Review Article, J Nurs Patient Care Vol: 3 Issue: 1
Patient Navigators as Essential Members of the Healthcare Team: A Review of the Literature
*Corresponding Author : Cynthia Mailloux PhD, RN, CNE
King’s College, Department of Nursing, 33 North River Street, Wilkes-Barre, PA, 18711, USA
E-mail: [email protected]
Received: November 04, 2017 Accepted: April 17, 2018 Published: April 25, 2018
Citation: Mailloux C, Halesey E (2018) Patient Navigators as Essential Members of the Healthcare Team: A Review of the Literature. J Nurs Patient Care 3:1. doi: 10.4172/2573-4571.1000122
In the U.S. an estimated 2.5 trillion dollars was spent on the management of chronic diseases. Today, a major problem being experienced is soaring healthcare costs. In addition, disparities among the underserved and low socioeconomic individuals exist because many have access needs, which contributed to non-compliance issues. Barriers that contribute to non-compliance may include, but not be limited to: transportation needs; finances; health literacy; cultural beliefs; and lack of education. These barriers can be eradicated with the use of a patient navigator. Patient navigators are health professionals such as a nurse, social worker, or lay person trained to help patients navigate the complex healthcare systems of today. Patient navigators assist patients with managing follow-up appointments, medications, transportation needs, and coordination of care. The use of a patient navigator is also one strategy that can help mitigate the effects of healthcare disparities. The purpose of the review of the literature was to identify the benefits of patient navigators as essential members of the healthcare team. The roles and positive outcomes to patients, as well as to healthcare systems, is described. The improvement in access to healthcare for the poor and underserved has improved patient outcomes which have contributed to lower healthcare costs. The positive outcomes of patient satisfaction and lower healthcare costs are an advantage to healthcare systems. These benefits support the need for patient navigators.
Keywords: Patient navigation; Patient navigator; Patient advocate; Community health assistant; Care coordinator; Outcomes and patient navigators; Barriers and patient navigation and Non-clinical patient navigators
In 1990, Dr. Harold P. Freeman, surgical oncologist, partnered with the American Cancer Society (ACS) to create the first patient navigation (PN) program in Harlem, NY. This program focused on women with poor cancer outcomes  and was a direct result of the 1989 hearings conducted in seven American cities, led by the president of the American Cancer Society. The testimony was primarily by poor Americans of all racial and ethnic groups diagnosed with cancer. Common issues that emerged among the participants included: apathy toward seeking care; fatalistic thoughts; financial sacrifices imposed on the family; and lack of knowledge related to disease. Based on these hearings, the American Cancer Society issued its “Report to the Nation on Cancer in the Poor .”
The Harold P. Freeman Patient Navigation Model was developed to assist low income women with cancer to minimize barriers to screening, diagnosis, treatment and follow-up care. “The program was shown to increase the rate of follow-up and reduce waiting time for breast biopsies for positive mammograms, leading to an increase in the diagnosis of breast cancer at an early stage and relatively high 5-year survival rates .”
Another example of a successful PN model is the Heart Success Transition Clinic (HSTC), designed to address gaps in care between the acute and ambulatory care setting. The patient navigator identifies patients with heart failure in the acute care setting and develops a plan with the patient for continuous follow-up care . The HSTC team assures that the patient remains stable based on evidence-based protocols. If the patient has transportation problems a virtual heart success clinic is delivered via telemedicine . This model has provided a successful approach for the healthcare system in the management of patients at higher risk, and those experiencing excessive costs. Since 1990, many more PN programs have been implemented and studied through funding provided by private foundations….as well as federal, state, and local governments . Foundations such as Susan G. Komen, and Avon, as well as the National Cancer Institute (NCI) and other federal government agencies, began to support this initiative. In 2005, U.S. policymakers supported the Patient Navigator Outreach and Chronic Disease Prevention Act (Public Law 109-18). The Act amends the Public Health Service Act to authorize the secretary of Health and Human Services through the Health Resources and Services Administration (HRSA) to make grants that would provide PN services to improve patient outcomes. Twenty-five million dollars, over five years, was awarded through granting agencies such as HRSA and NCI to determine if a patient navigator helps to reduce barriers to treatment and improve patient outcomes in underserved populations .
In 2007, 2.9 million dollars was appropriated to patient navigation. The Center of Medicare Services (CMS) supported six demonstration projects with the objective of identifying barriers in screening, diagnosis and treatment of cancer. These barriers included: fear of diagnosis; lack of transportation; knowledge; distrust of the healthcare systems; and co-morbidities . In addition, PN addressed the Institute of Medicine’s (IOM’s) six-aims for improvements to provide safe, effective, patient-centered, timely, efficient, and equitable care [7-9].
