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OBJECTIVE: A survey of hospital-based nurse executives was conducted to determine the extent, approaches, and outcomes of nurse navigator (NN) programs.
BACKGROUND: Nurse navigators are distinct from other recognized healthcare roles. Navigators most commonly focus on a single health condition with the goal of improving the provision of specified health services for an individual patient.
METHODS: An 11-question Internet-based survey was e-mailed to 580 nurse executives in Texas.
RESULTS: Of the respondents, only 24% implemented any type of NN program. Most of the respondents with navigators rated these programs as successful. Most of the NN programs served cancer patients. Sixty percent implemented noncancer NN programs, with most reporting quality improvement as the main outcome measure for patients with conditions such as diabetes, cardiovascular disease, and high-risk obstetrics.
CONCLUSIONS: Opportunities exist in demonstrating the value of NN roles. To increase support for the role, nurse executives should develop the programs to meet the clinical, marketing, and financial objectives of the organization and targeted patient populations.
An increasingly complex healthcare system stresses patients' ability to successfully navigate their care services without assistance. Although a role of the professional nurse is that of care coordinator, nurse navigator (NN) roles are being designed to facilitate patients' progress through the treatment process, payment mechanisms, and healthcare organizational structures. The role of the NN has the potential to remove or mitigate barriers to care, such as managing paperwork, interfacing with insurance companies, serving as coordinator for the healthcare team for indicated services, and helping the patient to understand treatment and care options. Published literature most prominently recognizes the role of NNs in caring for patients diagnosed with cancer1-8; however; the impact of an NN for other conditions and populations is less well understood.9-11
In December 2012, a survey was administered to hospital-based nurse executives (NEs) in Texas to determine the extent of implementation of NN roles and to identify the associated evaluative approaches and outcomes.
In 2012, Texas ranked 40th of all US states in selected health process and outcome measures and showed a strong indication of declining in the future, as compared with other states, according to the United Health Foundation.12 Given this performance, researchers sought to understand how leaders in Texas hospitals were supporting the role of NNs to improve health.
In 1990, Dr Harold Freeman developed the 1st NN role at Harlem Hospital in New York in an effort to expedite diagnosis and treatment while facilitating access to care for patients with abnormal breast screening results.2 The literature suggests that patients with cancer are the most likely to receive the services of an NN.13 Several national initiatives, including the Patient Navigation Research Program sponsored by the National Cancer Institute and American Cancer Society, have supported expansion of the NN role in cancer care.1 In 2001, the President's Cancer Panel recommended increased funding for community-based programs, such as patient navigator (PN) programs, to provide information, screening, treatment, and supportive care. The Patient Navigator Outreach and Chronic Disease Prevention Act of 2005 authorized federal grants to hire and train PNs to help patients with cancer and other serious chronic diseases access screening, diagnosis, treatment, and follow-up care. In 2006, the Centers for Medicare and Medicaid Services funded 6 demonstration projects to help minority Medicare patients overcome barriers in screening, diagnosis, and treatment through the use of navigators.1
Although NN programs most commonly target cancer patients, the literature supports that opportunity exists to extend NN programs to other chronic diseases.3 Populations suggested include patients with HIV,9 asthma,10 osteoarthritis,11 and high-risk obstetrical care.14 However, few studies have been published profiling the incidence and outcomes of these noncancer populations related to the care of NNs.
Although there is limited long-term, well-constructed research in this area, initial evaluation of navigator programs suggests improved patient outcomes. In 1 study, disease screening rates, adherence to diagnostic services after identification of an anomaly, and treatment improvement increased.1 In addition, an analysis of evaluations of NN programs from 2000 to 2010 identified improved patient satisfaction, positive changes in patient attitudes, increased understanding of the disease process and patient perception of more timely and accessible treatment.3
There is no single definition of a nurse (or patient) navigator. A review of the literature suggests 2 foci: (a) the provision of specified services to provide care and (b) removal of barriers to care.1,15 Wells et al1 suggests that the role of a PN, regardless of the professional discipline, can be operationalized as providing any service that assists patients in overcoming obstacles from screening to treatment, as well as coping with treatment and follow-up. According to Wells et al,1 PNs are responsible for (a) overcoming health system barriers, (b) providing health education about the disease from prevention to treatment, (c) addressing patient barriers to care, and (d) providing psychosocial support. It is acknowledged that the PN role has much in common with the scope of other healthcare professionals that also facilitate patient transitions through the care process and improve access to services.1 To contrast the roles, the case manager may be oriented toward complex care coordination, and an NN is typically targeted toward a single health condition. An NN typically removes or diminishes specific health system barriers particular to an individual patient (Table 1).1 A number of disciplines have skills consistent with the navigator role, including nurses, social workers, health educators, and laypeople.1 Education and background for navigators are reported to range from lay navigators16 to advanced practice nurses.17 This study focused on NN, consistent with the findings of Case,3 that the role of the navigator, in cancer care, corresponds with the conceptual perspectives of nursing.
