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BCCCP Patient Navigation


BCCCP Patient Navigation Debbie Webster, BSN, RN, LMSW May 3, 2011 Navigation and Diagnosis Patient Education Importance of diagnostic follow-up Explaining cancer ... – PowerPoint PPT presentation

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Title: BCCCP Patient Navigation

BCCCPPatient Navigation
  • Debbie Webster, BSN, RN, LMSW
  • May 3, 2011

Patient Navigation Defined
  • Timely movement of an individual through the
    health care continuum from prevention, detection,
    diagnosis, treatment support and end of life care
  • www.patientnavigation.com
  • Individualized assistance offered to patients to
    help overcome barriers to care, whether through
    the health care system or the environment
  • American College of Surgeons Cancer Program
    Standards 2011

Harold P. Freeman
  • Disease always occurs within a context of human
    circumstances including economic status, social
    position, culture and environment. These human
    circumstances can determine the length and
    quality of survival.

Navigation vs. Case Management
  • One of Navigations primary purposes is to
    decrease cancer disparities.
  • The focus on disparities is a major
    distinguishing factor between Patient Navigation
    and Case Management.

Disparities in Cancer Care
  • The 5-year survival rate after a 1st diagnosis of
    breast cancer is 90 for white women and 77 for
    African women.
  • Racial/ethnic differences in
  • Stage at diagnosis (Robinson-White, et. al. 2010)
  • Mammography utilization (Battaglia, et. al.,
  • Follow-up after abnormal breast screening
  • Racial/ethnic minority women often have the
    longest delays (Battaglia, et. al., 2007)
  • Early termination of treatment (Ell et. al., 2009)

Barriers to Care
  • Financial barriers (insurance)
  • Communication barriers (language)
  • Lack of information or misinformation
  • Missed appointments (might be due to work, child
    care or transportation issues)
  • Medical system (lost medical reports)
  • Fear emotional barriers

Cancer Burden
  • A patient without health insurance who has a
    diagnosis of cancer can expect a 15 lower 5-year
    survival than one who is insured.
  • Survival rates for those on Medicaid are
    essentially the same.

Navigations History
  • 1st program 1990
  • Harlem, NY
  • Population predominantly African American and
  • Most residents live in poverty
  • Most residents have a low educational level
  • The Goal - Increase 5-year survival rates of
    cancer by helping patients move through the
    diagnostic and treatment processes.

Does Navigation Work?1st program outcomes
1964-1986 1995-2000
Stage 0 0 12
Stage I 6 29
Stage II 45 38
Stage III 39 14
Stage IV 10 7
  • 1964-1986 the 5-year survival rate at Harlem
    Hospital 39
  • (60 for white women)
  • 1995-2000 the 5-year survival rate at Harlem
    Hospital 70

Does Navigation Work?Additional Outcomes
  • Earlier diagnosis
  • Stage 0 diagnosis went from 12.4 to 25.8
  • Stage IV diagnosis went from 16.7 to 9.4
  • Gabram et. al. (2008)
  • Diagnostic resolution
  • 90 of navigated Hispanic women followed through
    to diagnostic resolution compared to 66 of
    non-navigated women
  • Ell et.al. (2007)

More Outcomes
  • Battaglia et. al. (2006) reported that women were
    39 more likely to have timely follow up on a
    diagnostic evaluation after implementation of
    Patient Navigation.
  • Fang et. al. (2007) reported that the cervical
    cancer screening rate increased from 17 to 83
    in Korean women after the introduction of
    cervical cancer education and bilingual patient

Navigation in Cancer Care
  • Research consistently shows Navigation to be
    effective at moving patients across the Cancer
    Care Continuum
  • Identifying bringing patients into screening
  • Walking them through the steps of detection and
    diagnosis when necessary
  • Facilitating complete and timely treatment
  • An individualized needs assessment is key

Key components of Patient Navigation
  • Removing barriers to care for individual patients
  • Documenting these barriers
  • Implementation of a feedback system regarding
    barriers aimed at system level change (requires
    administrative support)
  • Vargas et. al. (2008)