Patient navigator programs have improved screening, cancer diagnoses, adherence rates, and other chronic treatment outcomes. In addition, services have contributed to improvement in health care disparities and survival rates [7,10]. At the Harlem Hospital, patient five-year survival rates went from 39% to 70% for breast cancer patients .
Since 2010, the ACA requires “insurance navigators” to help individuals navigate the state exchanges . These individuals also referred to as “patient navigators” within the ACA, and the principles of PN, can be found throughout the document.
The National Association of Healthcare Advisory Consultants (NAHAC) was established to standardize the PN industry . In 2011, the organization became non-profit and in 2013, was reorganized with a national patient advocacy credential and was accredited. The goal was to recognize the patient navigator as an integral member of the health care team .
A review of the literature (2007-2017) was conducted using PubMed and CINAHL databases. Search terms used were: patient navigation; patient navigator; patient advocate; community health assistant; care coordinator; outcomes and patient navigators; barriers and patient navigation; and non-clinical patient navigators. Published articles were found in multiple journals, mostly with a focus on oncology, patient navigation, and nursing. The reference lists of all retrieved articles were also searched for additional applicable studies and primary sources which provided the historical background. The search was completed with 33 references found consistent with the topic.
Patent Navigator: Definition and Role
Multiple names for a patient navigator exist throughout the literature. Primarily, the difference is in whether the individual possesses a clinical license from an accrediting agency. Clinical patient navigators can be nurses or social workers, as they hold a recognized license in the discipline. Non-clinical patient navigators do not hold a clinical license and are referred to as community health assistants, patient advocates, and/or care coordinators. Additional terms include: disease, case, or care management; and care navigator .
The American Medical Association (AMA) describes a patient navigator as someone whose primary responsibility is to provide personalized guidance to patients as they move through the healthcare system. The term patient navigator is often used interchangeably with “patient advocate,” and the role may be filled formally or informally by individuals with clinical, legal, financial or administrative experience, or by someone who has personal experience facing healthcarerelated challenges. Navigators can be employed by community groups, hospitals, insurance companies, or they may be independent consultants who offer fee-based services to people who are unwilling or unable to manage complex medical issues on their own .
The primary role of a patient navigator includes educating and connecting patients to resources and support services. Patient navigators are involved in the coordination of care among healthcare providers, scheduling appointments, identifying financial/social services, tracking outcomes, and access to transportation . In addition, a patient navigator provides support to minimize anxiety, identify appropriate social services, and track outcomes . As such, it is important to define the appropriate role of a patient navigator as part of a patient’s healthcare team—with the ultimate responsibility for patient care residing with physicians .
“Providing basic navigation is a core competency for patient navigators. There may be two different specialties of patient navigators; one which seeks to reduce health disparities and a second which focuses on treatment and emotional support .” While specific differences in their roles exist, i.e. nurse navigators overseeing cancer patients vs. non-clinical patient navigators assisting patients with appointments, transportation, filing insurance claims, all possess the commonality of assisting patients in navigating complex healthcare systems.
The patient navigator also serves as the point of contact for the patient who is being seen by multiple practitioners at a variety of healthcare settings . Individuals are assisted, particularly the medically underserved, in overcoming barriers encountered across the entire healthcare continuum. These types of barriers can be identified by a patient navigator and changes can be made in a patient’s plan of care to resolve these issues. Trusting relationships are established with patients and patient navigators have been responsible for problem solving, critical thinking, and supporting patients through a complex health system .
Patient navigators are one of the many strategies that can mitigate the effects of healthcare disparities. Based on this assumption, eliminating healthcare disparities in the U.S. was one of the Healthy People 2010 health objectives . Patient navigation programs are designed to implement a variety of evidence-based processes to help patients avoid readmissions. Processes can include scheduling seven-day follow-up appointments and discussing and providing the patient with documentation of treatment regimen, all prescribed medications, and community resources .
According to A. Matyas (Manager, Community Health Services, Geisinger Health Plan), “the need for community health assistants/ patient navigators is generally determined by resources. That population is divided, and high utilizers receive a home visit by the patient navigator. Patient navigators are also closely involved with our most medically complex patients and provide reinforcement of education, medication review, home safety assessment, and resource needs. In addition, referrals are received by patient navigators from inpatient case managers, physicians, social workers or other members of the healthcare team.” (personal communication, August 18, 2017)
Educational Preparation and Qualifications
As an emerging industry, there is no clear definition or standard training to call oneself a navigator or advocate. There is not a specific education or background requirement to work as a patient navigator . Different facilities will have different requirements to work in this position . The title of patient navigator does not yet have a universal definition or standardized certification requirements, though many navigators have received specialized training through workshops or online courses . Although a clinical degree is not required, individuals receive training in the roles and responsibilities, core competencies, cultural competence, negotiation of healthcare systems, communication skills, and access to quality of care issues .
