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. Learn more about the Institute at http://smhs.gwu.edu/gwci/.
In the first in this two-part series, Ms. Pratt-Chapman discussed the GW Cancer Institute’s patient navigator program and her work in helping to develop core competencies and free online training for oncology patient navigators. In this second part, she discusses why patient navigation has become a crucial component of healthcare and what she views as its future.
Q: Why have patient navigation and care coordination become essential to providing effective cancer care?
MPC: I don’t believe these services are specific to cancer. It’s a case where the fragmentation of the healthcare system can easily cause patients to feel overwhelmed. The level of healthcare disparities and fragmentation in the system has begged for solutions. I don’t think coordination and navigation are the cure-alls by any means. I think these are strategies to help reduce fragmentation in a system where even if you don’t have a severe or serious diagnosis, it can be extremely frustrating at best and paralyzing at worst.
Another major issue is limited workforce capacity. We have limited primary care physicians, oncologists, nurses, primary care providers, and many other types of caregivers. If there’s one message I repeat over and over again, it is that we need to collaborate and work together to make this healthcare system better.
Cancer patients need more social workers and nurses — these people provide critical clinical services that physicians cannot address given the volume of cancer patients in this country and the limited time doctors can spend with each person. Nurses and social workers play critical roles, and my excitement about the role of navigation is that I think there are a lot of gaps we can fill by providing some foundational knowledge and training people who can free up those with those specialized skills to optimize what they do best, such as providing clinical education in the case of nurses and counseling in the case of social workers.
There is so much information coming out all of the time, and patients need help making sense of it all given short appointment times and numerous changes in healthcare financing and patient expectations for care. Patients are demanding higher-quality and more patient-centered care, and I think they should, but in order to meet those needs, you have to create the right infrastructure and provide the right support.
Q: What is the City-wide Patient Navigator Network (CPNN)?
MPC: In 2010, I wrote a grant with the former director of the GW Cancer Institute to create a network of patient navigators across the city. What we were trying to do with CPNN was advance Washington, D.C.-specific navigation goals and bring together the different navigators across different facilities, primary care, tertiary care, community organizations, and others — all within D.C. — to help advance our cancer control plan. That is a U.S. Centers for Disease Control and Prevention-funded requirement for every state in the country. You are required to have a plan for cancer control. Navigation was identified as one of the priorities for the plan in D.C.
Under the direction of the former institute director, we led this initiative for a few years through a tobacco settlement fund that provided funding to coordinate it and expand navigation services across the city. My team did a lot of research about what works for navigation networks across the country; since funding expired, we eliminated CPNN as it originally existed and created a more sustainable approach which we renamed the Metropolitan Patient Navigation Network. We have included navigation colleagues in Maryland and Virginia, and we have a volunteer, shared leadership structure among the GW Cancer Institute, the Primary Care Coalition and Smith Center for the Arts. We focus on cancer awareness and professional development — bringing folks together to troubleshoot cases and make sure people at different organizations across the city are communicating with each other.
The focus of CPNN was direct service or providing patient navigation at various organizations across the city. Our focus now is really on education and technical assistance to help other organizations succeed with their own in-house navigation services, and we are now doing more in terms of research to try to answer important questions to drive the field forward.
Q: What do you hope for and envision as the future for patient navigation in the U.S.?
MPC: I certainly hope it expands. There is a lot of room to expand navigation outside of cancer, and that is already happening in some areas, such as in lupus, HIV, and diabetes.
What I think has to happen is we need to move away from the assumption that these navigation services are secondary, that grant funding will take care of them, and that they are not critical services. One of the things my team is working on right now is developing an evaluation tool to measure navigation value — to help identify some core, critical ways to measure the value of navigation across a wide variety of settings. This should allow us to collectively talk about navigation as something that is not a boutique service — a nice thing to have for marketing — but is critical to the delivery of care.
I also hope that administrators and payers increasingly view navigation as a key part of quality care and something that needs to be present to provide good care. I hope patients will continue to demand navigation services and that payers will recognize the navigation role — whether performed as a nurse navigator, a social worker, a patient navigator, or a multi-disciplinary care coordination team — as a necessary component of cancer services. I hope that payers will provide sufficient capitation, global or bundled payments to oncology practices to allow for sustainability of navigation as a baseline quality indicator for it to be a core part of cancer care before shared savings kick in for new payment models.
Q: What do you see as possible obstacles to the growth of navigation?
MPC: I worry that given the number of requirements that are put on clinicians and practices, the increasing demands on practices, and the changing financing structure that navigation could be something in jeopardy if we do not quantify its value. I would like for health plans and payers to view navigation as a requirement for a payment, as something that should be compensated for and compensated sufficiently so practices are encouraged to — and can afford to — offer it.
In 50 or 100 years, it would be great if we didn’t need as much navigation. If we could create a culture shift in this country so that people are more health focused and strong advocates for their own health — and could be that for family members — that would be amazing. We would always have the need for certain components of the navigation role given the way healthcare is structured here. But if we can make accessing care simpler and create strong self-advocates in the public at large, we could start tackling other challenges.
There’s a lot we can do in terms of health promotion and changing how people think about health in this country. Hopefully we can leverage caregivers, volunteers, and folks who share that vision to move us further along so those people who are paid to do this can really focus on the patients with the greatest need.
I would encourage navigators to look carefully at areas where they care grow professionally and set goals for themselves while also contributing to quality improvements where they work. I think we also have to collectively start building the case for the value of the field. This will help make sure navigation is something that’s going to stay and be recognized for its importance by the full healthcare team as well as payers in this changing, challenging but exciting value-based financing environment.