Expert Commentary From Dr Steven Patierno

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A Word From the Experts
Expert Commentary From Dr Steven Patierno
03/01/2008

Breaking Down Organizational Barriers in Patient Navigation: A Citywide Model

Patient navigation is growing around the country. Rarely has a new health care concept rooted itself in organized medicine so quickly, as evidenced by grants and the support it has received, such as a $25 million patient navigation bill signed by President Bush1 which funded 8 grants awarded by the National Cancer Institute,2 as well as 6 demonstration projects supported by the Centers for Medicare and Medicaid Services.3 These key factors undoubtedly have driven its remarkable advent: the multicultural diversity of our society; the increasing complexity of modern medicine; and our mazelike health care system. As things now stand, even a well-educated person with access to resources is hard-pressed to know how to maximize the quality of a medical encounter in the face of critical illness. Imagine how daunting this task must be for someone who is undereducated, who is poor, or who faces language barriers.

Systematic barriers, which are inherent in the current US health care system, exacerbate the unequal burden of disease borne by medically underserved minorities and other vulnerable populations nationwide. In oncology, this medicosocial inequality is known as cancer care disparity.

There are many challenges facing the population in Washington, DC, including:

  • Cultural diversity - approximately 60% of the population is African American,4 with a rapidly growing Hispanic community.5
  • Poverty - in 2006, approximately 1 in 5 residents lived below the poverty line.6
  • Lack of health care coverage - many in its minority communities lack health insurance.7

DC's population has the highest cancer mortality rate in the country.8 The challenges noted above may be factors contributing to these circumstances. Compounding this issue, it is well known that minority women and men present at an earlier age with more advanced breast and prostate cancers.9

On the whole, cancer care disparities in DC are not attributable to lack of medical facilities or publicly subsidized health coverage: Washington, DC, has 10 hospitals, a broad network of community clinics, and a government-sponsored safety-net insurance program. However, the facilities are unevenly distributed geographically. DC is operationally divided into quadrants: Northwest, Northeast, Southwest and Southeast.10

The Southeast quadrant, geographically isolated by the Anacostia River, has no mammography facility, and its only hospital is unable to provide adequate services. Although recently improved, historically the safety-net insurance program was not broadly accepted due to very low and delayed reimbursements.


http://en.wikipedia.org/wiki/Image:DC_satellite_image.jpg

The George Washington University Cancer Institute (GWCI), in the heart of DC, is dedicated to eliminating cancer care disparities and bringing comprehensive optimal cancer care to all members of the community. To address the citywide crisis of disparate cancer care, the oncology center has developed a unique model called the DC City-wide Patient Navigation Research Program.

This program is one of 9 patient navigation initiatives funded by the National Cancer Institute and the American Cancer Society. Through this grant and other funding sources, we have created a citywide network of 12 patient navigators that covers 5 hospitals, 2 community health care advocacy groups, and the DC Department of Health. Through monthly meetings, shared training, shared resource manuals, and a Web portal, navigators work cooperatively and seamlessly to support patients who must crisscross the city for different aspects of their care. They are trained to assist patients in reducing the barriers to obtaining health care while addressing cultural and psychological factors that may impact health outcomes.

The DC City-wide Program is evaluating whether or not using patient navigators can reduce the breast cancer disparity in Washington, DC, by decreasing time from suspicious breast finding to diagnostic resolution and time from diagnosis to breast cancer treatment initiation. Active sites include: 1) Breast Care Center at George Washington University's Medical Center; 2) Capitol Breast Care Center, a mammography screening facility affiliated with Georgetown University's Lombardi Cancer Center; 3) Howard University Cancer Center at Howard University Hospital; 4) Preventorium at Washington Hospital Center; 5) Nueva Vida, a community outreach and support group targeting Latinas with cancer; 6) Providence Hospital; and 7) Center for Breast Health at Washington Hospital Center.

Coordinating a citywide network across 7 different health care institutions presents many challenges. For example, each institution has a separate Institutional Review Board for protection of patient privacy, with different requirements, expectations, and levels of risk avoidance. However, a complex infrastructure has been established with site-specific Standard Operating Procedures, providing for common data collection and communication links to ensure protocol adherence. All navigators meet monthly for training and administrative coordination with a GW-based program manager. The existence of the well-established DC Cancer Consortium, plus the commitment of DC's major medical centers to reducing cancer care disparities, suggests that a citywide patient navigation network will continue to be sustainable and successful after conclusion of the research study.

GWCI has fully integrated the navigation programs with cancer prevention and control, cancer screening, palliative care, and cancer survivorship programs. This better enables us to address the systemic barriers that limit patient access to cancer screening, treatment, and survivorship programs alike. The network of navigators includes lay navigators, medical social workers, nurses, and nurse physician-assistants. This diversity benefits everyone by bringing together a wide range of perspectives, background training, and skills in a single network.

While there will always be organizational barriers to overcome, there is hope and a model through the DC City-wide Program for organizations to examine, adopt, and adapt to meet the needs of their own patient community. More information about the DC City-wide Program can be found at http://crchd.cancer.gov/pnp/pi-patierno-description.html.

References:

  1. News from the office of Congresswoman Deborah Pryce. President Bush signs Pryce Patient Navigator bill into law. Available at: http://www.house.gov/price/press%20releases/063005_patient_navigator.htm. Accessed: December 18, 2007.
  2. National Cancer Institute. NCI awards $25 million for Patient Navigator Research Program for minority and underserved cancer patients. Available at: http://www.cancer.gov/newscenter/pressreleases/PatientNavigatorGrants. Accessed December 18, 2007.
  3. Cancer disparities demonstrations. Available at: http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/CPTD_Awardee.pdf. Accessed December 18, 2007.
  4. US Census Bureau. State & County QuickFacts. District of Columbia. Available at: http://quickfacts.census.gov/qfd/states/11000.html. Accessed November 20, 2007.
  5. Suro R, Singer A. Latino growth in metropolitan America: changing patterns, new locations. The Brookings Institute - Survey Series - Census 2000. July 2002:1-18.
  6. US Census Bureau. American FactFinder. Washington city, District of Columbia - selected economic characteristics: 2006. Available at: http://factfinder.census.gov/. Accessed November 20, 2007.
  7. FamiliesUSA. How will association health plans affect minority health? Separating fact from fiction. Available at: http://www.familiesusa.org/assets/pdfs/Fact-Sheet-AHPs-MinorityHealth83aa.pdf. Accessed November 20, 2007.
  8. Statemaster Web site. Health statistics: Cancer death rate per 100,000 (most recent) by state. Available at: http://www.statemaster.com/graph/hea_can_dea_rat_per_100-death-rate-per-100-000. Accessed November 20, 2007.
  9. Schwartz KL, Crossley-May H, Vigneau FD, Brown K, Bauerjee M. Race, socioeconomic status and stage at diagnosis for five common malignancies. Cancer Causes Control. 2003;14:761-766.
  10. Wikipedia Web site. Image: DC satellite image. Available at: http://en.wikipedia.org/wiki/Image:DC_satellite_image.jpg.
    Accessed November 20, 2007.