Edward Partridge, MD, is director of the University of Alabama at Birmingham Comprehensive Cancer Center and principal investigator of a 2015 study into the use of lay navigators. He discusses the implementation of a lay navigation program, its value and the benefits of using lay navigators in conjunction with a nurse navigation program.
Q: What is your background of working with lay navigators?
Dr. Edward Partridge: Academically, I have about 20 years of experience using lay people for delivery of health messages. It began with a study in the Black Belt of Alabama and Mississippi Delta, which have traditionally rural, underserved populations, mostly African-American. From these areas we recruited and trained mostly African-American women, but some men, to promote breast and cervical cancer screening in their respective counties.
We were able to demonstrate that lay navigators — individuals without health care degrees — who are trained in the importance of breast and cervical cancer screening could increase screening rates in the African-American population and eventually eliminate disparities in mammography screening in the Medicare population in those targeted counties.
Q: How did this experience carry over to your work at UAB?
EP: In 2005, we recognized at UAB that we were under-accruing our African-American population for clinical trials. Our baseline African-American population of cancer patients is 21% and our accruals for clinical trials in 2005 was about 11%.
We trained four African-American women to serve as clinical trial navigators. They would meet with African-American patients with a new cancer diagnosis who were potentially eligible for trials and would discuss the pros and cons of participation. If the patient was eligible for the trial, the navigator would help overcome any barriers to participation, such as transportation, babysitting and financial obstacles.
In three years, we doubled our accruals to 22% with the navigators.
Q: In 2012, the UAB Comprehensive Cancer Center received a $15 million Health Care Innovation Challenge Grant Award from the Center for Medicare and Medicaid Innovation (Innovation Center). What was the grant for?
EP: When the Innovation Center put out its request for applications, the basic premise was to find delivery models that achieve better health, better health care and lower costs. We proposed to recruit lay navigators — non-social worker, non-nurse navigators, which is how we described “lay” for purposes of the grant — then train and assign them to Medicare patients we knew were traditionally high utilizers of downstream services (e.g., ER, ICU, hospitalization). We wanted to expand the navigators into several community-based cancer centers that were part of the UAB Health System Cancer Community Network.
We also proposed to navigate not only the acute care period, the treatment phase, but also provide navigation during survivorship and end-of-life care. Based on our literature searches, we found that there was a little information on survivorship and nothing on end-of-life around lay navigation.
We received the grant and developed the program, which was called the Deep South Cancer Navigation Network.
Q: How were the lay navigators trained?
EP: We developed detailed training curriculum here at UAB with a number of investigators, scientists and other collaborators. Lay navigators were trained to use a distress assessment during their initial visit with the patient that allowed them to design their intervention plan.
The lay navigators are trained not to make clinical decisions. If the decision is clinically based, they know to kick it up to their site manager. Each of the cancer centers has an RN that serves as the site manager. That RN is the point person for the lay navigators if a clinical issue needs to be addressed.
We also trained our navigators in a program called “Respecting Choices,” which is a high-level discussion about end-of-life choices that a lay person can administer. The navigator sits with the patient and their caregiver and asks questions like, “If you can’t make medical decisions, who will make them for you? What’s important for you at the end of life?” They get the conversation going between the patient and caregiver about how to handle end-of-life issues if and when they arise. We do require college education, not a professional degree, for these navigators.
Q: Why use lay navigators for this work?
EP: The lay navigator can deal with all of the non-clinical issues. Something as simple as arranging transportation for an appointment, which a lot of social workers do now, can be kicked down to the lay navigator. That frees the social worker up for something more urgent, such as another patient who has significant social issues. Now the social worker is not spending 20 minutes on the phone trying to arrange transportation for a cancer patient. That is still critically important, but you don’t need any clinical expertise or training to make that connection.
We’re not going to be able to train enough professionals to handle all of the work necessary to effectively navigate care. We have to figure out how we can take lay, non-professional individuals to address logistical issues that social workers and nurse navigators often get bogged down with but does not require a professional.
Q: What were the results of the Deep South Cancer Navigation Network program?
EP: As we expected, providing care to navigated patients were initially more expensive than non-navigated patients because we are targeting those with metastatic, advanced diseases; cancers we know are problematic, like brain, head and neck, lung, pancreatic and ovarian; and we also target anyone with significant comorbidities, like congestive heart failure or diabetes. We also target people on particular drugs, such as digoxin or warfarin, that we know end up bringing patients back to the ER. That initial investment in navigated patients proved to be well worth it.
Through the program, we were able to demonstrate reductions in hospitalizations, ICU visits, modest reductions in ER visits, increased participation in hospice, and significant decreases in costs in the navigated versus non-navigated patients. Costs were reduced by about $17 million in our 10,000+ navigated patients. I think we have demonstrated that a lay-trained navigator can help connect the dots and intervene with problems earlier that might otherwise cause an ER visit.
We were a little surprised to also find a pretty significant drop in cost for the navigated patients in the survivorship phase. We need to do a little more analysis, but our hypothesis is our navigators are doing a better job of getting elderly patients with several comorbidities to a primary care physician, endocrinologist or cardiologist and making sure they get adequate follow up.
It’s been really interesting to understand how we can extend our healthcare delivery by using lay people. You don’t actually need a physician or clinician to keep a well person well or a sick person as well as possible and out of the hospital. You need someone coordinating their care.
Q: How do lay navigators work with nurse navigators?
EP: I think lay navigators complement our nurse navigators. At several of our sites which have nurse navigators, the lay navigators extend the quality of the interaction between nurse navigators and patients.
It’s the same with the social workers. The social workers were initially very concerned when they heard about what we were doing with lay navigators. Now they say they don’t know how they got along without the lay navigators. They really work with and use each other to help our patients.
Q: What are your plans for your navigation program going forward?
EP: Funding for the study ended on Dec. 31, 2015, so UAB is now covering the lay navigators’ salaries to keep them working.
We have applied for the Medicare Oncology Care Model. Basically, the Centers for Medicare & Medicaid Services will pay you $960 more per chemotherapy episode in exchange for providing benchmarks on utilization and meeting quality measures. It’s an alternative payment model (APM). We’ve also negotiated with Blue Cross Blue Shield of Alabama and VIVA Health, a UAB self-insured group, to have an APM with their patients. If those two and Medicare come on board, that covers about 90% of cancer patients in Alabama. We’ll be able to really ramp up our navigation program and extend it to all patients.
This is the beginning of APMs, which is where I see the future going. Organizations are not going to be able to pay for navigators with existing dollars because there are no extra existing dollars in systems. APMs provide an infusion of new dollars. In exchange for those new dollars, you need pretty significant reduction in downstream utilization. That’s the way it should be for high-quality care.
We’re going to get paid for value, and I think navigators are going to be invaluable in such a system. I would be surprised if navigation, including the use of lay navigators, is not part of the answer for the future delivery of healthcare. I personally intend to continue to make it a big part of our cancer care delivery here.