Cancer Continuum
  • Prevention Detection Diagnosis
    Treatment Survivorship

Prevention Navigation
  • Primary prevention
  • Targeted outreach
  • HPV vaccinations
  • Colorectal cancer screening polyp removal
  • Secondary Prevention
  • Targeted outreach to identifying cancer at an
    earlier, more treatable stage
  • Increasing the of enrolled patients who are up
    to date on breast and cervical cancer screenings

Navigation and Outreach
  • CDC recommends the following
  • Client reminders
  • Small media
  • One-on-one education
  • Reducing structural barriers
  • The Community Guide
  • www.thecommunityguide.org

Outreach - Client reminders
  • Effective with print or telephone communication.
  • Reminding people they are due (or late) for
  • Can include things like
  • Information about screening
  • Benefits of screening
  • Ways to overcome barriers to screening
  • The Community Guide
  • It is important to have a feedback system in
    place to determine if the client followed-up on
    the reminder.

Outreach Small Media
  • Videos printed communications (letters,
    brochures, flyers, newsletters)
  • Convey educational or motivational information
  • Describe screening tests and procedures
  • Provide reasons for and benefits of screening
  • Suggest ways to overcome barriers to screening
  • Can address a general population or tailored to a
    specific population
  • The Community Guide

Outreach One-on-one Education
  • Can be by telephone or face-to-face
  • Nurse, health educator, lay health advisor,
  • Education can be general or targeted to the
    specific circumstances of the individual
  • The Community Guide

Outreach Reducing Structural Barriers
  • Activities that make it easier for people to
    access preventive services
  • Modifying hours of service to meet client needs
    (evening and weekend hours)
  • Offering services in alternative nonclinical
    settings (mobile vans)
  • Transportation assistance
  • Translation services
  • The Community Guide

Navigation and Detection
  • Navigation increases the percentage of patients
    who complete their screening or diagnostic test
  • Decreasing missed appointments
  • Increasing the timeliness of screening completion
  • Decreasing the number of patients who are lost to

Navigation Screening
  • Education on importance of cancer screening
  • Explaining cancer screening process
  • Reminders of appointments
  • Assistance in rescheduling if appointments are
  • Emotional support addressing fears
  • Assistance with transportation, child care or
    other barriers to screening

Navigations Impact on Screening
  • Research shows that any type of navigation aimed
    at increasing screening has an impact
  • Detrich (2006) tested telephone navigation and
    found that it impacted screening rates of
    mammography, pap tests and colorectal cancer

Navigation and Diagnosis
  • Patient Education
  • Importance of diagnostic follow-up
  • Explaining cancer diagnostic test process
  • Patient Support
  • Emotional support addressing fears
  • Reduce Barriers
  • Appointment Reminders

Navigation and Diagnosis
  • Easy and timely access to surgical consultations
    post-abnormal finding is essential to a womans
    emotional well-being
  • Increasing the timeliness (decreasing number of
    days) between abnormal screening result and
    diagnostic completion
  • Navigate through health care setting

A patients perspective
  • "Sara feels like an angel sent to me. Its
    unbelievable to have someone within the medical
    system come alongside you, anticipate your needs,
    hear your concerns, and offer help.
  • Breast cancer patient
  • Steelquist, 2009

Care Coordination Problems
  • A 2006 survey
  • Half of cancer patients say that care was
    uncoordinated at times. The sickest patients and
    those with the deadliest tumors were most likely
    to encounter a problem.
  • Records or test results did not reach doctor in
    time for appointment - 13
  • Left a doctor's office with critical question
    unanswered - 15
  • Confused about prescription medication - 20
  • Sent for duplicate tests - 21
  • Given conflicting information from doctors or
    nurses - 25
  • Any of these coordination problems - 50
  • USA Today

