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A National Patient Navigator Training Program

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A National Patient Navigator Training Program
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    http://hpp.sagepub.com/  Health Promotion Practice  http://hpp.sagepub.com/content/11/2/205The online version of this article can be found at: DOI: 10.1177/1524839908323521 2010 11: 205 srcinally published online 30 December 2008 Health Promot Pract  A. ValverdeElizabeth A. Calhoun, Elizabeth M. Whitley, Angelina Esparza, Elizabeth Ness, Amanda Greene, Roland Garcia and Patricia A National Patient Navigator Training Program  Published by:  http://www.sagepublications.com On behalf of:  Society for Public Health Education  can be found at: Health Promotion Practice  Additional services and information for http://hpp.sagepub.com/cgi/alerts Email Alerts:  http://hpp.sagepub.com/subscriptions Subscriptions:  http://www.sagepub.com/journalsReprints.nav Reprints:  http://www.sagepub.com/journalsPermissions.nav Permissions: http://hpp.sagepub.com/content/11/2/205.refs.html Citations:  at UAMS Library on June 9, 2011hpp.sagepub.comDownloaded from    A National Patient Navigator Training Program Elizabeth A. Calhoun, PhDElizabeth M. Whitley, RN, PhDAngelina Esparza, RN, MPHElizabeth Ness, RN, MSAmanda Greene, RN, PhD Roland Garcia, PhDPatricia A. Valverde, MPHAs patients enter health care systems for cancer diagnoses,treatment, and follow-up, many barriers can arise (Dohan& Schrag, 2005; Freeman, 2004a, 2004b; Guidry,Matthews-Juarea, & Copleland, 2003; National Institute of Health, National Cancer Institute, 2001). This is particu-larly true for patients who are medically underservedwith limited or no access to health care and other neededservices (Freeman, Muth, & Kerner, 1995). Patient naviga-tion (PN) programs have emerged as one way to reducedisparities by assisting patients and their caregiversthroughout the cancer continuum. Although many PNprograms within hospitals, clinics, and other agencieshave provided training for their navigators, until recentlythere has not been national training with a defined cur-riculum for PNs. This paper describes the developmentand evaluation of a standardized national trainingprogram for PNs. > BACKGROUND Much has been written on the topic of health dis-parities outlining the differences in incidence, morbid-ity, and mortality between various groups, particularlyracial and ethnic populations. Cancer death rates vary by age, race, and ethnicity and although national trendsoverall may show a decrease, this trend is often notshared by all populations (Haynes & Smedley, 1999).   Patient Navigation is an intervention aimed at addressing cancer health disparities by eliminating barriers todiagnosis, treatment, and services. Three major patient navigation (PN) programs (The National Cancer Institute,The American Cancer Society &The Center for Medicareand Medicaid Services) are underway to address theneeds of medically underserved cancer patients. Therehas not been national training with a defined curriculum for patient navigators (PNs). Curriculum for training thePNs was created by experts from the three programs. Theefficacy of training was evaluated using a pre- and  posttest. The data show that overall the posttest scoresimproved from the pretest. In addition, having a highschool education or greater or having more years of work experience were significantly related to improvements onthe posttest. The first successful standardized national training program was attended by 116 PNs representing 85 cities with the goal to reduce health disparities for medically underserved.  Keywords:  patient navigation; training; underserved  populations H ealth disparities among cancer patients are as vari-able as the disease itself with many causative fac-tors such as socioeconomics, health belief systems,insurance coverage, and access to care and health literacy. Health Promotion Practice March 2010 Vol. 11, No. 2, 205-215DOI: 10.1177/1524839908323521©2010 Society for Public Health Education  Authors’ Note: The Patient Navigation Research program is funded by the National Cancer Institute (NCI) through its Center to ReduceCancer Health Disparities, National Institutes of Health, and Depart-ment of Health and Human Services. Study data are the result of the collaborative efforts of the NCI Center to Reduce Cancer HeathDisparities, American Cancer Society, and the NCI Program Evalua-tion Contractor, NOVA Research Company. 