Expert Commentary From Ana Natale-Pereira MD, MPH University of Medicine and Dentistry of New Jersey

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A Word From the Experts
Expert Commentary From Ana Natale-Pereira MD, MPH University of Medicine and Dentistry of New Jersey
06/30/2009

Community Workers as Patient Navigators

Ana Natale-Pereira, MD, MPH, is an Associate Professor of Medicine at New Jersey Medical School (NJMS) and a primary care physician at the University Hospital, both part of the University of Medicine and Dentistry of New Jersey (UMDNJ) in Newark. UMDNJ-University Hospital serves as a safety-net hospital for a large portion of the underserved population in northern New Jersey. Approximately 60% of the patients receive charity care, and about 40% of the patients speak a language other than English. Through her daily interactions treating these underserved populations, Dr. Natale-Pereira recognized the challenges these patients experience in trying to navigate their way through the maze of the health care system. Dr. Natale-Pereira’s passion for improving health outcomes in underserved populations, particularly in preventing cancer, led her to the work of Harold P. Freeman, MD, who pioneered the first-reported patient navigation program at Harlem Hospital.

Since she began conducting patient navigation research, Dr. Natale-Pereira has witnessed the positive impact of patient navigation programs. We recently had an opportunity to speak with Dr. Natale-Pereira, who shared with us her thoughts on the importance of engaging the community, the potential role of the community health worker as patient navigator, and her current involvement in the Centers for Medicare and Medicaid Services (CMS) cancer prevention and treatment demonstration (CPTD) project.

Why Start in the Community?

As a primary care physician tending to underserved populations, Dr. Natale-Pereira has witnessed the limited awareness and knowledge about cancer that exist, particularly in the Latino population.

The first cancer prevention project that Dr. Natale-Pereira participated in was through Redes En Acción: National Hispanic Latino Cancer Network, which is a National Cancer Institute (NCI) funded program to improve cancer disparities among Latinos. When working with the community (churches, adult day care centers, and other community-based organizations) to improve awareness and education of colorectal cancer prevention, Dr. Natale-Pereira began to see first hand the community need for facilitation of services and the horror stories about navigating through the health care system.

This experience taught her that it is necessary for a navigator to understand the culture, its barriers and limitations, and applying these learning to raise knowledge and awareness of cancer in the community, before the community can be expected to embrace the importance of cancer screenings. As she explained, “community leaders can serve as the first contact for getting the community educated as well as serve as a link to the health care system.” That experience also convinced Dr. Natale-Pereira that providing patients with a person trained to help them navigate the health care system could dramatically improve the access to health care for those patients.

Dr. Natale-Pereira points out that she has recognized cultural differences even within the various Hispanic populations she has served. Providing patients with a community-based liaison who understands cultural barriers and has been trained on how to usher patients through the health care system can improve access for these populations. A patient navigator who can understand the patients’ needs and can address inherent community barriers is a powerful tool for reaching out to underserved patients.

A patient navigator’s role, Dr. Natale-Pereira explained, should be defined by what the navigation program hopes to accomplish. In the communities served by NJMS, the patient navigator needs to be able to connect with a patient at the community level and function as the bridge that crosses cultural and language barriers to help the patient effectively access the health care system.

The Community Health Care Worker as Patient Navigator

Dr. Natale-Pereira described the patient navigator as having a unique personality. “You need a person who is selfless, yet aggressive in the spirit of service.” Patient navigators need not be cancer experts or health care professionals, but they need to have sufficient knowledge to address patient issues in accessing care and in bringing important issues to the attention of the patient’s physician, such as suspicious test results or side effects. Gaining this knowledge is important for community health workers to perform navigation. The patient navigators facilitate health care services, as well as identify and provide resources within various communities in the greater Newark area. The community health workers serve as advocates for patients and are comfortable talking to providers as well. They must come from the same community as the patient.

Dr. Natale-Pereira shared an example of how the close ties community health workers have with the community can benefit patients. In her most recent research project with CMS, as a result of their daily experience, the patient navigators have created a resource guide, specifically listing the services and resources they have identified as most amenable to helping the Hispanic populations in Newark. The binder of resources, which the patient navigators have created based on their knowledge of the community, can be used by both patients and navigators to help patients move more smoothly through the health care system. It includes such resources as a list of services available in Spanish, as well as agencies with people who speak Spanish and cater to these populations.

CMS—Cancer Prevention and Treatment Demonstration for Racial and Ethnic Minorities

Currently, Dr. Natale-Pereira is at the 3-year mark in a planned 4-year project to decrease disparities in cancer care. Known as the Medicare Cancer Prevention and Treatment Demonstration for Racial and Ethnic Minorities, this CMS-sponsored demonstration project aims to assess the impact of a patient navigation program on patient-related and cost-effective outcomes at 6 centers throughout the United States. Many patient navigation projects begin when a patient is diagnosed, for example, with cancer. However, Dr. Natale-Pereira noted that this CMS program is unique because it focuses mainly on a ‘cancer-free population’ to assess the utility of a patient navigation intervention in cancer prevention. Previous research in the Hispanic community made Dr. Natale-Pereira cognizant of the fact that a community outreach/education program would need to be completed in tandem with recruiting patients for the study. She explained that the successful enrollment of patients in this project has been associated with outreach efforts, such as lectures on colorectal, cervical, breast, and prostate cancer screenings presented at local churches and community organizations. After the lectures, Medicare beneficiaries are invited to enroll in the program. Compared with other centers participating in the project, UMDNJ has the highest population of dual eligible (Medicare and Medicaid) patients.

Dr. Natale-Pereira noted that through this demonstration project, CMS is taking steps to assess whether patient navigation programs reduce cancer health disparities in the Medicare populations and what the best methods of implementing such programs would entail. She anticipates that, through research, patient navigation can be proven to be a cost-effective concept appropriately provided via a fee-for-service program or as a major component to the medical home model.

In Conclusion

Dr. Natale-Pereira firmly believes that “patient navigators will provide enormous support in improving the care and the outcomes of the population that is served in safety-net hospitals.” They are trusted members of the community, who provide comfort, support, and a voice for the patient. She currently is working with the UMDNJ administration to adopt some of the best practices identified through patient navigation programs. While much work remains to make patient navigation programs the standard of care, Dr. Natale-Pereira hopes to see this change occur in the next 10 to 15 years. She also sees an opportunity to extend patient navigation beyond cancer care to assist patients with all of their chronic diseases.

References:

UMDNJ University Hospital. Fast Facts 2006-2007. www.theuniversityhospital.com/about/facts.html/. Accessed May 12, 2009.