The patient navigator may be a community health professional, such as a nurse, social worker, health educator, or a lay health worker holding either a social science degree or higher in another discipline . Some healthcare systems will employ individuals holding a certificate in PN, rather than a degree. According to the Vice-President of Care Coordination and Integration, Geisinger Health Plan, “healthcare systems view a formal certification in PN at a higher level than a community health worker/assistant.” (J. Sciandra, personal communication, August 2, 2017)
Formal educational programs are developing throughout the country to provide college-level coursework leading to a minimum of a certificate in PN. “Many organizations or schools now offer ‘certificates’ in navigation or advocacy but none are a national credential .” Some courses run from as little as a few weeks, to as comprehensive as a master’s degree. Presently, PN is not a regulated profession.
Patient navigation training programs are growing in popularity because accreditation standards are requiring the use of patient navigators in some healthcare institutions. Patient navigation programs are available nationally to offer information, guidance, and education to patients and care givers for a specific population or disease. Two such national programs are the National Cancer Institute’s Patient Navigation Research Program (NCI-PNRP) and the Center of Medicare and Medicaid Services (CMS) Cancer Prevention and Treatment Demonstration Project .
In Pennsylvania, a pilot program was conducted from July 2013-March 2014 by the Highmark Foundation and Accenture at three western hospitals-St. Vincent Health System in Erie, Allegheny Valley in Pittsburgh, and Jameson Health System in New Castle. The pilot program resulted in documented improved patient outcomes, and as a result the Harold P. Freeman Patient Navigation Institute, with the help of Highmark and Accenture, rolled out a PN training program in 35 locations in the country .
Target Populations Served by Patient Navigators
In the U.S. an estimated 2.5 trillion dollars, 75% of annual healthcare costs, are spent on chronic diseases . Initially, the primary focus for a patient navigator was patients with cancer. However, PN is used with other chronic conditions such as diabetes, cardiovascular disease, asthma, and obesity. There has been an increase in the number of conditions utilizing patient navigators based on positive patient outcomes that healthcare systems have been experiencing. In large medical centers, the patient navigator has been used to navigate the care of patients with heart disease, strokes, and other medical conditions for which the system is trying to determine cost effectiveness and quality of care outcomes. Navigators are highly used in populations that are at risk for poor patient outcomes such as those experiencing access issues, health literacy problems, and low socioeconomic status. Other areas where PN systems are being implemented include public health clinics and healthcare organizations.
Barriers When Utilizing Patient Navigation Programs
There are many barriers identified in the literature that contribute to patients not following through with care. One study found that 47.4% of patients did not report a barrier to care, while 23.3% reported one barrier and 24.2% reported two or more . One main reason identified as a barrier was the lack of understanding of the need for specific care. Other major barriers were: fear of pain and the diagnosis of cancer; time; socioeconomic status; child care issues; lack of transportation; no medical insurance; inconvenient hours; family support; ethnicity; health literacy; poor communication skills; and cultural beliefs [7,9].
Meredith  found the most notable barriers for attaining appropriate diagnosis and treatment for breast malignancies included: ethnicity – African American and Hispanic women; low socioeconomic status; access to health insurance; continuity of care; communication; educational level; decreased social support; understanding of health coverage; family health priorities; and cultural beliefs. Communities that lack social assistance and supportive programs may be a factor contributing to poor outcomes in patients. Addressing these barriers by using a patient navigator has been found to decrease related healthcare disparities .
Cost of a Patient Navigator
Patient navigation services are not directly covered by insurance as it is not a billable service. “Well-designed studies would need to demonstrate both efficacy and cost effectiveness to make the argument for securing reimbursement for navigation .”
However, the benefits of cancer PN in many cases outweigh the costs associated with a PN program. The cost of these programs varies and depends on the type of staff utilized. Using professionals versus lay personnel will contribute to higher costs for the service. Some healthcare systems use volunteer navigators who may require more oversight or supervision by a more educated person. Many healthcare systems may utilize professional staffs that are paid a salary for their expertise . The cost to establish and maintain a PN system includes: salaries; benefits; office space; computers; transportation needs; supplies; telephone system; educational material; etc. Many of these costs are covered by grants, private donations, healthcare systems, or state and federal legislation . According to Gardner, “the call for this sort of help is growing louder as insurers shift away from paying a fee for each test, office visit, and hospital stay to a “value” system in which hospitals and doctors lose money if patients don’t get and stay stable or well .”
