Reducing Barriers to Care: Patient Navigators in the Field

Navigators in the Tampa Bay area facilitate the provision of individualized care to help patients receive timely diagnostic resolution of abnormal breast and/or colorectal cancer screenings and get timely treatment. They address a multitude of issues related to transportation, insurance, family support, fear, and other emotions involved with a cancer diagnosis as well as the complexities of the healthcare system, said Ercilia R. Calcano, administrator of the Patient Navigator Research Program (PNRP) at H. Lee Moffitt Cancer Center in Tampa, Florida. The Moffitt PNRP, 1 of 8 programs funded by the National Cancer Institute, is evaluating the use of patient navigators to reduce delays to diagnosis and treatment of breast and colorectal cancers. The choice of using lay navigators from the community was based on feedback from a community advisory board and participating primary care clinics, as well as formative research with community members using focus groups. It was felt that patient navigators hired from the community would build trust and meet literacy, communication, and cultural needs of patients in the project.

The 7 community clinics where patients received patient navigation are located in a large geographic area and included the following populations: African-Americans, Hispanics (primarily migrant farm workers), and rural whites. At each community clinic, the PNRP supplied a trained lay patient navigator who had deep knowledge of the community. Most navigators were Spanish–English bilingual, thus enhancing the ease of communication. The clinics “really had to be involved in this project to make it work. They had to do quite a bit, but at the same time their patients were going to benefit from having a navigator,” explained Calcano. Each clinic provided space for a navigator to use approximately 3 days per week, where she picked up the referrals from clinic staff and contacted patients. After making contact with a patient, the navigator met with the patient at his or her home or in the clinic during an appointment to assess the patient’s needs and strengths, Calcano told the Academy of Oncology Nurse Nav igators. After identifying the patient’s barriers to diagnosis or care, the navigator worked closely with the patient to address them.

Much of the program’s success is credited to its use of a lay navigation model. “The strength of this model is that the navigators go out to the patients, they see them in their own familiar environment to help address barriers, whatever they are,” said Calcano. Most of the barriers, such as assisting patients in scheduling appointments or helping them apply for insurance or financial assistance, require attention outside the clinical environment, before patients arrive at the diagnostic and treatment facilities. “Lay navigators,” continued Calcano, “can complement the services provided by nurse navigators whose skills are especially valuable when patients have complex medical and psychosocial needs.”

Many patients experienced transportation barriers. Calcano gave these examples: “If there was only one car in the patient’s home and one of the patient’s daughters or sons needed that car to go to work, then the patient had no way to get to their appointment. Or if the community clinic had a van that drove patients to the diagnostic or care facility every Monday morning and the patient was not scheduled on a Monday morning, then the patient did not have transportation.” The navigators efficiently worked with different community services to create linkages between patients and services. This included finding solutions such as partnering the patient with a community agency, a friend, or a church member to obtain transportation.

Patients also faced communication barriers. “One of the other issues we face, especially with the migrant farm worker community, is that patients change their telephone numbers often as they migrate,” shared Calcano. “So, when a staff member tries to follow up on an appointment, he or she can’t find them.” As the navigators often live in the community, they are much more adept at locating the patient through a family member.

The study is now in its last year and, therefore, the navigation phase has ended. To help the patients from the participating clinics, however, the program disseminated the patient navigation model by “working with each clinic by asking them to identify some key people for the navigators to train to do basic navigation activities.” It also created a resource guide for the participating clinics, and established strong linkages between the clinics and the cancer center. Those linkages, training, and resources have helped the clinics to better assist their patients in identifying where the resources are, facilitating patients’ access to follow-up care, and obtaining some of the basic skills needed to navigate the patients. Also, thanks largely to the efforts of these navigators, funding was obtained to implement another navigation program with the Tampa Bay Community Cancer Network, to address cervical cancer disparities.