An assessment of patient navigator activities in breast cancer patient navigation programs using a nine-principle framework.

Cancer care has long been documented as an arena of racial, ethnic, and socioeconomic disparities (Freeman 1989; Koh 2009). Disparities in care delivery impact patient outcomes (Battaglia et al. 2007). One of the emerging health care delivery models designed to reduce cancer care disparities is patient navigation. Named in the early 1990s by Harold Freeman, patient navigation aims to reduce delays in care for disadvantaged populations by addressing barriers to care through one-on-one intervention (Freeman, Muth, and Kerner 1995). Since its inception, patient navigation has expanded rapidly and is now used in many settings across the cancer care continuum (Freeman 2012; Stanley et al. 2013). By 2003, over 200 navigation programs were documented (Hede 2006). The National Cancer Institute has funded patient navigation through a number of programs, including the Community Network Programs (Braun et al. 2012) and the NCI Community Cancer Centers Programs (Swanson et al. 2012), as well as individually funded grants. Three large-scale national patient navigation programs represent the largest coordinated implementation efforts to date: The American Cancer Society with 137 navigators, the Centers for Medicare and Medicaid’s Medicare Cancer Prevention and Treatment Demonstration for Racial and Ethnic Minorities (Mitchell et al. 2010), and the National Cancer Institute Patient Navigation Research Program (Freund et al. 2008). The NCI Patient Navigation Research Program recently reported results indicating navigation produced more timely diagnostic resolution following abnormal screening (Battaglia et al. 2012; Dudley et al. 2012; Hoffman et al. 2012; Markossian, Darnell, and Calhoun 2012; Paskett et al. 2012; Raich et al. 2012; Wells et al. 2012). Despite this demonstrated effectiveness, there is little systematic examination of how programs outside of these organizations are implemented (Stanley et al. 2013). Patient navigation programs have been shown to vary in terms of navigator training, services provided, outcomes measured, and efficacy (Wells et al. 2008). This is in part due to the lack of reimbursement for navigation and reliance on institutional, foundation, or research grant funding to establish and maintain programs. The Commission on Cancer has mandated that all accredited cancer centers implement patient navigation programs by 2015 (Commission on Cancer 2012) despite the somewhat limited range of systematic program evaluation conducted. Given the rapid diffusion of patient navigation as an intervention to reduce cancer outcome disparities, there is an identified need to clarify the scope of navigation and ascertain commonalities to develop comparative evaluations (Esparza and Calhoun 2011). A unifying definition of patient navigation has been hindered by the lack of a process to come to consensus around the definition of navigation while allowing for variation in local implementation. One existing model for measuring the implementation of patient navigation programs is a nine-principle framework developed by Harold Freeman and colleagues during a 2010 summit on the measurement of patient navigation (Freeman and Rodriguez 2011). The model suggests a set of consensus characteristics without explicitly addressing variations in local context. This framework was not presented with data from existing programs to assess how well it reflects the organization and function of navigation programs. Thus, this exploratory study aims to evaluate how closely these principles reflect the practice of navigation in self-identified breast cancer patient navigation programs through independent observation of routine navigator activities.