Navigation and Treatment
  • Continued assistance with navigating the health
    care setting
  • Tracking patients diagnosed with cancer into the
    start of treatment
  • Increasing timeliness (decreasing number of days)
    between diagnosis and initiation of cancer
  • Coordinating care among different providers
  • Have medical records available at appointments
  • Assist in scheduling of follow-up appointments
    and their reminders

Navigation and Treatment
  • Decrease disparities by improving access
  • Ensure unrestricted access to all services
  • Build awareness of all available services
  • Help clarify choices
  • Dispel fears so patient seeks appropriate care
  • Dispelling fear can increase compliance with
    treatment care recommendations
  • Education on the treatment phase
  • Understand and manage side effects

  • Even more than the cancer fears, the financial
    worries were eating me alive. I knew treatment
    was going to be expensive and I didnt want to
    burden my kids. But I wanted to live
  • A breast cancer patient
  • Steelquist, 2009

Navigation and Survivorship
  • Transitional care
  • Proactive management of health
  • Long-term (Survivorship) Care Plan
  • Maintain appropriate follow-up
  • Symptom management
  • Wellness/nutrition
  • Emotional concerns
  • Support groups
  • Stress management

Navigation and Survivorship
  • Few models on this type of navigation
  • No research has been done
  • Many hospital Nurse Navigators add survivorship
    issues into their plan of care for patients
  • Follow up calls on HRT therapy

We cant hire a Navigator
  • Patient Navigation Team
  • In many programs, the roles of the Navigator is
    divided among multiple staff
  • Unmet needs are identified and then split based
    on the skills of each team member

  • Poverty should not be an offense punishable by
  • Harold Freeman, MD
  • cancerpatientnavigation.org

Illustration Guy Billout
  • American College of Surgeons Commission on
    Cancer. (2011) Working draft Cancer program
    standards 2012 Ensuring patient-centered care.
    Retrieved on February 7, 2011 from
  • Battaglia, T., Roloff, K., Posner, M., Freund,
    K. (2007) Improving follow-up to abnormal breast
    cancer screening in an urban population. Cancer.
    109(2) 359-366.
  • Center for Disease Control. (2010) Using evidence
    for public health decision making Screening for
    breast, cervical and colorectal cancer. The Guide
    to Community Preventative Services.
  • Dillon, T. (2006) Cancer care often
    uncoordinated. Retrieved on April 7, 2011 from
  • Ell, K., Vourlekis, B., Xie, B., Nedjat-Halem,
    F., Lee, P., Muderspach, L., Russell, C.,
    Palinkas, L. (2009) Cancer treatment adherence
    among low-income women with breast or gynecologic
    cancer. Cancer. (October) 4606-4615.
  • Ell, K., Vourlekis, B., Lee, P., Xie, B. (2007)
    Patient navigation and case management following
    an abnormal mammogram A randomized clinical
    trial. Preventative Medicine. (44) 26-33.

  • Fang, C., Ma, G., Tan, Y., Chi, N. (2007) A
    multifaceted intervention to increase cervical
    cancer screening among underserved Korean women.
    Cancer Epidemilogy, Biomarkers Prevention.
    16(6) 1298-1302.
  • Freeman, H. (2004) A model patient navigation
    program. Oncology Issues (September/October)
  • Freeman, H. (2008) Patient navigation Community
    centered approach to reduce cancer mortality.
    Retrieved on January 20, 2011 from
  • Gabram, S., Lund, M., Hatchett, N., Bumpers, H.,
    Okoli, J., Johnson, B., Kirkpatrick, G., Brawley,
    O. (2008) Effects of an outreach and internal
    navigation program on breast cancer diagnosis in
    an urban center with a large African-American
    population. Cancer. 113(3) 602-607.
  • Pfizer. Cancer patient navigation overview.
    Retrieved on February 14, 2011 from
  • Robinson-White, S., Conroy, B., Slavish, K.,
    Rosenzweig, M. (2010) Patient navigation in
    breast cancer a systematic review. Cancer
    Nurse. 33(2) 127-140.
  • Steelquist, C. (2009) On the right path.
    Retrieved on February 11, 2011 from
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