A patient navigator belongs to an emerging field created by pressures on care providers to make people healthier. In 2012, the American College of Surgeons Commission on Cancer (CoC) required healthcare facilities seeking accreditation to have a PN process in place by January 1, 2015 to receive payment for services . Partially because of these reasons, hospitals generally offer navigator services at no cost to patients who are believed to benefit; usually those who have complex health problems and a lack of adequate support at home or in their communities. While providers don’t typically receive any insurance reimbursement for patient navigation, sometimes the patient navigator is covered through grant or research funding. It is expected the navigators will pay for themselves by lowering the overall cost of care and improving patient outcomes .
According to T. Sokola, Chief Administrative Officer, Geisinger Central Region- Geisinger Healthcare System, “when a patient navigator is part of the plan of care, because no separate fee can be submitted for reimbursement, the services are absorbed in the cost based on the DRG (Diagnosis Related Group) payment from the insurance companies. No incremental payment would be made by insurance no matter what the hospital billed. The same is true for an out-patient navigator in a hospital-based clinic. The cost of the navigator would need to be covered by the payment for the visit or procedure. It does not matter if it is a RN or Social Worker. I know of no billing code for this work.” (personal communication, July 30, 2017)
Benefits and Outcomes of Patient Navigation
Healthcare facilities are becoming increasingly aware of the benefits of utilizing patient navigators. “The sum of net benefits from patient navigators seems to be considerable .” According to Rodak “the potential benefits of patient navigators include improved health outcomes, increased patient satisfaction, decreased no-show rates and reduced disparities in care .” Patient navigators guide patients through transitions of care, which can reduce readmissions and avoid cuts to hospitals’ Medicare payments. These benefits can help hospitals increase revenue .
This is supported by Bresnick who reports significant financial savings of as much as 4.5 times the salary of a patient navigator. The study confirms that care coordinators and patient navigators are an inexpensive and effective way to ensure patients understand responsibilities, take medications, and attend appointments . Another study conducted in October 2013, found that 49% of providers intended to hire care coordinators within the year, while payer collaborations with ACOs have already stressed the benefits of hiring dedicated patient navigators to help simplify the healthcare system .
Several studies suggest PN programs are an intervention that has shown effectiveness in reducing healthcare disparities. One study looked at two groups of patients; those who received PN services and those who did not. The authors found “patient navigation programs reduced healthcare disparities between married and unmarried participants, in time to diagnostic resolution .” Another study by Freeman et al. looked at five-year survival rates of breast cancer patients. The study attributed the increase in survival rates to increased access to screening, improved culturally appropriate outreach initiatives, and PN programs .
Ferrante et al.  found that by using a patient navigator the patient experienced less anxiety, shorter time to diagnosis, and satisfaction when used in urban minority women with abnormal mammograms. The navigator provided emotional and social support that the patient otherwise would not have received. Improved breast quality care was found in patients using a patient navigator with breast cancer . Patient education, teamwork, and coordination of care were also found to be major contributors to positive outcomes. These findings are consistent with the overall goals of the Triple Aim for improving healthcare which are: improving the experience of care; improving the health of populations; and reducing per capita costs of healthcare . Patient navigation programs can be instrumental in assisting with the achievement of these outcomes.
Patient navigation has become a successful option for healthcare organizations trying to overcome the challenges of a fragmented care continuum. Patient navigators, clinical and non-clinical, are fast becoming critical liaisons among the different settings within a system of care . Patient satisfaction and re-hospitalization rates are two important outcomes that can assist in whether the program is useful. While continued research on PN is still needed, studies to date show that PN are effective in improving patient outcomes.
From 2016-2024, the need for patient navigators in healthcare systems, insurance companies, and physician offices is projected to increase by 50% . The Bureau of Labor Statistics (BLS) considers the field of PN a “bright outlook’’ occupation because “it is projected to have many job openings and is a new and emerging occupation [31,32].” “The job outlook for patient navigators is good. More and more healthcare facilities are expected to employ patient navigators as the Affordable Care Act has created a need to ensure patient satisfaction and quality healthcare at an affordable cost .”
As of 2015, The Harold P. Freeman Patient Navigation Institute, launched in 2007, has trained 3,000 navigators . There are many other training programs which have increased the number even higher such as: Sonoma State University; UCLA; Misericordia University; and Cleveland State University . In 1990, Dr. Freeman had a belief that if women with poor cancer outcomes had navigators to assist them through the healthcare system, more lives could be saved. His vision to begin the first PN program, which served as a model for those that followed, was realized and clearly supported by data in the literature. Since 1990, his vision has resulted in the expansion of the use of patient navigators for both men and women, and with a variety of illnesses, not just cancer.
Perhaps Freeman’s own words say it best. “Patient navigation has the potential of substantially assisting as an effective approach to improving access to life-saving healthcare, especially for the poor, the uninsured, and other medically underserved Americans .” After all, isn’t that the goal of a healthcare team; of which patient navigators are essential members?
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