For over 2 decades the American Cancer Society (ACS) has supported and recognized the value of patient navigation in ensuring that patients have the resources needed to overcome barriers to their cancer care. The ACS started with a few patient navigation pilot programs as early as 1999 that were based on the Harold P. Freeman model of nonclinical patient navigation.1 The goal of that program was to reduce disparities by removing barriers to timely cancer care from the time of diagnosis through treatment, with the ultimate goal of improving health outcomes. Based on the success of these pilots, the ACS developed a national program in 2005, and currently there are over 60 ACS patient navigators within healthcare systems nationwide.
Working alongside the healthcare team, the ACS patient navigator helps patients from the point of diagnosis through the end of treatment. Patient navigators do not simply assist patients through the healthcare maze in a timelier fashion; they play a critical role in coordinating care and improving the patient’s psychological well-being and quality of life, providing patients with the tools and resources they need to be more engaged in their own care and self-management. Patient navigators ultimately help save patients’ lives by helping to eliminate nonmedical barriers resulting in timely initiation of treatment, treatment adherence and completion, and appropriate posttreatment follow-up care.
This article focuses on the orientation and training of nonclinical patient navigators, whose role is to provide cancer information, resources, and support to remove barriers to care and links to emotional support programs and services for cancer patients, their families, and caregivers. The information shared is based on 20 years of experience as well as an evidence-based training program.
Onboarding New Navigators at the ACS
Hiring qualified navigators is one of the most critical steps in the onboarding process. Nonclinical patient navigation is a unique role in healthcare because there is no universally accepted course of study or degree program that is the industry standard for this role. Many educational backgrounds can be a good fit, including social work, dietetics, nursing, and public health. Knowledge of healthcare systems and oncology is also very helpful. Focusing on competencies is a good way to hire well. Decision-making, collaboration, drive for results, and desire to learn are critical competencies to consider and seek out when hiring navigators.
In the experience of the ACS, nonclinical patient navigation is not a well-understood role in health systems, and few systems have prior experience having navigators on staff. Doing some groundwork before hiring and placing a navigator is crucial to ensure that the health system staff understand the role, the scope, and how the navigator will integrate with other roles in the system, such as care coordinators, social workers, nurse navigators, financial advocates, etc. Gaining the understanding and buy-in of key staff early on is important to help ensure that the navigator is accepted into the system and that staff members are starting to think about how to integrate the role into the patient care process, and how referrals will be made.
Health systems vary in their structure, patient needs, and gaps in services, so some customization may be necessary in creating the navigator role and training. For example, a health system may need a navigator to work with the clinical trials department to help underserved populations with barriers to participation in clinical trials such as childcare, transportation, financial issues, etc. This work is within the role of the navigator as the ACS defines it; however, this will require the navigator to participate in additional training on clinical trials to gain more in-depth knowledge of this area than is typical. Having knowledge of needs and gaps ahead of time can help a manager craft a more meaningful orientation and training for the navigator and ensure a better fit with the hospital. Other examples of more specialized roles for nonclinical navigators include placing a navigator in a safety-net hospital where the majority of patients face socioeconomic barriers. This will require more training on cultural disparities in cancer and of financial resources to help not only with transportation and lodging, but also with utility bills, eviction issues, and food resources. It will also be necessary to ensure that the navigator is trained on how to work with other healthcare staff to ensure that they are aware of the issues facing the patient and how they can impact the patient’s participation in treatment, etc.
Onboarding training for a new navigator at the ACS takes 4 to 6 weeks, depending on the skill set the new hire is bringing to the role. Someone well-versed in oncology may need less time. Setting aside a block of time up front to learn the basics of the organization, the programs and services available, and getting to know staff, resources, and internal processes pays off with a more prepared and confident staff when they start working with patients. A key focus of new hire onboarding is relationship building with coworkers, both at the ACS and in the hospital. To foster a collaborative atmosphere, the navigator manager asks key staff to meet with the new hire to share their role and how the 2 roles intersect and can support each other. The manager provides a brief agenda to help guide the conversation and ensure important topics are covered, and also encourages an open, free flow of ideas and questions. Seasoned staff members also take turns being “lunch buddies” for the first week or so to eat with the new hire and just get to know each other. These efforts have been very successful in helping the new hire feel more comfortable reaching out for information or help once they are in place at their health system.
