As reported in the structured interviews with 7 health systems, size of the health system encompassing the cancer hospital ranged from 3,000 to 70,000 employees. Patient navigation programs began as early as 2004, with the latest program being introduced in 2021. All the hospitals studied report having navigation services available to all cancer patients. Type of navigator varied across sites with the most common type being nurse navigators (n=7), followed by lay navigators (n=3) and volunteer navigators (n=2).
Description of Publicly Available Online Patient Navigation Information (Table 1)
Nearly all health systems had dedicated pages on their website for cancer patient navigation (n=6). However, the one health system that did not have a separate cancer patient navigation section of their website did provide a number for patients to call. Specific navigation services available to patients were not outlined on the websites of 2 out of the 7 hospitals. However, the 3 out of the 4 hospitals that outlined the navigation services available on their website included services such as patient education, scheduling, assistance with managing side effects and symptoms; the other 1 out of 4 hospitals provided a more general description of services such as coordination of care. In terms of providing contact methods for patients on their website. The hospitals had a mix of contact methods: patient navigation online inquiry form, email address, phone number to general cancer support services, phone number for the broader general medical center, phone number for scheduling cancer care appointments, as well as direct phone numbers for navigators. A patient navigation online inquiry form was used at 1 hospital, 1 hospital used an email for general support services, 1 hospital had no contact method, 2 hospitals had a phone number for general cancer support services, and 1 hospital listed a phone number for a featured nurse navigator as well as the general phone number for the hospital.
Qualitative Description of Patient Navigation Programs & Services Provided (Table 2)
Hospitals utilized a combination of disease-specific navigators, as well as non-disease specific navigators. Navigators at all hospitals played a key role in coordination of care and patient education. Some of the most common services that navigators connected patients to included financial assistance, social work, emotional support/counseling, dietician services, palliative care, genetic counseling, fertility preservation, hospitality homes, rehabilitation services, and transportation assistance. Some of the hospitals had longer resource lists compared to others. The overall depth of resources seemed to vary by hospital due to location and local resources. For example, a hospital in the more rural part of the state did not have the ability to connect patients to the same number of resources compared to a hospital in a more metropolitan region of the state. Some of these extra resources in the more metropolitan part of the state include things like wellness programs such as exercise, yoga, and nutrition services, as well as robust rehabilitation programs and support groups for both the patient and family members. In addition to connecting patients with these services, many of the hospitals within the study had a cancer center where patients could use computers, seek food/water, as well as other amenities. One hospital even had massage chairs and a resource library for patients to utilize.
Types of Navigators at Each Health System
The three main types of patient navigators available to patients at the hospitals studied include clinically trained nurse navigators, lay navigators, and volunteer navigators. 2 out of the 7 hospitals studied provide navigation services through all three types of navigators: clinically trained nurses, lay navigators, and volunteer navigators. 1 out of the 7 hospitals studied provide services through clinically trained nurse navigators and lay navigators, without the use of volunteer navigators. The rest of the hospitals studies (4 out of 7) provide navigation services solely through clinically trained nurse navigators.
Configuration and Referral Patterns of Patient Navigation Services at Each Health System (Table 3)
Referral: Generally, patients are identified within the hospitals system and are contacted to conduct a barrier assessment. At 1 of the 7 hospitals, Hospital G, patients may self-refer for navigation services.
Connecting with the Patient/Diagnosis: Generally, navigators make contact with patients around the point of diagnosis. At 5 out of the 7 hospitals, navigators intend to meet with patients prior to their first appointment to connect and conduct a barrier assessment. While at 1 out of the 7 hospitals, the navigator meets with patients at their first oncology visit to establish care. At all 7 hospitals, an emphasis is placed on the beginning of the patient’s journey, starting at diagnosis and 1st consultation. A barrier assessment is completed around the time of initial contact with the patient at all 7 hospitals. At all 7 hospitals, patients are contacted either right before or after their first appointment. A barrier assessment is completed around this time as well. However, at hospital G, for breast, lung, and GI patients, navigators may intervene at the point of biopsy.
Treatment: At all 7 hospitals, patients are followed through their course of treatment. At one of the hospitals specifically, volunteer navigators exclusively follow up with patients in person while an oncology nurse navigator follows up with patients via phone. At one of the 7 hospitals, hospital D, a social work navigator conducts a barrier assessment at multiple points throughout the patient’s treatment continuum, including after the first appointment, after the start of treatment and once treatment has finished. 3 out of the 7 hospitals noted that navigators meet with patients in person as much as possible. The other 4 hospitals did not specify whether patients are followed up with patients in person or through phone.
Survivorship: At one of the 7 hospitals, hospital D, a final barrier assessment is completed during the first survivorship visit. Only one of the 7 hospitals, hospital D has a survivorship program. This program is run by social work navigators, not very robust.
Future Direction of Patient Navigation for Cancer Patients in North Carolina (Table 4)
Future direction at each health system:
Overall, all hospitals wish to bolster their programs by increasing navigators and the number of available support services to ensure that every patient has access to navigation services if needed and desired. Specifically, 4 out of the 7 hospitals mentioned increasing the number of navigators across disease groups within their programs in order to bolster services and cover all disease groups. One hospital noted that they wish to switch to disease-specific navigators at their satellite facilities as opposed to general navigators. Additionally, 3 out of the 7 hospitals noted that they wish to improve their forms, data collection, and tracking. Two hospitals noted that they wished to do this in order to demonstrate the positive downstream financial impacts of patients; the other hoped it would better inform their process. 2 out of the 7 hospitals mentioned improving their standard of work, including how they triage patients based on need and how they follow patients throughout their care.
Desired future direction of patient navigation in general:
Hospitals wish to see an expansion of patient navigation into other chronic diseases. Hospitals also hope that navigation becomes more financially sustainable. While one hospital noted that they wished for this service to be made reimbursable, others were intent that these services do not become a billable service so as not to risk these services becoming at cost to the patient. They want coverage for navigation services by payers without cost to the patient, as the patients who need these services the most are often financially at-risk patients. They wish to have support across health care sectors for navigation and greater accessibility to these programs for patients while also increasing the financial sustainability for these programs for health systems.