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Assessment of patient navigation programs for breast cancer patients across the city of Boston

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Abstract

Purpose

Healthcare systems contribute to disparities in breast cancer outcomes. Patient navigation is a widely cited system-based approach to improve outcomes among populations at risk for delays in care. Patient navigation programs exist in all major Boston hospitals, yet disparities in outcomes persist. The objective of this study was to conduct a baseline assessment of navigation processes at six Boston hospitals that provide breast cancer care in preparation for an implementation trial of standardized navigation across the city.

Methods

We conducted a mixed methods study in six hospitals that provide treatment to breast cancer patients in Boston. We administered a web-based survey to clinical champions (n = 7) across six sites to collect information about the structure of navigation programs. We then conducted in-person workflow assessments at each site using a semi-structured interview guide to understand site-specific implementation processes for patient navigation programs. The target population included administrators, supervisors, and patient navigators who provided breast cancer treatment-focused care.

Results

All sites offered patient navigation services to their patients undergoing treatment for breast cancer. We identified wide heterogeneity in terms of how programs were funded/resourced, which patients were targeted for navigation, the type of services provided, and the continuity of those services relative to the patient’s cancer treatment.

Conclusions

The operationalization of patient navigation varies widely across hospitals especially in relation to three core principles in patient navigation: providing patient support across the care continuum, targeting services to those patients most likely to experience delays in care, and systematically screening for and addressing patients’ health-related social needs. Gaps in navigation across the care continuum present opportunities for intervention.

Trial registration

Clinical Trial Registration Number NCT03514433, 5/2/2018

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Acknowledgements

The authors would like to acknowledge the partnership of TRIP’s stakeholders and community organizations: Boston Patient Navigator Network, Boston Breast Cancer Equity Coalition, Boston Public Health Commission: Pink & Black, Massachusetts Department of Public Health: Office of Community Health Workers; The National Center to Advance Translational Science, the Boston University Clinical and Translational Science Institute (CTSI), University of Massachusetts CTSI, the Harvard CTSI, Tufts CTSI; our partner institutions Boston Medical Center, Brigham and Women’s Faulkner Hospital, Massachusetts General Hospital, Tufts Medical Center, Beth Israel Deaconess Medical Center, and Dana Farber Cancer Institute; and finally the TRIP Consortium and our patient navigators.

Translating Research Into Practice (TRIP) Consortium

  • Beth Israel Deaconess Medical Center (Ted A. James MD, Susan McCauley RN, Ellen Ohrenberger RN BSN, JoEllen Ross RN BSN, Leo Magrini BS)

  • Boston Breast Cancer Equity Coalition Steering Committee (Susan T. Gershman MS MPH PhD CTR, Mark Kennedy MBA, Anne Levine MEd MBA, Erica T. Warner ScD MPH)

  • Brigham and Women’s Hospital (Cheryl R. Clark MD ScD)

  • Boston Medical Center (William G. Adams MD, Sharon Bak MPH, Nicole Casanova BA, Katie Finn BA, Christine Gunn PhD, Naomi Y. Ko MD, Ariel Maschke MA, Katelyn Mullikin BA, Laura Ochoa BA, Christopher W. Shanahan MD MPH, Samantha Steil BA, Tracy A. Battaglia MD MPH, Victoria Xiao BS)

  • Boston University (Howard J. Cabral PhD MPH, Clara Chen MHS, Carolyn Finney BA, Christine Lloyd-Travaglini MPH, Stephanie Loo MSc)

  • Dana-Farber Cancer Institute (Magnolia Contreras MSW MBA, Rachel A. Freedman MD MPH, Yoscairy Raymond BSW CCHW, Deborah Toffler MSW LCSW)

  • Dana-Farber/Harvard Cancer Center (Karen Burns White MS)

  • Equal Hope (Anne Marie Murphy PhD)

  • Massachusetts General Hospital (Carmen Benjamin MSW, Beverly Moy MD, Jennifer S. Haas MD MPH, Caylin Marotta MPH, Aileen Navarrete BA, Sanja Percac-Lima MD PhD, Emma Whited BA, Amy J Wint MSc)