205  at UAMS Library on June 9, 2011hpp.sagepub.comDownloaded from   In addition to the statistics that describe the problem,additional research has noted differences in quality of care and delivery (Institute of Medicine [IOM], 2003).Racial and ethnic populations tend to receive lower quality health care than Whites even when insurancestatus, income, age, and severity of conditions are com-parable. For example, the IOM report, Unequal Treat-ment: Confronting Racial and Ethnic Disparities inHealth Care , points to racial differences in treatment asanother contributing factor in lower cancer survival ratesfor Black females. The IOM defines “disparities in health-care as racial or ethnic differences in the quality of healthcare that are not due to access-related factors orclinical needs, preferences, and appropriateness of inter-vention” (pp. 3-4). According to this definition, there aretwo levels to account for the observed disparities, one atthe operational level of the health care system and itslegal and regulatory environments and second, discrimi-nation at the individual or the patient-provider level.Based on these findings, eliminating health dispari-ties in the United States was one of the health policyobjectives for the Healthy People 2010. The HealthyPeople 2010 process, guided by the Office of DiseasePrevention and Health Promotion, U.S. Department of Health and Human Services, is a strategic nationalhealth plan for the first decade of the new century(Aday, 2004).PN is one of many interventions that have been sug-gested to mitigate the effects of health disparities. Infact, PN dates to the American Cancer Society’s Report to the Nation of Cancer in the Poor in 1989 (AmericanCancer Society, 1989), a report completed by Dr. HaroldFreeman, during his tenure as the Society’s President.The report revealed that low-income persons fre-quently face financial and nonfinancial barriers whenattempting to seek cancer diagnostics tests and treat-ment and often do not seek proper and/or timely care because of these barriers. Due to late stage cancer diag-nosis and/or incomplete cancer treatment, the poor dis-proportionately experience pain, suffering, and death.Furthermore, the poor report higher levels of fatalism,which often prevents them from seeking care.Freeman and colleagues were the first to identify an association between low socioeconomic status andracial differences in cancer survival (Freeman, 1989).They noted that 56% of African American women with breast cancer in Harlem had symptoms for more than 3months and that late diagnoses influenced the stage of the disease. Nearly all of the persons in this study wereof low socioeconomic status and almost 50% had nohealth insurance.Mortality from cancer can be significantly reducedthrough screening programs that detect abnormalitiesat their earliest stages and through early treatmentdesigned to eliminate cancers before they become fatal.Lack of adherence to initial screening recommenda-tions and follow-up treatment for abnormal results limits the effectiveness of screening programs and con-tributes to disparities in cancer mortality related toadvanced stage at presentation. In general, 30%-40% of women do not complete follow-up care for abnormal breast and cervical cancer results (Holm, Frank, &Curtin, 1999; Nelson, Geiger, & Mangione, 2002).A summary of barriers that impede cancer screeningand follow-up care for abnormal test results includecost (Gregg & Curry, 1994); transportation difficulties,inconvenience, and unfamiliar surroundings (Gregg &Curry, 1994); insurance issues (O’Malley, Forrest, &Mandelblatt, 2002); lack of physician recommendationand usual source of care (Holm et al., 1999; Kinney2002; Lannin, Matthews, Mitchell, & Swanson, 2002);lack of continuity in care and trusting doctor–patientrelationship (O’Malley, Forrest, & O’Malley, 2000); inef-fective doctor-patient communication (Denberg, Wong,& Beattie, 2004); lack of knowledge (Gregg & Curry1994); attitudes and misconceptions about the purposeand side effects of screening and fears of cancer(Baldwin 1996; Gregg & Curry, 1994; Davis, Emerson, &Husaini, 2005; Denberg et al., 2004; Lannin et al., 2002;Snow 1983); and attitudes about seeking health care 206HEALTH PROMOTION PRACTICE / March 2010 The Authors  Elizabeth A. Calhoun , PhD, is Associate Professor inHealth Policy and Administration at the University of Illinois in Chicago, Illinois.  Elizabeth M. Whitley  , RN, PhD, is Director of Community Voices at Denver health, Denver, Colorado  Angelina Esparza , RN, MPH is the Director of Patient Navigator for the American Cancer Society in Atlanta, Georgia.  Elizabeth Ness , RN, MS is Director for Staff Development at the Center for Cancer Research at the National Cancer Institute in Bethesda, Maryland.  Amanda Greene , PhD, RN, is Senior Researcher/ProgramEvaluator at NOVA Research Company in Bethesda,Maryland.  Roland Garcia, PhD, is a Program Director, Health DisparitiesBranch, Center to Reduce Cancer Health Disparities at theNational Cancer Institute, Rockville, Maryland.  Patricia A. Valverde , MPH, is Senior Research Assistant at the Colorado School of Public Health of the University of Colorado, Denver.  