The work to establish a distinct role for the NN supports the recommendations of The Institute of Medicine (IOM) to reconceptualize the nursing profession as "health coaches, care coordinators, informaticians, primary care providers and health team leaders."18(p30) Suggesting that the US healthcare system must shift from the acute care setting to the community, the IOM implores nurses to develop practice opportunities in a greater variety of settings, including primary care medical homes and accountable care organizations.18
The institutional review board of the university affiliate of 1 of the investigators approved the study. The sample of 580 NEs was extracted from a database compiled by the hospital survey unit of the Texas Department of State Health Services, Center for Health Statistics. A series of 3 e-mails were sent to all NEs included in this list, requesting their participation in an Internet survey hosted by Zip Survey. The e-mails included the name and contact information of the investigators, the purpose of the survey, the rationale for surveying regarding the NN role, and the potential benefits of this online survey. Survey responses were collected anonymously, ensuring no more than minimal risk for participants.
The investigator-developed survey contained 11 questions pertaining to the participant's job title, hospital organization size and location, the existence of an NN program, and the primary objectives of the nursing organization. Four subsequent survey questions were posed only to those participants who answered affirmatively that their organization implemented a noncancer NN program. Noncancer NN programs were the subject of interest because of lack of published literature and the potential for improved care in other diseases. These questions pertained to the patient populations covered by the program, the main rationale for developing the NN program, the duration of the existence of the NN program, and program evaluative measures. All respondents who had implemented NN programs were asked about the program's success, as determined by objective measures. For the purposes of the survey (Supplemental Digital Content 1, http://links.lww.com/JONA/A262), an NN program was defined as a program that "assists a patient to overcome barriers to screening, diagnosis, or treatment to achieve timely and effective care."
Of the 580 Texas NEs surveyed, 76 completed the survey (13.1%) (Table 2). This sample of Texas acute care hospitals reflects the make-up of US hospital organizations, where 35% of the nation's hospitals are defined as rural.19 The organization size varied from acute hospitals of 500 beds or more (4%; n = 3), 499 to 300 beds (12%; n = 9), 299 to 100 beds (28%; n = 21), and fewer than 100 beds (57%; n = 44). The American Hospital Association categorizes hospitals sizes differently, but our survey contained similar numbers of hospitals in the United States with fewer than 100 beds (54% vs 58%) and US hospitals considered "large" (8% vs 4%).19 The remaining 6 organizations (8%) in the sample included a pediatric orthopedic specialty hospital, an inpatient rehabilitation hospital, 2 critical access hospitals, a psychiatric hospital, and a long-term care acute care hospital.
Of the 76 respondents, only 24% (n = 18) implemented any type of NN program. Of these, 8 NN programs served cancer patients, 6 served cancer patients and another patient population, and the remaining 4 served other patients diagnosed with other diseases besides cancer (Table 3). According to the NEs surveyed who implemented NN programs, 16 considered the programs to be "successful" (89%) as determined by objective measures, and the remaining respondents (11%; n = 2) had not yet generated outcomes from the programs. No respondents reported that their program results were unsuccessful or made no difference or achieved mixed results. See Table 4 for the characteristics of implemented NN programs.
Of the 10 NEs who implemented noncancer NN programs, the main rationale for developing the program included "increase access to diagnosis and treatment" (n = 3), "decrease cost of care" (n = 1), and "improve quality" (n = 6). Most of the noncancer NN programs (70%; n = 7) (Table 5) measured quality of care to assess their programs, including disease screening rates, patient retention in treatment, patient satisfaction scores, physician/staff satisfaction scores, patient-reported symptoms, and patients' scores test evaluating understanding of disease processes. Surprisingly, only 2 noncancer NN programs formally measured access to care (eg, adherence to diagnostic follow-up care services, time interval between diagnosis and initiation of treatment), and none actually measured cost or charges of care services.
