An article in the current edition of the Archives of Internal Medicine highlights one of the fundamental shifts currently underway in medical care, namely the rapidly burgeoning use of patient navigators to improve health outcomes, particularly for people in need.
As I reflect on this topic, I am amazed how quickly this concept has taken root-especially in cancer treatment-only to realize that this is an overnight success story that took over 20 years to develop.
The research report in the Archives was fairly straightforward, although if you read the article carefully you will catch a nugget of how difficult it was to accomplish.
In research that was funded by the American Cancer Society, a group of community health centers called the Cambridge Health Alliance randomly assigned patients into one of two groups to see if they could improve the rates of screening for colorectal cancer. One group received what the authors called "usual care," and the other group was able to get up to six hours of help from patient navigators, who are specially trained health care workers able to assist people to get the care they need by addressing problems and barriers to care proactively and with a flexible approach.
To make the hurdles more difficult, these patients were generally low-income, multicultural, and spoke a variety of languages. They were people who had difficulty accessing regular health care for a variety of reasons, including personal beliefs, lack of insurance coverage, and cultural and language barriers among others.
235 patients were assigned to receive assistance from the patient navigators while 230 were assigned to routine care (meaning a recommendation from a health professional to get screened for colorectal cancer, given the opportunity).
Those in the patient navigation group received letters from their health professional, brochures and information about colorectal cancer screening, and offered the services of a patient navigator.
For those patients who accepted the navigation services, they were able to have thorough discussions about the value of screening, the approaches to screening (usually colonoscopy or fecal occult blood testing), a discussion about their barriers to screening, an explanation of how the tests worked, help in scheduling a colonoscopy if that was their choice, and help in getting prepared for the colonoscopy. If they didn't have insurance, the navigator did what they could to get them insurance if they were eligible. The navigators also provided psychosocial support.
The result was that about 1 out of 3 of the patients who were assigned to the navigation services got screened for colorectal cancer, while only 1 out of 5 in the "usual care" group was screened. The navigators made a median of 8.5 telephone calls to their patients (median means half had fewer calls and half had more calls) and spent an average of 107 minutes in total on the phone during the six months of the study.
(It's important to note that 23% of the patients assigned to the navigation group could not be contacted, making the results even more impressive.)
In summary, the navigation program was successful at achieving its primary goal which was to increase the number of people who had screening for colorectal cancer.
We tend to read articles like these, and view them as nice, neat packages of research. We rarely get a sense of the difficulties the investigators face during their research. In this case, the authors shared the fact that during the research the Alliance had what they described as "serious financial problems" resulting in some of the health centers closing and doctors leaving. They speculate that had this not happened, their results may have been even more positive.
So what have we learned?
Like other smaller studies, this research shows patient navigation works.
Many of us reading this blog tend to assume that everyone functions at pretty much our level of understanding about our health. But that's not the case. There are many people out there who don't know how to access the health care system, who don't have the money or insurance to access the health care system, who may be afraid of the health care system, or have personal/cultural beliefs that are longstanding which lead them to ignore their health and avoid the health care system.
Navigation is intended to address these issues, and help people get the care they need. This study shows that even under very difficult cultural, economic, educational and financial circumstances people can get appropriate medical care if someone is willing to take the time to take their hand and guide them through the process.
Why is this so important? Because until about 6 or 7 years ago, patient navigation as we know it did not exist.
Today, the American Cancer Society-which actively supports patient navigation nationwide, especially for people in need-funds 135 patient navigation sites across the country in cancer treatment facilities from cancer centers to physician based practices. In 2010, patient navigators affiliated with the Society served 84,000 patients and their caregivers with 113,000 services. 24% of those patients were medically underserved, and 60% were newly diagnosed. Over the past 6 years, our program has increased capacity by 40% every year.
Mind you, this started from scratch.
A couple of years ago, there was no patient navigator movement in this country. Now it is proven to be very effective, and is being adopted by cancer centers across the country. And, in a forthcoming set of guidelines for quality cancer care, the Commission on Cancer is going to require that cancer programs make patient navigation services available as part of their accreditation process.
As I said at the beginning, this is an overnight success that didn't happen overnight.
Back in the 1980's, Dr. Harold Freeman was a volunteer leader at the American Cancer Society. Dr. Freeman was vocal about the needs of those who were medically underserved, and led an ACS initiative called "Cancer and the Poor." In the 1990's, Dr. Freeman started a navigation program at Harlem Hospital to improve the care people received at that hospital.
Dr. Freeman's courage to confront the country with an issue it was choosing to ignore and his groundbreaking work in patient navigation were in fact the foundation of what we see today. This research confirms his vision that to do better in health care we must address issues and barriers constructively and effectively for those who need our help.
Doing what we have always done is not going to get us where we need to be when it comes to the health of our nation. Patient navigation is now very much a part of a much needed transformation of our health care system.
Maybe at the heart of patient navigation is the relearned lesson that offering an ear to listen and a hand to help can have remarkable impact on the health of those in need.
A noble lesson, indeed.