Training an ACS navigator to become fully competent in the role takes about 1 year. Planning navigator training with this long-range thinking can help ensure that learning and coaching opportunities are made available over the year and help both the manager and new staff from trying to include too much information into the first few months. New staff often feel overwhelmed by all they need to master as they begin their role, so this approach of taking the long view of training can take pressure off the navigator during the onboarding process. This approach also allows for incorporating the concept of just-in-time training—that is, providing training close to the time when staff will be ready and able to use the information (as opposed to trying to provide it all during the onboarding period). In the clinical trials example discussed previously, the navigator was going to begin this work 6 months after being hired, so training on this topic was delayed until after the onboarding training was completed. Just-in-time training may not always be possible. For example, many navigators must receive training on the electronic health record system before they are expected to use it. To assist with learning retention, practice scenarios and access to a training database could be helpful. Another option is to have the new navigator help with some basic data entry or searches on behalf of another staff member.
To assist in promoting navigator self-paced learning and provide structure to the learning process, a training checklist is a helpful tool. This document lists the objectives of training for the first 6 weeks, assigned reading, meetings, and online learning. The navigator manager spends the first 2 to 3 days with the new staff and reviews the document, introduces staff to coworkers, explains the organization and how to find resources and tools online, sets expectations, and provides a calendar of meetings and trainings that the new navigator will continue to build on.
The following topics are included on the ACS Patient Navigator Training Checklist:
- Role of the navigator and how it fits with other roles, including what is in scope and out of scope for this role
- Patient and caregiver assessment, including needs and barrier identification through follow-up
- General cancer information, including diagnosis and treatment with more in-depth modules on breast, lung, prostate, and colorectal cancer, as well as survivorship, pain, nutrition, clinical trials, and caregiver needs
- HIPAA and patient privacy and confidentiality, cultural competency, health literacy, and cultural disparities in cancer
- Basic information on local, state, and national resources especially about transportation, lodging, financial assistance, emotional support, and what is available in the health system. It is critical that the navigator is trained on the criteria for and availability of resources in the community to ensure that the resources suggested for a patient have a high likelihood of meeting the patient’s needs. For example, Maine’s Meals on Wheels program serves 4600 people annually, but it also has a waiting list of 400 to 1500 people
- Basics of health insurance, Medicare, and Medicaid
Mentoring is also an important way to enhance learning. In cases in which a navigator is the sole navigator on-site, a seasoned navigator is assigned as a mentor for the new navigator with regular check-ins and support for at least a 6-month period and as needed thereafter. In cases where several navigators work in close proximity, a less formal mentoring process with many seasoned navigators may occur. The new navigator is able to spend at least a day shadowing the mentor in the day-to-day work, and later when the new hire has been working with patients for at least a month, the mentor then shadows the new hire. The manager also shadows the new hire twice during the first year to enhance knowledge and skill development. The manager also reviews 1 case per month with staff to monitor progress.
Ongoing Skills Development for Building Competency
Providing ongoing training and feedback to navigators is essential to ensuring professional development. Continuing education should be offered regularly and in a variety of formats. The ACS has implemented a model of continuing education that goes beyond the basics offered in onboarding new navigators and focuses on 3 areas for professional development, including coaching and problem solving, financial navigation, and data collection and reporting.
Coaching and Problem Solving
To actively participate in all aspects of the cancer journey, the patient must be able to solve the myriad problems that present themselves. Research has shown that people who have the tools to solve their unique problems report greater feelings of success, better quality of life, and a greater sense of control over their life and treatment.
Patients who are actively involved and engaged in their healthcare and cancer experience, including problem solving, report higher patient satisfaction and better outcomes. Studies have shown that more engaged and activated patients are also more likely to adhere to treatment recommendations, and that it is possible to increase patient activation by providing tailored patient-centered goal development, support, and coaching.2
Navigators can play a unique role in motivating and coaching individuals to become better problem solvers. There are a number of coaching approaches available that use a systematic, organized method to help patients and caregivers develop problem-solving skills. The basic steps in coaching include:
- Identify the barrier/problem and establish a goal for overcoming/managing
- Identify the current challenges or issues that may be causing the problem or making it difficult to manage
- Discuss possible solutions or options for overcoming
- Make a plan with measurable, trackable action steps
Although empowering patients is a core competency of most navigation programs, few have developed training to directly address developing this skill with navigators. The ACS developed a training program for navigators designed to help empower patients through tailored action planning and coaching. Key training components include:
- Conducting a comprehensive patient triage process that includes measures to assess: (1) patient activation, (2) barriers, and (3) acuity
- Analyzing assessment results to: (1) coach patients in problem solving and action planning; (2) track patient action plans, coaching, and practical strategies used to follow up with the patient; (3) support and coach patients on using action plans to overcome barriers to care; and (4) collect and report on program impact data to key stakeholders
- Working with healthcare teams to provide coordinated care, including key roles the navigator can play in facilitating coordinated care
- Multimodal sessions to accommodate different learning styles, including self-paced online/print learning activities and resources, in-person practicums, shadowing experiences, mentorship, and peer and supervisor experiential learning
- Ongoing support to provide navigators with technical assistance, and peer sharing4
- Guidance for supervisors to support navigators in the ongoing training and development process, including supporting supervisors in developing their own skills in providing coaching support for the navigators they manage
The enhanced navigation process resulting from this training approach allows for patient goal and outcome tracking. Preliminary results from the ACS training suggest that navigation with coaching and action planning tailored to the patient activation level is a successful method to assist vulnerable populations with overcoming nonmedical barriers to cancer care and increasing patient activation/engagement and satisfaction.
