Expert Commentary From Dr Harold Freeman

Program Support

A Word From the Experts
Expert Commentary From Dr Harold Freeman
12/18/2007

Evaluating Lay vs Professionally Trained Patient Navigators

Poor and uninsured Americans face formidable barriers to obtaining timely diagnosis and treatment of cancer.1,2 As a result, they have a significantly higher cancer death rate. Patient navigation is a pioneering model of supportive care that has been shown to help reduce and eliminate barriers to early diagnosis and treatment of cancer in poor and uninsured Americans.3,4 Although patient navigation may be applied across a broader spectrum of cancer care, there is a particularly critical window of opportunity to save lives from cancer: from the point of an abnormal finding to the point of resolution of the finding by further diagnosis and treatment. Navigation applied during this interval can help make an impact in increasing cancer survival in poor and uninsured Americans.

As patient navigation programs have been more widely adopted in recent years, the question of who should serve as navigators has emerged as a point of some debate. Should navigators be lay people? Social workers? Nurses? Case managers? Some other group? Fundamental to this debate must be the consideration that the primary purpose of navigation is to help patients obtain timely quality health care. All other considerations are secondary to that of patient benefit. However, an important countervailing consideration is the cost effectiveness of patient navigation. The sustainability of patient navigation as a health care-related model is necessarily related to whether or not the program is cost effective. With this point in mind, it is logical to determine what level of skills is required at various phases of patient navigation.

We have found that there is a spectrum of patient navigation extending from services that may be provided by trained lay navigators to services that require navigators who are professionals, such as nurses and social workers. One principle that should be observed in determining who should navigate is the level of support required during a particular phase of a patient care. Another key principle is that health care professionals should ideally provide patient-related care that requires their level of education and experience and should not be assigned duties that do not require their skills.

With these principles in mind, we have determined that lay navigators are capable of carrying out many key aspects of patient navigation that do not require professional health care training or expertise. These tasks may include, but are not limited to, helping patients obtain financial support, eliminating communication barriers, and assisting patient's timely movement through an often complex health care system. A critical requirement is that lay patient navigators be closely integrated into the professional and administrative team at a given center and that the referral process from the lay navigator to various health care professionals be smooth. Furthermore, the lay navigator, in the program we have pioneered and described, is the only person we can identify in the health care system with responsibility for overseeing the entire movement of the patient from the point of initial abnormal finding (which most often proves to be benign) to resolution by further diagnosis and treatment of cancer if necessary. Health care professionals, such as nurses and social workers, may play a critical role as patient navigators when the resolution of barriers encountered by patients requires their level of expertise. For example, nurses may be very effective at explaining treatment options or in clarifying the meaning of a medical finding. And social workers are particularly helpful in providing support to patients who have complex social crises and economic hardships.

In short, trained lay navigators are capable of carrying out certain prescribed levels of patient support. Moreover, it is neither necessary nor cost effective to assign health care professionals to tasks that do not require their level of training and experience. It is preferable to utilize such health care professionals to navigate patients who have more complex medical and social barriers.

In summary, patients who face barriers to timely cancer diagnosis and treatment are best served by a coordinated system with a range of navigators extending from trained lay navigators to health care professionals. Such a system can best meet the diverse needs of patients. While both lay and professional navigators provide services that can augment the cancer care continuum, the cost savings from the appropriate use of lay navigators may increase the viability and sustainability of the patient navigation program and ultimately may prove to be pivotal in improving cancer outcomes, especially in low-income and uninsured populations. The decision whether to use lay versus professionally trained navigators (or preferably both) should ultimately be based on the unique needs, structure, and patient population of each organization. We look forward to future studies that may more clearly demonstrate which approach fits best under various circumstances and at different sites.

References:

  1. Freeman HP, Muth BJ, Kerner JF. Expanding access to cancer screening and clinical follow up among the medically underserved. Cancer Pract. 1995;3:19-20.
  2. Freeman H. Race, poverty, and cancer. J Natl Cancer Inst. 1991;83(8).
  3. Grann V, Jacobson J. Health insurance and cancer survival. Arch Intern Med. 2003;163:2123-2124.
  4. McDavid K, Tucker TC, Sloggett A, Coleman MP. Cancer survival in Kentucky and health insurance coverage. Arch Intern Med. 2003;163:2135-2144.