at UAMS Library on June 9, 2011hpp.sagepub.comDownloaded from   (Harris, Miller, & Davis, 2003). Although a physicianrecommendation for cancer screening is associatedwith patient compliance (Lannin et al., 2002), such rec-ommendations are less common for Black women andwomen without a usual source of care (Harris et al.,2003). But even with a doctor recommendation andinsurance, nonadherence to screening recommenda-tions remains problematic.PN is an emerging field. Dr. Harold Freeman coinedthe term patient navigator to describe trained communityhealth workers who help patients overcome access to care barriers. In 1990, he implemented a novel patientnavigator program to combat poor survival rates among breast cancer patients treated at Harlem HospitalCenter, most of whom were African American, unin-sured, and diagnosed at a late stage. After 6 years, thisprogram was associated with dramatic improvementin survival rates. The percentage of women who pre-sented with early stage breast cancer increased seven-fold and patients’ 5-year survival rate significantlyincreased from 39% to 70% because of PN and screening(Freeman, 2004a).Since then, similar PN programs have been initiated inother settings. Though there are many definitions of a PN,it is generally agreed that they are health care profession-als or highly trained outreach workers that coordinatehealth care for patients and assist them in navigatinghealth care systems. The primary role of the PN includesconnecting patients to resources and support systems,assisting with interaction between health care providers,streamlining appointments and paperwork, helpingpatients identify and access financial services, assistingpatients to arrive at scheduled appointments on time andprepared, assuaging patients’ fear and anxiety, identify-ing appropriate social services, and tracking all outcomesand interventions. The work of the PN is to enhance, notsupplant, the activities of other members of the healthcare team.Many programs adapt the PN model to best serve theculture and linguistic attributes of the specific population.For example, in the Native Sisters PN program, NativeAmerican navigators assist women in follow-up after anabnormal diagnosis, accompany the patient to the healthcare facility for biopsy and or treatment, assist in steeringwomen through various health care facilities and offices,and provide emotional support throughout the cancerdiagnosis and treatment process (Burhansstipanov et al.,1998, Hiatt et al., 2001) deployed PNs to increase breast and cervical cancer follow-up of abnormal resultsfor African American, Chinese, and Latina and Whitewomen. The intervention was uniquely delivered to eachracial or ethnic group.PN has received a great deal of attention in recentyears and there are many programs emerging across theUnited States in a variety of settings. In 2005, the U.S.Congress passed and President Bush signed the NationalPatient Navigation Act to establish more patient naviga-tor programs across the United States. Despite thispromising beginning to expand the field of PN, severalissues need to be addressed. Specifically, clearly defined,standardized training to prepare PNs with core knowl-edge, skills, and competencies is necessary. The trainingprogram developed and described here was designed tomeet the needs of multiple programs. Current Program Development  Three large multisite PN programs are currently under-way to address the needs of medically underserved cancerpatients, each with a unique approach and design. Theseinclude the National Cancer Institute’s Patient NavigationResearch Program (NCI-PNRP), the American CancerSociety Patient Navigation Program (ACS-PNP), and TheCenter for Medicare and Medicaid Services’ (CMS) CancerPrevention and Treatment Demonstration Project.PNRP includes eight sites funded by NCI plus an addi-tional site funded by ACS. The primary outcomes of thePNRP are (a) time to diagnostic resolution, (b) time to ini-tiation of cancer treatment, (c) patient satisfaction withcare, and (d) cost effectiveness of navigation (Freund et al., in press). The NCI-PNRP targets health disparitiesin four cancers, chosen on the basis of several factors.Breast cancer will kill more than 40,000 women in theUnited States in 2006 (American Cancer Society, 2006a).The cervical cancer death rate is 50% higher amongHispanic women than among non-Hispanic Whitewomen, which can be attributed to delayed follow-upafter an abnormal screen (American Cancer Society,2006b). According to Surveillance, Epidemiology, andEnd Results (SEER) Program data, African Americanshave higher cancer mortality rates than any otherracial/ethnic group (National Cancer Institute, 2006).Prostate and colorectal cancers are the second and thirdmost common cancers among American men and the sec-ond and third leading cause of cancer deaths, respec-tively (American Cancer Society, 2006a).The ACS PNP has more than 80 programs nation-wide developed to offer information, guidance, andservice resources to cancer patients and their care-givers. The goal of an ACS Patient Navigator Program isto deliver timely information and available treatmentand supportive service programs, promote informeddecision making, and enhance the quality of life forACS constituents undergoing cancer treatment by the Calhoun et al. / PATIENT NAVIGATOR TRAINING207  at UAMS Library on June 9, 2011hpp.sagepub.comDownloaded from   optimal utilization of ACS services and programs andother resources as needed.The CMS demonstration project has six navigationsites in a demonstration project on PN. The study uses arandomized control design to study various models of patient navigator programs to help minority beneficiariesnavigate the health care system in a more timely andinformed manner. The CMS sites