Financial barriers are the most commonly identified barriers to care and among the most difficult to address. There are limited programs and services to assist patients with financial needs. Financial navigation is a needed skill with few training resources available. The ACS is currently working on a focused continuing education module providing navigators with skills to help patients address their financial barriers using a more proactive approach and ensuring that patients are taking full advantage of all the resources available to them. The module will use a problem-solving approach with information and guided practice targeting financial barriers and challenges.
Data Collection and Reporting
The ACS sets a mutually determined target for the number of patients served in the first year to ensure navigators are becoming integrated into the flow of patient care and are receiving referrals. In addition, tracking the number of newly diagnosed and the number of uninsured and underinsured patients served as a percentage of navigator caseload have been successful program metrics. The health system’s analytic caseload and case mix information are helpful in determining these goals. Monitoring the types of services provided can give insight into the barriers addressed with patients and help demonstrate the value the navigator is bringing to the health system. Transportation and lodging provided are important metrics to indicate the success in removing these key barriers. However, a goal for the future would be to be able to show decreased time from diagnosis to initiation of treatment, fewer missed appointments, improved quality-of-life measures, and fewer emergency department visits or hospitalizations.
Gaps and Future Directions
Program sustainability is one of the biggest challenges currently facing the field of navigation. As we work to establish the true impact and value of navigation, it will be necessary to better define the role of navigators and to assess which navigator activities result in the best patient outcomes. Without these data, it will be impossible to ensure that programs are maximizing the role of the navigator in supporting patients with the greatest needs.
The need to collect program outcomes demonstrating the impact and cost-benefit of navigation programs is essential to ensuring their sustainability. Patient navigators should be trained to understand their role in data collection metrics and reporting to demonstrate their value to the oncology program to guide improvement in their work and professional development.
Relatedly, navigators need additional training on the practical and program impact aspects of data collection and evaluation. Explaining the importance of ensuring complete and quality data collection to measure impact on program outcomes, including patient experience, clinical outcomes, and return on investment, can have a significant impact on sustainability of navigation programs.5
The ACS has 20 years of experience in patient navigation but recognizes that this is still a relatively new and developing role. A strong emphasis on a quality onboarding experience for new navigators, with an emphasis on learning from experienced staff and continuing education over time, are key to creating a strong program. In addition, ongoing training that includes skill development to help empower patients to feel confident to navigate for themselves, enhanced financial resource knowledge, and data and reporting for program improvement are important.
Case Study: Coaching for Activation
A 62-year-old breast cancer patient had difficulties managing symptoms and side effects from her radiation treatment. The patient navigator met with the patient, and after a thorough assessment, including assessing her activation level, determined that the patient needed assistance getting answers to some key questions. The navigator helped the patient write questions and list items she wanted to ask her cancer care team during her next examination. The navigator provided the patient with an action plan that included basic steps to help ensure she could follow through on a conversation with members of her medical care team to get her questions answered. During follow-up, the patient shared that she implemented the action steps and obtained helpful tips from the radiation oncology nurse about how to improve her energy. The patient then shared that she had lack of knowledge and understanding of her treatment, including long-term side effects. The navigator coached the patient to help clarify the key questions and to develop an action plan to ensure she obtained accurate and complete information related to the treatment options. The navigator also provided her with ACS materials to read. At follow-up, the patient reported that she felt empowered to make a list of questions to ask the doctor to make an informed decision about the hormonal therapy medication she would need to take for 5 years. The navigator provided the patient with a written action plan outlining these next steps. At final follow-up, the patient’s activation score increased from baseline, helping to demonstrate her increased confidence and involvement in her healthcare.
- Freeman HP, Rodriguez RL. History and principles of patient navigation. Cancer. 2011;117(15 Suppl):3539-3542.
- Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff (Millwood). 2013;32:207-214.
- Simmons LA, Wolever RQ. Integrative health coaching and motivational interviewing: synergistic approaches to behavior change in healthcare. Glob Adv Health Med. 2013;2:28-35.
- Project ECHO. The University of New Mexico. Project ECHO: A Revolution in Medical Education and Care Delivery. https://echo.unm.edu.
- Johnston D, Sein E, Strusowski T. Standardized evidence-based oncology navigation metrics for all models: a powerful tool in assessing the value and impact of navigation programs. Journal of Oncology Navigation & Survivorship. 2017;8(5):220-243.