Results suggest that, to some extent, NEs in this sample have a nebulous understanding of the NN role. Of the 58 participants who responded that their facility had "not implemented an NN program," 7 (12%) answered that, although they have not implemented an NN program, they do have a team of nurses whose main objective is to improve the experience (timeliness, effectiveness) of an individual patient. According to Wells et al,1 timeliness and effectiveness are key factors of NN programs, as compared with case management or patient advocacy roles. It is unknown whether these teams could be classified as NNs, case managers, patient advocates, or a combination of roles.
These results represent the 1st application of the described survey instrument. Although the authors reviewed all individual questions for understandability, no established reliability statistics verified that the questions would evoke consistent responses. In addition, the unstable validity of some of the survey questions was apparent in the results, specifically when the subjects without NN programs indicated that they employed a team of nurses whose main objective essentially agreed with the main characteristics of NN programs (improve individual patient care experience). Finally, the unexpectedly low response rate for this study (13.1%) may limit the generalizability of the results. Although true of most surveys, this possible nonresponse error may influence the study results given the diversity of hospitals, both in size and mission, in a large state containing disparate regions, such as Texas. Despite these limitations, the results of this survey provide a glimpse of the penetration of NN programs and the understanding (or lack of understanding) of the potential of the NN role in improving patient care among NEs.
The literature suggests expansion of NN programs. Our results demonstrate that these roles have a minor presence in Texas hospitals, with only 1 in 4 hospitals reporting at least 1 position for an NN. In response to the changing dynamics of healthcare outcome measurement, NEs should work collaboratively to establish national standards for education and consistency in this new role and monitor outcomes on large scales.
Certification and accreditation criteria for these roles should be developed to support professional and patient excellence in this new care coordination component of practice. Current certification programs for individuals seeking specific PN competencies include the National Consortium of Breast Centers20 and the Harold P. Freeman Patient Navigation Institute21 programs. In addition, the Committee on Cancer accredits more than 1500 healthcare organizations in the United States, and to meet the continuum of care services standard for accreditation by 2015, centers must offer patient navigation services.22 These criteria and programs need to be enhanced to extend beyond cancer care to other vulnerable populations. The continued implementation of NN roles with distinct competencies will help establish the contribution of nursing in this new aspect of care.
It has been suggested that some organizations have supported the development of NN roles as a component of marketing to patients.23 Nursing leaders must harness this support and add the professional nursing measures focused on specific patient populations that will demonstrate our value in this emerging field. Additional research is needed to understand the factors associated with the implementation of NNs from multiple aspects to encourage wider program adoption.
Published data reporting the financial benefits of the NN roles are sparse. In an era of resource constraints, decreased inpatient length of stay, and increased complexity of care, the NN roles may be well positioned to deliver improved patient satisfaction scores that impact reimbursement and the provision of cost-effective, high-quality care. To this end, future research regarding financial impact of NN programs is warranted.
In this study, none of the 10 noncancer programs reported measuring financial outcomes (costs or revenues) for their NN programs. Although not conclusive because of the small size of our survey sample, our results suggest that NEs may lack information regarding the return on investment of the NN programs. Although a workgroup of the American Cancer Society National Patient Navigator Leadership summit published examples of financial cost measures to assist in implementation,24 no discussion regarding the potential incremental revenues of NN programs has been found in the literature to complete the financial profile. By tracking and reporting financial measures, such as cost and incremental revenue, in addition to patient outcome statistics, nurse leaders can leverage the unique training and experience of NNs, as suggested by the IOM, "to enable the full economic value of [nurse] contributions across practice settings."18(pS-3)
Moving forward, a more complete understanding of the role of a distinct NN role, including competencies, expectations, measures, and the extent to which they improve the outcome of patients and populations, is essential to improving patient care through the full potential impact of nursing practice.
The authors acknowledge Lea Ann Biafora, MS, RN, Cancer Patient Advocate and Healthcare Navigator, for her guidance in this project.
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