throughout the countryare targeting specific racial and ethnic groups to reducedisparities in early detection and treatment of cancer. Thesix sites expect to enroll more than 13,000 beneficiariesover the course of the 4-year demonstration.All three programs employ PNs who are trained, cul-turally competent health care workers who assistpatients to overcome barriers to care, negotiate healthcare systems, and access quality care (Dohan & Schrag,2005).PNs have a variety of backgrounds ranging fromhealth care professionals to lay or peer navigators(Dohan & Schrag, 2005; Doll, Stephen, Barroetavena,Linden, Poole, & Fyles, 2005; Giese-Davis, et al.; 2006;Hardy, Wynn, Huckaby, Lisovicz, & White-Johnson,2004; Johnson, Green, Anderson-Lewis, & Wynn, 2004;Psooy, Schreuer, Borgaonkar, & Caines, 2004).Because PN services are the primary intervention inthese programs, standardized training is needed toensure the dissemination of key knowledge, skills, andcompetencies to reduce access and other barriers fre-quently experienced by underserved populations.In June 2006, NCI-PNRP, ACS-PNP, and CMS deliv-ered such a training program. Through the combinedefforts of these organizations, more than 170 PNs andtheir supervisors from the three programs describedabove received 3 days of training at the MorehouseSchool of Medicine National Center for Primary Care inAtlanta, Georgia. All of these organizations, althoughunique in their services, target populations, and meth-ods, share the need to assure that their PN staff are wellequipped to identify and address the barriers and needsof cancer patients, to improve outcomes. The trainingprogram is described in detail in the following text. > TRAINING The level of training and expertise required for suc-cessful PN has not been previously defined. Dohan andSchrag called for a better definition of the role of PNs to create a more standardized training (Dohan &Schrag, 2005). PN literature makes very little mentionof training, though a 1-day training session for naviga-tors who were cancer survivors is described in one arti-cle (Giese-Davis et al., 2006).PNs vary with respect to educational and health careexperience. Generally, they fall into two main categories,professional (e.g., registered nurse, licensed socialworker) and peers or lay persons. PNRP requires minimaleducation, at least a high school diploma or GED, some basic computer skills, and fluency in English, whereasthe ACS Patient Navigator Program employs, primarily but not strictly, professional (Bachelors degree or higher)level staff including nurses, social workers, and cancersurvivors. To ensure all three programs (PNRP, ACS, andCMS) had adequate preparation across core competen-cies; a standardized national training program was imple-mented prior to enrolling patients.  Developing a Training Curriculum Theoretical frameworks . The curriculum content uti-lized the Social Cognitive Theory (SCT), which incor-porates both the individual and structural factors thatinfluence health behavior (i.e., screening, follow-upafter abnormal test; Bandura, 2004). SCT was selectedas the best model for this project because it incorpo-rates systemic determinants of behavior change as partof the guidance for changing health behaviors. SCTgoes beyond the identification of predictors of behaviorand behavioral change and specifies a core set of deter-minants for health behavior, the mechanisms throughwhich these determinants operate, and guidelines fortranslating these into effective health practices. In the srcinal patient navigator model developed byHarold Freeman, the PN was envisioned as a proactivepatient representative who focused on addressing theconcrete needs of patients by identifying and removing barriers to the timely receipt of care. For example, PNseliminate financial barriers for cancer treatment byassisting patients without insurance coverage to applyfor Medicaid or Medicare insurance. Informational sup-port is the provision of advice, suggestions, and infor-mation. Providing information to patients about theirhealth condition in a way that patients can understandis a central activity of PNs. Appraisal support involvesproviding constructive feedback, affirmation, and socialcomparisons to build self-evaluative skills. When PNsteach patients about steps they can take to successfullynavigate the health system, they are helping patientsgain skills to take ownership of their health.The delivery of the training was guided by adult learn-ing theory pioneered by Malcolm Knowles in 1990. Heidentified the adult learner as autonomous , self-directed , practical, and goal oriented. A dult learners have accu-mulated a foundation of life experiences and knowl-edge that may include work-related activities, familyresponsibilities, and previous education. Adult learners bring a variety of experiences, both personal and pro-fessional, to a learning situation. They are most inter-ested in learning about subjects that have immediaterelevance to their job or personal life and need to be 208HEALTH PROMOTION PRACTICE / March 2010  at UAMS Library on June 9, 2011hpp.sagepub.comDownloaded from 
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