In the 29 years since Harold P. Freeman, MD, introduced the concept of patient navigation for breast cancer patients at Harlem Hospital in New York City, navigation services have evolved considerably. Today, thousands of nurses, social workers, and trained lay people are working to help patients with cancer overcome barriers to care and achieve the best quality of life possible. The use of oncology nurse navigators is gaining particular steam right now, through the establishment of core competencies, the creation of a national certification program, and growing attention to the need for payment models that will sustain patient navigation in cancer care.
Navigator Role & Contributions
The exact number of navigators working with oncology patients isn't known, but 8,200 navigators of all types are members of the Academy of Oncology Nurse & Patient Navigators (AONN). The Oncology Nursing Society (ONS), AONN, the American Cancer Society, and the National Navigation Roundtable are leading efforts to formalize the navigator role in oncology and to ensure its growth through evidence and sustainable payment models. A certification process for oncology nurse navigators and oncology patient navigators is in an active testing phase and could lead to a clearer picture of the navigator population—and potentially further growth for the discipline.
The first patient navigators, recruited by Freeman in 1990, were not health care professionals but members of the Harlem area community who wanted to help patients with breast cancer and received training to do so. By 1995, these first navigators had helped improve 5-year survival rates among patients treated for breast cancer.
Over time, formal definitions and competencies have been established for the navigator role. Today, patient navigation is defined by the ONS, the Association of Oncology Social Work, and the National Association of Social Workers as “individualized assistance offered to patients, families, and caregivers to help overcome health care system barriers and facilitate timely access to quality health and psychosocial care from pre-diagnosis through all phases of the cancer experience.”
“Navigators are the thread that seamlessly pulls the health care system together,” said Sharon Gentry, RN, MSN, CBCN, ONN-CG, who established the first nurse navigator role in North Carolina. She is a member of the AONN Leadership Council and practices as an oncology nurse navigator at Novant Health Derrick L. Davis Cancer Center in Winston-Salem, N.C. “The navigator serves as the eyes to identify where the patient is going, to prepare the patient for where they're going to go, and to help that patient with everything he or she encounters there.”
Another pioneer in nurse navigation, Tina Evans, RN, BS, puts it this way: “When you see diagrams depicting what navigation is about, the patient and family are in the middle with the nurse navigator by their side. All the disciplines are surrounding them. The patient, family, and nurse navigator are the hub. Everyone else makes up the spokes.”
Evans is the Vice President of Navigation Systems for OncoNav, a producer of documentation software for navigators working in the oncology setting. She became an oncology nurse navigator after her own battle with breast cancer in 2001. After she completed treatment, she accepted a position in the Baltimore area that allowed her to create a nurse navigator role, drawing on her own experience to do so.
“I know what I had missed in the way of guidance and help, and what I had needed in terms of advocacy,” Evans said. “When I began working with these women, I began doing for them what I wish someone had done for me: one-on-one answering of questions and achieving understanding of the diagnosis and exactly how it was going to be treated.”
During interviews with Oncology Times, Gentry and Evans both emphasized that nurse navigators can help patients with cancer feel empowered during a time that causes significant fear and uncertainty. Some of the key ways nurse navigators do this is by identifying actual and potential barriers to care, facilitating good outcomes, and fostering good communication. Research performed over the past decade has shown that these actions lead to improved outcomes.
As reported by the National Navigation Roundtable in its 2019 publication, Patient Navigation in Cancer Care: Review of Payment Models for a Sustainable Future, “Studies have shown that navigators have a positive impact on patient care across a variety of outcome measures, including: process-of-care measures, patient-reported outcome measures, and clinical outcome measures.” This document also urges the integration of patient navigation into current and emerging payment models.
Metrics, Certification & More
AONN has long recognized the need to document the positive impacts of patient navigation. Since its formation 10 years ago, the academy has worked on projects such as the the identification of domains of care for nurse navigators and patient navigators, and the creation of certification exams for nurse navigators and patient navigators. The organization's work complements and reflects that of the ONS, which published core competencies for navigators in 2013 and updated them in 2017. In 2015, the Commission on Cancer added navigation as a standard for program accreditation.
AONN recently introduced three certifications that are in use pending accreditation by the American National Standards Institute: oncology nurse navigator–certified generalist, oncology patient navigator–certified generalist, and oncology nurse navigator–certified generalist thoracic. Certification is an important step toward more widespread reimbursement for navigator services and thus the hiring of navigators. “To facilitate reimbursement, we need to have certification,” Gentry said.
In the area of evidence and metrics, AONN launched a national multisite study in 2018 to document the barriers and challenges encountered by navigation programs when implementing metrics measures. This work, which is being done in collaboration with the American Cancer Society and Chartis Oncology Solutions, is based on AONN's determination of three main categories of metrics: business performance/return on investment, clinical outcomes, and patient experience. The study will evaluate the validity and reliability of 10 navigation metrics: barriers to care; time from diagnosis to initial treatment; navigation caseload; number of navigated patients readmitted to the hospital at 30, 60, and 90 days; psychosocial distress screening; social support referrals; palliative care referrals; identifying patient learning style preferences; navigation knowledge at time of orientation; and patient experience and satisfaction with care.
“These standard metrics will provide a starting point and baseline metrics for all navigation programs that are evidence-based through literature support, patient preference, and clinical practice using the AONN domains of certification as reference points,” AONN's Leadership Council wrote in a news release about the study. The organization will develop a metrics repository where program outcomes and performance improvement initiatives can be shared for the benefit of all navigation programs.
“The ultimate goal [of the multisite study] is navigators' use of evidence-based, patient-centered processes to educate patients and their caregivers so that they can fully participate in their treatment decisions through the entire care continuum,” Gentry said. “It is a win-win situation, with patients receiving value-based outcomes and patient navigation programs delivering business-savvy models of care.”
Navigators' important contribution of education is intertwined with clear communication throughout the diagnosis and treatment of cancer. “The role of the oncology nurse navigator is to advocate for and facilitate communication between the patient and family and the entire cancer care team,” Evans said. “... It is important to recognize that communication is a two-way street and the navigator is often the ‘interpreter’ between what the physician has told the patient and what the patient is able to comprehend and process. The trusting relationship that navigators establish with their patients often leads to more open dialogue, so that the patient feels heard. This improves compliance with care, improves outcomes, and leads to higher satisfaction with the cancer care experience.”
Michelle Perron is a contributing writer.
For more information on navigators in oncology, visit these links: