Patient Navigators: Experience in a Community Hospital

To the Editor: Our breast cancer care team hails from a teaching hospital in an economically depressed community (Flint, MI), where approximately one third of our citizens live below the poverty level and where we have the unfortunate distinction of having one of the highest unemployment rates in the nation (eg, 15.2% v 7.8% in Albuquerque, NM). Thus, we do appreciate the multiple references made by McAneny1 in her commentary regarding the expense aspect of a patient navigator service. Yet we feel that the value of this program for our patients needs to be told. We also hope to clarify the role of the patient navigator—and argue against some of the suppositions in the commentary. McAneny1 describes the division of navigator functions into two components: first, to be present when the patient learns the diagnosis, and second, to assist the patient with appointments, tests, and procedures, “ensuring that the insurance companies pay for all of these.” Regarding the first component, McAneny references the emotional blockade experienced by a patient upon first learning his or her diagnosis, resulting in a shutdown of cognitive functioning; thus it is crucial to have another “friendly set of ears present to help the patient recall the discussion.” However, she feels that this role is best embraced by a family member or friend rather than a “stranger.” There are two key flaws in this reasoning—one of which she herself highlights in the article. First, she reflects that family members or friends may indeed “get details wrong” because of factors such as low health literacy; thus how can we assume that their presence will aid the patient in recalling key details? In addition, we must also recognize that family and friends are subject to the same emotional blockade as the patient. Second, the description of the patient navigator as being a stranger is not accurate. In our hospital, the patient navigator is a familiar presence, because her efforts with the patient begin immediately with screening and diagnosis from an abnormal mammogram or detection of a palpable mass. Regarding the second component, McAneny1 concludes that if our health care system necessitates navigators, then “we need a new system.” She offers ideas that would allow care to be “coordinated at the physician level.” On the surface, this statement appears to contradict the widely accepted belief or principle that a multidisciplinary team that collaborates to coordinate care is the ideal approach for patients. Furthermore, in evaluating the role of the patient navigator, McAneny also cautions that such services can become expensive quickly and are not reimbursable. She poses the question, “How many patients could one navigator navigate?” Our patient navigator has helped 150 patients in the past year. Whether one judges this to be a financially reasonable number, we assert that there are other key considerations (such as increased patient compliance with diagnostic and treatment regimens) legitimizing the cost. Finally, McAneny1 states that the patient navigator also functions as “an appointment secretary for the patient.” This reference trivializes the role. Although we do not believe that this was McAneny's intent, it is critical that we understand and emphasize the substantial benefits that have been demonstrated to date with the use of navigators—in particular for low-income and minority women. The reduction or elimination of delays in diagnostic resolution of abnormal-screening mammograms is significant; it is these delays in follow-up after cancer screening that have contributed to stark racial/ethnic disparities in cancer outcomes. Navigation programs are also a highly effective strategy for decreasing patient anxiety and increasing patient satisfaction. In summary, the navigator helps women overcome obstacles that prevent them from obtaining or completing needed care. This may range from assessing financial resources to developing the ideal team to care for each patient. Central to her efforts are reducing treatment delays, including those that may stem from noncompliance, by offering real solutions to patient problems. Our analysis of program evaluation data unconditionally supports the continued presence of the navigator.