Wednesday, December 4, 2013

Who Should Navigate?


by Dr. Harold P. Freeman, MD
Recently, I received a very thoughtful and moving message from a person named Sandie Himmelman. She is a Certified Brain Injury Specialist who has, herself, undergone three brain surgeries. Sandie writes: "I want nothing more than to be a patient navigator! It is my passion and my purpose in life." For the past several years, she has volunteered her services as a patient navigator to many patients who have undergone surgery for benign brain tumors. However, she has found that "being a non-nurse navigator has not been acceptable to the hospitals, doctors and other medical staff" where she lives.
Sandie wrote because she had read something on the Harold P. Freeman Patient Navigation Institute Facebook page indicating that we value the work of nurse navigators. (This is true, as I will explain below.) She asked for our thoughts on the value of non-nurse navigators and whether she should continue to pursue her passion of being a patient navigator for patients who have undergone surgery for benign brain tumors.
In responding to Sandie, I wish to take this opportunity to communicate my ideas and philosophy, as the originator of the concept of patient navigation, to all who may have similar questions and concerns. 
A fundamental question raised by Sandie is: WHO SHOULD NAVIGATE? 
As a background for answering this question, please note that I have described a "health care continuum" across which individuals seeking or requiring care may be navigated. This continuum includes prevention, detection, diagnosis, treatment, and post-treatment quality of life.
Many people, particularly the poor and uninsured, meet significant barriers to timely movement across various phases of the health care continuum. Frequent barriers encountered by patients include - but are not limited to - financial barriers, information barriers, communication barriers, medical system barriers, fear and distrust. We have shown that patient navigation can save lives and improve quality of life by removing barriers to timely diagnosis, treatment and supportive care along this continuum.
To clarify my position on the questions raised by Sandie, I refer to two of the "Principles of Patient Navigation" which I have promoted and written about:    
·      The determination of who should navigate should be based on the level of skill required in a given phase of navigation. There is a spectrum of navigation extending from services that may be provided by trained non-professional navigators to services that require navigators who are professionals.  
·      Delivery of patient navigation services should be cost-effective and commensurate with the training and skill necessary to navigate an individual through a particular phase of the continuum.  
In other words, the skills and qualifications necessary to be an effective patient navigator vary greatly based on the role the navigator is to fill. For example, navigators helping patients understand medical conditions and coordinating treatment need considerably more formal clinical expertise than navigators helping patients to identify medical resources and in guiding patients through an often complex care system. 
I have found that non-professional patient navigators, appropriately trained and directed, can be very effective in eliminating financial, communication and system barriers to timely care across ALL phases of the health care continuum, including outreach, diagnosis, treatment and post-treatment survivorship.
Nurse navigators are having a significant impact on the health care system. Nurse navigators have been particularly effective in assisting and coordinating the care of patients after diagnosis and during treatment. In the treatment phase, a navigator with such medical knowledge may often make a huge difference in the patient's outcome.
In the three patient navigation programs I have developed in Harlem over the last 24 years, most of the navigators are trained non-professionals. These navigators typically work on a team with professional navigators including nurses and social workers. 
It follows from the above that nurse navigators and other professional navigators should not be assigned duties that can be performed by non-professionals. This would not be cost-effective and would not properly utilize their level of training. It also goes without saying that non-professional navigators are not qualified to carry out the duties of professionals such as nurses and social workers.  
THE NATIONAL PICTURE
In 2005, Congress passed the Patient Navigator and Chronic Disease Prevention Act, which was signed into law by President George Bush. The Patient Navigator Act was based principally on the patient navigation model, which had been developed in Harlem.
The recently enacted Patient Protection and Affordable Care Act (ACA) requires that navigators be utilized to assist uninsured individuals in obtaining health insurance through the "Exchanges" which have been set up in every state. Recently, the US Health and Human Services Department has made available about $70 Million to employ members of communities as patient navigators for this purpose. Moreover, several government agencies including the National Cancer Institute, the Center for Medicare and Medicaid, the Centers for Disease Control and the Health Resources and Services Administration have, in recent years, provided more than $100 Million in funding for patient navigation demonstration research, most of which explores the possible impact of non-professional navigators in reducing health disparities. I believe that this level of support by the government for patient navigation programs is an encouraging sign that non-professional navigators (along with professional navigators) will be included in the health care system as effective providers of patient support.
Below is a diagram illustrating the Freeman Patient Navigation model:
 
THE MILE RELAY/PATIENT NAVIGATOR ANALOGY: PASSING THE BATON
As an analogy, patient navigation may be seen, in some ways, as being similar to a mile relay race. In the relay, there are four runners, each carrying a baton which will be passed to the next runner. In such a race, let us imagine that the runners are navigators and that the baton is the patient. The object, of course, is to win the race, which is not over until the final runner crosses the finish line with baton (patient) in hand. Each runner is assigned to a phase of the race. It is essential that the baton (patient) not be dropped when passed to the next runner. All the runners are on the same team and are overseen by a coach.
Similar to the mile relay, patient navigation, in its highly developed form, is also a team effort whose navigators, carrying out various phases, require oversight by a coach or coordinator. And it is important to be reminded that, just as is the case in the mile relay, the race is not over for the patient until he or she crosses the finish line.
FINAL THOUGHTS
In developing a patient navigation program, "Who should navigate?", in my opinion, is not the first question that should be asked. More importantly, the first question must be: "What are the needs of an individual who is seeking timely quality health care?" After determining the patient's needs in a particular phase of care, a navigator with appropriate skills can take responsibility. 
We must do all we can to harness, integrate, and apply the power and energy of all kinds of patient navigators -- non-professionals and professionals -- whether they are working individually or within health care systems, with the goal of eliminating the social, economic, cultural, and medical system barriers to timely, often life-saving, quality health care for each individual in need.
I wish to thank Sandie Himmelman for expressing her concerns, and I advise her to seek further training in navigation and to continue to pursue her passion to be a patient navigator. We need such motivated and inspired patient navigators. Her energy, experience, and strong desire to help others serve as an inspiration to us all. 

Harold P. Freeman, MD
Founder, CEO and President
Harold P. Freeman Patient Navigation Institute