Expert Commentary From Linda Fleisher, MPH

Program Support

A Word From the Experts
Expert Commentary From Linda Fleisher, MPH

One Size Does Not Fit All

Those involved in addressing health disparities across the cancer continuum from screening to survivorship understand the profound need of patients to be navigated through what is often a complex and overwhelming experience. In response to this need, many organizations are looking at patient navigation. However, there are numerous patient navigation models and approaches that have been adopted by health care systems. The question might even be asked: What is patient navigation? Patient navigation has been described as a program, a person, and even an organizational model.

For the past 3 years (2005-2008) Fox Chase Cancer Center, located in Philadelphia, has been part of the Pennsylvania Patient Navigation Pilot Program through a grant provided by the Pennsylvania State Department of Public Health. As we began talking to colleagues involved in patient navigation throughout the Philadelphia region, it was clear that many struggled with the meaning of patient navigation. Some mentioned that they have many support services already in place, but do not call them patient navigation. Others had specific views of what type of individual should serve as a patient navigator.

Role Definition and Acceptance

Patient navigation has been received by some as a promising intervention to improve patient care, but it has flagged concerns in others who see navigators as individuals who simply replace or duplicate preexisting positions. Most of us now would agree that the purpose of navigation is not to replace or overlap existing roles, but to complement them by filling in gaps in services and proactively facilitating the delivery of care to all patients. Depending on patients' needs and the institution's resources, navigators may be volunteers or paid staff. To add to the confusion, we have seen navigators identify themselves as care coordinators, program and project managers, directors, social workers, and chaplains. The diversity of job titles confirms that patient navigation programs can utilize a variety of staff to achieve a single goal—improving the timeliness and quality of patient care.

Not surprisingly, communication with other staff members has been important in reducing friction and increasing acceptance of navigators. In the case of our patient navigation program being implemented in 2 community cancer centers, navigators have facilitated their acceptance by making themselves more visible to other members of the cancer team, participating in rounds, and sharing success stories at staff meetings. As trust builds, we have seen members of the care team increasingly refer patients to the navigators.

Establishing a Program

In order to facilitate an ongoing dialogue about patient navigation and discuss current issues, a day-long regional workshop was held in the fall of 2007, with support from Pfizer and Fox Chase Cancer Center. Participants were from health care organizations located throughout Pennsylvania, Delaware, and southern New Jersey, which either had a patient navigation program or were interested in developing one. The workshop provided an opportunity for those with programs to share best practices, and for those just getting started to learn from the experiences of others. Over the course of the day, the more seasoned participants shared 5 main points common to their experiences:

  1. An organizational needs assessment is a necessary starting point to identify gaps in services and begin to explore appropriate models of patient navigation.
  2. Promoting the program among staff and the community will help to get early buy in from physicians, surgeons, and radiologists and build patient interest.
  3. Continued open dialogue between cancer care staff and navigators will help to ensure cooperation among all members of the team and to establish more clearly defined roles and boundaries.
  4. If resources are limited, starting with a few tasks to help establish program credibility can help generate larger financial and staff support in the future. This might involve limiting the program to a particular group of cancer patients (eg, breast, cervical) or addressing 1 or 2 barriers common to most cancer patients.
  5. Realize it may take as long as 12 to 18 months to establish a smoothly running program. Changes in navigator personnel and program operations or fluctuations in patient volume are common and may affect data collection.
Lessons Learned

So how do you define patient navigation? Is it an individual who guides a patient or a model that an institution adopts? Do navigators provide clinical or psychosocial support? Are they professionals or members of the community? The answers to these questions will help to illuminate which approach best fits the needs of your patients and organization. A continued dialogue will help us to further understand patient navigation and the various roles navigators can play to support patients through the cancer care continuum. As the practice of patient navigation expands, there is a great deal to be learned about the process, political climate, and day-to-day challenges in planning and implementing a navigation program.

Fox Chase's Pennsylvania Patient Navigator Demonstration Project

A team at Fox Chase Cancer Center in Philadelphia, Pennsylvania has designed this project and is collaborating with 2 health care institutions who reach underserved populations. The program (2005-2008) focuses on patients at the point of diagnosis who have just started their cancer treatment and relies on lay navigators. These navigators focus primarily on psychosocial issues and are not clinically trained. They understand the community, have excellent interpersonal skills, and proactively reach out to patients that are experiencing many barriers to care. The patient navigators are housed within a hospital-based setting, are fully integrated into the cancer program, and work closely with social workers, nurses, and physicians. This pilot study will provide important insights regarding the implementation of a hospital-based patient navigation program.

I would like to thank my collaborator at Fox Chase, Dr Suzanne M. Miller, Director, Psychosocial and Behavioral Medicine Program.