Mandi Pratt-Chapman, MA, is director of the George Washington University (GW) Cancer Institute at the GW Cancer Center in Washington, D.C. The GW Cancer Institute is an organization committed to fostering healthy communities, responsive healthcare professionals and supportive healthcare systems through applied cancer research, education, advocacy and translation of evidence to practice. Ms. Pratt-Chapman is the lead author for the GW Cancer Institute’s core competencies for oncology patient navigators and her team developed the first free online training program in the U.S. for oncology patient navigation. Learn more about the Institute at http://smhs.gwu.edu/gwci/.
In this first in a two-part series, Ms. Pratt-Chapman discusses how the GW Cancer Institute works with patient navigators and efforts the organization has taken to support navigators throughout the country.
Q: What is the GW Cancer Institute’s history of working with patient navigators?
Mandi Pratt-Chapman: The GW Cancer Institute works closely with our clinical affiliates at GW Hospital and GW Medical Faculty Associates. Over the past several years, we have collaboratively enhanced and expanded our patient navigation services for those who come to GW for cancer care.
We started a navigation program around 2007. The prior director of the institute was principal investigator for one the nine national sites for the National Cancer Institute’s Patient Navigation Research Program. The goal of that research was to look at how patient navigation impacted time to diagnosis, time to treatment, patient satisfaction and cost-effectiveness.
When I came on board, we grew our in-clinic navigation program and initiated national training on patient navigation and cancer survivorship through our Center for the Advancement of Cancer Survivorship, Navigation, and Policy. We wanted to catalyze navigation programs across the country and help bring training to programs that were just getting started, both in terms of how to build a program and helping to develop patient navigation skills.
Over the past few years, we realized that there have been fewer financial resources available to navigators for training. To respond to this need, we have improved and translated our evidence-based trainings and disseminated them online for free, so people can use that information and put it into practice as quickly as possible.
Q: In April, the GW Cancer Institute published core competencies for oncology patient navigators. Why did you feel it was important to develop these competencies?
MPC: For years, we’ve essentially been on a gerbil wheel. We have buy-in for the concept of patient navigation and navigation programs, but until now we had no consensus on what a navigator should know and be able to do, what their role on the healthcare team is and how it fits with other team members. You can’t really measure the value of something that you can’t define — you can’t truly explain why something is important or show how it’s important if the way it works from setting to setting is so highly variable — so that was an area of concern for us.
I also think that when people talk about navigation, they sometimes lump together nurse navigators with patient navigators that don’t have a clinical license. While the navigation component is certainly something nurse navigators and patient navigators have in common, the specific scope of practice of each is very different. Confusing that can be dangerous.
To address these concerns, we really wanted to define what it is that a patient navigator is doing, provide a clear scope of practice, and delineate that role in contrast to other members of the healthcare team. Once we did that, the next step was to determine what, in order to fill this role, you need to know and be able to do. That’s where the competencies come in and the training that we launched in May 2015. Now all patient navigators can at least have access to foundational training and have a clear sense of role boundaries and strategies going in on day one as a navigator to do their job.
I believe that clear competencies are critical as the basis for training and professional development. Competencies also clarify the role to funders, administrators, people making decisions about patient services, and to health plans and insurers who are demanding more care coordination and a certain level of quality in the clinical setting. I think there’s a crucial place for navigators — patient navigators and nurse navigators as well as social workers and other members of the care coordination team — as part of that overall picture of what care should look like given the way our healthcare system is structured.
Q: What has been the response to the core competencies thus far?
MPC: We posted the competencies in fall 2014. As of early September, we had more than 1,100 downloads. For people to actually go to a website and download core competencies in a specific profession, that’s pretty good. I’m definitely happy with the results thus far.
Q: In May, the GW Cancer Institute developed the first free online training for oncology patient navigation in the U.S. What is the purpose of this training and what do you hope participants take away from the educational experience?
MPC: Everything we do here is meant to be applied. I really want our work to be about how to take what we know and put it into practice, or, if there is a gap in what we know, how to create research that finds the information we need to advance improvements in practice. So we developed this free, 20-hour, self-paced online training based on adult learning theory. It’s interactive — there are quizzes and assessments you need to complete to move onto the next stage in the training — and the training really reinforces, through videos and other resources, the foundational skills and knowledge reflected in the core competencies.
