Harold P. Freeman, MD, is considered the pioneer of patient navigation after he initiated and developed the nation’s first patient navigation program. He is the founder of the Harold P. Freeman Patient Navigation Institute, which supports patient navigation training. The Institute opened its doors in 2007 to offer patient navigation training to address the growth in patient navigation programs, and offer standards and best practices customizable to meet each program’s needs.
In part one of this two-part series, which can be accessed here, Dr. Freeman spoke about the beginnings of patient navigation and his feelings on its evolution. In part two, Dr. Freeman discusses nurse navigation, the effects of the Affordable Care Act (ACA) on patient navigation, and what he hopes for the future of navigation.
Q: How do you feel about the growth of nurse navigation?
HF: It’s really wonderful to see how nurses have embraced the model. There’s now a nurse navigation society which is having an impact, and we have seen nurse navigators become very prominent in cancer centers. They are doing great work around the country.
Navigation has also tended to bring more attention to what nurses do in cancer care, going beyond just belonging to a department. Nurses are taking a huge role in embracing the personal aspects of navigating the patient through the system, which goes beyond their assignment to a specific sub-specialty.
The Oncology Nursing Society published a book on patient navigation, for which I wrote the preface. I think the embracing of patient navigation to a large extent by nurses, particularly the nurse oncologist, has been a big step forward in the acceptance of navigation nationwide.
Q: Do you feel the ACA has helped or hindered patient navigation?
HF: It’s difficult to determine what impact ACA has had on navigation to date. We haven’t had enough time to judge it yet.
However, I was very pleased to see the language of ACA embrace the concept of navigation. It did two things. As noted earlier, it called for the use of patient navigators to assist people in working through the exchanges. While that’s only an element of navigation and not the whole navigation concept, I like the idea that they have taken that on and are paying money for the service. ACA also renewed the “Patient Navigator Outreach and Chronic Disease Prevention Act.” That act is a much broader navigation concept.
In evaluating the two ways ACA supports navigation, it looks to me to give the possibility that ACA could help patient navigation move to higher levels.
What ACA has not done is determine how to pay for patient navigators. That’s a work in progress. There was an attempt by New York Congressman Steve Israel to do so when he introduced the “Patient Navigation Assistance Act” into Congress in 2014, but the bill did not pass. Had it passed, it would have put payment for patient navigators under Medicaid.
At the moment, we still don’t have a means for the federal government to pay for the services of patient navigators. That’s unfortunate.
Q: What do you envision and hope for the future of patient navigation?
HF: It often seems to me that what the nation tends to do is related to finance and how people are paid. Something that has happened recently in last few years that might drive the system to more easily encompass the use of patient navigation is the decision of the government to reimburse according to outcomes and not according to how many procedures are performed.
That kind of movement toward getting people paid for doing their work according to outcomes, more specifically good outcomes, would require good coordination of patient care. And patient navigation is a key to better coordination.
As a result, we may be on a path toward further embracing the concept of patient navigation, which has to do with seeing the patient through the entire health care race. In a mile relay race, the race isn’t over until the last runner crosses the finish line. The concept of ensuring patients get into and through the health care system to a point of resolution, which is a navigation concept, is different from whether you served them well at a single, particular part of their illness. I think that the movement toward coordinated care is consistent with the use of patient navigation and navigators.
Here’s another analogy. I’m taking a flight from New York to Los Angeles. It’s a big plane. Let’s say the plane represents the American health care system. Some people need special help to get on the plane, such as those individuals in wheelchairs. They receive that assistance. That’s navigating people to get onto the plane.
When on the plane, there are some people are in first class, some in coach. First class has better food, more cocktails and bigger seats. You have to allow for that in life in general. But everybody is still able to get on the plane. Some may even need extra help during the flight, so you help them.
I would hope that with this health care plane, all people can get on the plane. Those who need special help before or during the flight can get that help — can get navigated — while on the plane. When the plane lands, it lands at the same time and safely for everybody on the plane. That’s the health care system I think we should strive for.
I think the concept of patient navigation is a paradigm shift which allows us to think about the needs of individual patients within a large system, What has happened more in the last decade is health care has become more of a commodity than a human service, and that’s an unfortunate shift. We need to make adjustments, and I think navigation is the kind of adjustment we need.
Q: Do you think the country is ready for such a paradigm shift?
HF: I do. I started as a surgeon in Harlem. Had I continued just being a surgeon, I would have been operating on people most of whom were going to die from their disease. I had to step back from that and consider how I get these patients to move into and through this system in a timely way to receive quality care. That’s a different concern from being a good specialist.
I think we need to continue to deliver high-level specialty care. But we must also ensure that all patients can get into the health care system and make sure they can get through it in a timely manner. That’s what navigation does.
I would hope that over time, patient navigation would become an integral part of the health care payment system. In cancer care, patient navigation has already been defined as a mandate by the American College Surgeons, so we seem to be moving in that direction. I believe there will be a growing tendency for hospitals to pay for navigators.
It is surely a good thing to provide high-quality specialty services. But, in addition, we must ensure that patients have access to care from the point of an abnormal finding to resolution by timely treatment.