs assessment in the six counties that we primarily serve and looked at the health disparities. Our oncology nurse navigators address the barriers identified: minority populations, access to care, and prevention screening programs. We have partnered with community outreach and are working on a quality initiative related to early diagnosis of lung cancer.”
Improving Patient Outcomes
If patient navigation programs sound incredible, it’s because they are. In 2011, Freeman reviewed the results for Harlem Hospital. In a 22-year period preceding Harlem Hospital Cancer Center’s patient navigation program, only 6% of patients with breast cancer presented with stage 1 disease, while 49% presented with stage 3 or 4 disease; the average five-year survival rate was 39%. After the program was initiated, 41% of patients with breast cancer presented with stage 0 or 1 disease, 21% had stage 3 or 4 disease, and five-year survival was 70%.
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