I’m really excited about our training and quite proud of it. It’s something we have wanted to do for awhile. We intentionally developed the training to be free and available online because we felt like that was the best way to reach the largest number of people. Some people are not paid as navigators, and salaries for those who are paid as professional navigators are often not enough for them to personally be able to afford training. Increasingly, institutions do not have funds to send staff to training either.
I’m thrilled to say that I am chairing a task force for the Academy of Oncology Nurse & Patient Navigators (AONN+) to establish a certification process for patient navigators in 2016. Our training will help navigators prepare for the certification exam. We will beta test the exam at the AONN+ regional meeting in May 2016 and roll out the official certification exam at the AONN+ annual meeting in the fall of 2016. The areas being tested are directly aligned with our training, so those interested in being certified should definitely check out our training before taking the exam.
Since we launched the training, more than 700 people have enrolled and are in the process of taking the training, with more than 85 people completing it, which is huge since it has only been available for a few months and it takes 20 hours to finish the full course.
Q: What are your patient navigators’ primary responsibilities, and how do they help patients?
MPC: The top need that our navigators at GW fill right now is patients’ need for reliable cancer information. They provide evidence-based information to patients. As you can imagine, when patients are diagnosed with cancer, they have a lot of questions. Providing information from the American Cancer Society to patients or directing them to where they can go to get the answers to their questions are, by far, the top ways our navigators are assisting patients.
But their work certainly extends beyond just sharing information. They coordinate a lot of transportation assistance — finding out which transportation programs patients are eligible for and helping to connect the dots there. Our navigators provide financial assistance, insurance assistance, medication assistance, and more. One of our navigators does a lot of referral corrections from community primary care clinics to imaging. We are also providing services in Spanish. We have a good number of Spanish patients, so making sure they are getting information in a language that is accessible is also a significant way we are supporting patients.
Q: Do all nurse navigators play the same role?
MPC: Not all navigators perform the same services, and we distinguish between those with and without clinical training. Some of the tasks that would be role appropriate for a “patient navigator,” which is how I describe navigators without a clinical license, would be helping to assess what barriers a patient might experience that would prevent them from getting through their cancer care treatment and identifying resources responsive to the needs that patients have identified. Those may be practical needs, social needs, physical repercussions of treatment, or concerns associated with treatment, emotional needs, and even spiritual needs.
Educating patients is where things can get a little trickier. It is very appropriate for a nurse navigator to be clinically educating patients. When we talk about providing education for patients by patient navigators who are not licensed, they focus on who to go to for information, what the multi-disciplinary nature of cancer care looks like, the next steps in patients’ treatments, reinforcing information they get from their oncologist, and making sure patients are getting to the right source of information.
Being a navigator is also about being an advocate, which means making sure patients’ voices are represented in their treatment planning and that navigators are a proponent for patients. This is important in terms of supporting shared decision-making and checking in with patients to make sure they are able to adhere to the next appointment or their medications schedule. Our navigators are also helping to encourage patients to develop advocacy skills and really be able to problem solve on their own.
There are many ways someone without a clinical license can help fill needs patients have given how confusing and fragmented our healthcare system is and how complex cancer care can be.
Q: How are navigators connected with the patients they help?
MPH: That happens in a number of different ways, depending on the setting. Here we have navigators housed in particular clinics. We have some navigators in imaging. Whenever there is an adverse screening in breast imaging, those navigators identify the needs of the patient and triage the patient based on the level of risk. They help make sure they get prompt diagnostic resolution and transition the patient to someone who is a navigator in the surgical, medical oncology, or radiation oncology areas. We have one navigator housed in radiation oncology, and she is currently working to move more upstream to identify issues from the surgery clinics that are funneling patients to radiation oncology to try to address those patient needs sooner.
Q: How are patient navigators assigned these various responsibilities?
MPC: We have, in part, used the Commission on Cancer distress screening requirement to help. When patients fill out their distress thermometer and identify that they have practical or logistical concerns, then the navigator is assigned to reach out to the patient to help with those concerns. If it’s a clinical concern, patients are triaged to a nurse or their physician. If there’s a mental health or psychosocial concern, the patient is triaged to a social worker.
At another institution where there is less volume than we have here, there may be more continuity with one person: You might have a navigator across a patient’s entire trajectory of care. It depends on the setting, the volume of the clinic and the purpose of the navigators. Some navigators are more research oriented and trying to make sure people know about clinical trials they might be eligible for or how to ask related questions. It really varies from institution to institution.
In the second part of this two-part series, Ms. Pratt-Chapman shares insights on why patient navigation is critical, barriers to navigation’s success and the future of navigation.