Oncology care is one area where care coordination, access to good care, and healthcare collaboration come to the fore.
The stakes are very high, the treatments are long-term and complex, care teams are interdisciplinary and cross the continuum of care, and there are often outcome disparities related to socioeconomic status.
So I was really interested to review the proceedings of a workshop looking at Establishing Effective Patient Navigation Programs in Oncology, published by the National Academy of Sciences. The work raised some important questions about when patient navigation is effective, what problems it solves -- and what its crucial shortcomings are.
The context for the publishing of the proceedings of this workshop: The National Academy of Sciences, who published it, was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. In itself, it is a fascinating example of interdisciplinary collaboration.
The question explored in this workshop is whether, how, and under what circumstances, patient navigation can be a key tool for improving oncology outcomes. Of course, delivering high-quality cancer care to all patients presents numerous challenges, including difficulties with care coordination and access. The supposition is that "patient navigation" can be an important tool for meeting these challenges.
Patient navigation is defined in the paper as, "a community-based service delivery intervention designed to promote access to timely diagnosis and treatment of cancer and other chronic diseases by eliminating barriers to care.” (Freeman and Rodriguez, 2011). Navigation can improve early detection and screening, increase clinical trial enrollment, and remove barriers to care, etc.
How does that relate to healthcare collaboration? In one way it is the same. The goals are the same, and the impetus for the development of the practice is the same. On the other hand, there are a few key differences. Patient navigation:
- It is disease-specific. Instead of looking at the whole patient across the continuum of care they need, the program focuses on cancer care.
- It is centralized. Ultimately, patient navigation is a centralized hub approach. There is a central patient navigator, not team collaboration among all the parts of the team.
- It doesn't change the fundamental care and collaboration patterns. Patient navigation is a bit of a stop-gap for a medical system that's working in sub-par ways, rather than a more fundamental transformative tool in how we do medicine in the first place.
Key unresolved questions of patient navigation are described:
"Unresolved questions include where patient navigation programs should be deployed, and which patients should be prioritized to receive navigation services when resources are limited. Patient navigation systems are often implemented as an attempt to address socioeconomic disparities in care delivery. Therefore, many interventions have been clustered in pre-dominantly minority and economically underserved areas, often in urban cancer centers. However, navigation programs often go beyond poor and underserved patients, to aid all patients. Experts also continue to debate whether patient navigation should be proactive or reactive, and who benefits most from using navigation programs, particularly with regard to ongoing concerns about the cost and value of care."
The description of these unresolved questions brought to the fore one of my key concerns about the patient navigation model. Everyone, everywhere, deserves and should receive collaborative, connected care. In order for that to be a reality, however, that would mean that our workflows would be supportive of collaboration throughout medicine, not that we create workarounds to treat the consequences of care when it's not collaborative. Patient navigation requires an assigned navigator -- which is an expense -- rather than enabling more efficient and time-proven workflows that are enhanced by technology such as Hybrid Store-and-Forward Telemedicine.
On one hand, this kind of patient navigation initiative is deeply impressive. Healthcare is facing so many challenges that if we don't have some "stop gap" programs patients will certainly be suffering needlessly. But so many parts of this feel like band-aids. The patient navigation itself is a bit of a band-aid for a system that isn't enabling its healthcare providers to collaborate. And then even the tools that patient navigation programs are encouraged to employ -- like videoconferencing -- to oversee navigation, are not as helpful as transforming workflows and enable true team collaboration.
Ultimately, I'm firmly in support of this kind of program. I'm also in support of programs that seek to shift the structures, workflows, and systems whose limitations create the need for this kind of program in the first place.
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