Wide Variability Revealed in Patient Navigation Structures, Services, and Processes in Six Boston Hospitals

Patient navigation is increasingly becoming standard of care in cancer centers, but a new study published in Supportive Care in Cancer that assessed these programs in one large US city demonstrated the broad heterogeneity of their resources, structures, processes, and services provided. Amy LeClair, PhD, MPhil, assistant professor, Clinical and Translational Science, Tufts University Graduate School of Biomedical Sciences, and researchers at five other Massachusetts medical centers, analyzed patient navigation programs in the city of Boston to understand the various structures and processes they use to provide care to individuals with breast cancer. This study formed part of the pre-implementation work for the local Translating Research Into Practice (TRIP) program, which is working to create regional patient registries, systematic screen for social barriers to care, and patient navigation services for minority and/or low-income women with breast cancer in Boston (NCT03514433).

Patient navigation seeks to reduce barriers to receiving timely, high-quality care. Oncology navigators assist with scheduling appointments, arranging care between providers, addressing patients’ financial and health insurance needs, and a range of other concerns tailored to individual patients. Nurses, along with social workers, frequently fill the navigator role based on their holistic expertise of the clinical, psychosocial, and logistical issues involved in cancer care.

Since being introduced in the 1990s, patient navigation has been shown to improve cancer screening rates, patient satisfaction with care, and efficient treatment initiation. Patient navigation has been required for accreditation by the American College of Surgeons’ Commission on Cancer since 2016. The three core principles of patient navigation are: 1) support for patients across the cancer care continuum; 2) targeting patients at highest risk and most in need of navigation services; and 3) systematic screening to address patients’ health-related social needs. All Boston academic cancer care hospitals have patient navigations services, but to date this has not eliminated disparities in breast cancer mortality, Dr LeClair and her colleagues observed.

The team surveyed breast oncology clinicians who had a high level of involvement with patient navigation services at six Boston hospitals. After these staff completed an online survey describing the staffing composition of the navigation programs, research team members conducted on-site visits to assess the workflow and navigation processes with multiple members of the treatment teams. The researchers were most interested in capturing the programs’ characteristics, systems, and processes for identifying and following patients, and approaches to screening for patient’s health and social needs.

The results of the study indicated that although all six hospitals had navigation services, they varied widely in their services and processes. Most sites had non-clinic staff in the navigator role, while a few had nurse practitioners or social workers. Navigators were supervised either by clinicians or breast surgeons. Only one site had navigation services funded through the operative budget; the other sites either had the program funded completely through grants or a combination of the operating budget, grants, and philanthropy.

Sites also varied widely in how they delivered care. Some sites introduced services during the screening and diagnosis phases, but others did not start until treatment initiation. Eligibility criteria for navigation services also varied, as did the frequency of interactions between patient and navigator. Some sites utilized in-person interaction simultaneous with clinic visits, while other relied on the phone.

None of the sites systematically assessed health-related social needs. Some sites screened, but their criteria for doing so were unclear. Within the sites that did screen, the most frequent needs addressed were access to food, transportation, ability to pay utility bills, and child and elder care responsibilities. In response, some sites referred patients to a social worker and others provided lists of service organizations.

Overall, the research team noted the inconsistent roles and processes of patient navigation across the sites. They identified three different types of gaps: a lack of care across the treatment spectrum, with patients frequently being handed off, or services breaking down, and a lack of standardization about which patients should be targeted for navigation services and how to identify and address patients’ social needs. The Commission on Cancer allows for flexibility in programs, to allow hospitals to respond to meet the needs of their local populations, but having core processes in navigations programs may help improve patients’ care at the individual and populations levels, the researchers suggest..

The researchers also believe that to be most effective at addressing healthy inequities in breast cancer, navigation programs should implement processes to identify patients most at risk for delays in care. Because the six sites varied in the points in time at which navigation was available for patients, there was potential for delay in efficient start of care. This may be due to differences in race, ethnicity, and socioeconomic status of the populations served, the researchers suggest. While standardized assessments of social determinants of health are not yet widely used, they can allow navigation to proactively address the barriers to patients getting the most appropriate care rather than waiting for those barriers to impact their cancer care (e.g., reducing missed appointments due to lack of transportation or childcare).

Based on these study results, the research team suggests that patient navigators and those involved with navigation services in their cancer clinic should seek to ensure their programs are tailoring their services to the needs of the patients they serve. Aspects to consider are the points in time when services are initiated, ways to identify patients in need of navigation, and the ability to detect and address the needs of the most vulnerable patients. While navigation programs need not all be identical, they should be held to their goal of supporting patients, especially those who are at risk for disparities and inequities in care, the researchers assert.