  • Tufts Medical Center (Karen M. Freund MD MPH, William F. Harvey MD MSc, Danielle Krzyszczyk BA, Amy M. LeClair PhD MPhil, Susan K. Parsons MD MRP, Feng Qing Wang BA)

  • University of Massachusetts Lowell (Serena Rajabiun MA MPH PhD)

  • University of Massachusetts Medical School (Stephenie C. Lemon PhD)

NOGA

  • Award Number U01TR002070

    • The National Center For Advancing Translational Sciences

    • The Office of Behavioral and Social Sciences Research of the National Institutes of Health

NIH CTSA Awards

  • Harvard: UL1TR002541

  • Tufts: ULTR002544

  • Boston University: UL1TR001430

  • University of Massachusetts Medical School: UL1TR001453

American Cancer Society #CRP-17-112-06-COUN

Funding

Research reported in this publication was supported by the National Center for Advancing Translational Sciences and the Office of Behavioral and Social Sciences Research of the National Institutes of Health under Award Number U01TR002070. Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under the Harvard University CTSA Award Number UL1TR002541, Tufts University CTSA Award Number UL1TR002544, Boston University CTSA Award Number 1UL1TR001430, and University of Massachusetts CTSA Award Number UL1 TR001453-03.

Author information

Authors and Affiliations

  1. Department of Medicine, Tufts Medical Center, Boston, MA, USA

    Amy M. LeClair, Karen M. Freund & Susan K. Parsons

  2. Women’s Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA, USA

    Tracy A. Battaglia & Naomi Y. Ko

  3. Department of General Internal Medicine, Boston Medical Center, Boston, MA, USA

    Tracy A. Battaglia, Nicole L. Casanova, Naomi Y. Ko & Katelyn R. Mullikin

  4. Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA

    Jennifer S. Haas & Beverly Moy

  5. Beth Israel Deaconess Medical Center, Boston, MA, USA

    JoEllen Ross & Ellen Ohrenberger

  6. UMass Medical School, Worcester, MA, USA

    Stephenie C. Lemon

Authors
  1. Amy M. LeClair
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  2. Tracy A. Battaglia
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  3. Nicole L. Casanova
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  4. Jennifer S. Haas
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  5. Karen M. Freund
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  6. Beverly Moy
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  7. Susan K. Parsons
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  8. Naomi Y. Ko
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  9. JoEllen Ross
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  10. Ellen Ohrenberger
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  11. Katelyn R. Mullikin
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Contributions

Amy M. LeClair: Conceptualization, methodology, writing-original draft, writing-review, editing, project administration

Tracy A. Battaglia: Conceptualization, funding acquisition, methodology, project administration, resources, supervision, validation, writing-review, editing

Nicole L. Casanova: Conceptualization, methodology, writing-original draft, writing-review, editing, project administration

Jennifer S. Haas: Conceptualization, funding acquisition, methodology, project administration, resources, supervision, validation, writing-review, editing

Karen M. Freund: Conceptualization, funding acquisition, methodology, project administration, resources, supervision, validation, writing-review, editing

Beverly Moy: Conceptualization, resources, validation, final review

Susan K. Parsons: Conceptualization, resources, validation, final review

Naomi Y. Ko: Conceptualization, resources, validation, final review

JoEllen Ross: Investigation, writing-review, editing

Ellen Ohrenberger: Investigation, writing-review, editing

Katelyn R. Mullikin: Writing-review, editing

Stephenie C. Lemon: Conceptualization, funding acquisition, methodology, project administration, resources, supervision, validation, writing-review, editing

Corresponding author

Correspondence to Amy M. LeClair.

Ethics declarations

Ethics approval

The present study received institutional review board approval from the Boston University Medical Center/Boston Medical Center Institutional Review Board (IRB# H-37314). The study’s formative work, described in this paper, was given a Non-Human Subjects Research designation, as the goal was to create a generalizable protocol for navigation process planning and improvement.

Consent to participate

The study’s formative work was given a Non-Human Subjects Research designation, and therefore, participants were not required to be consented.

Consent for publication

The study’s formative work was given a Non-Human Subjects Research designation, and therefore participants, were not required to be consented.

Conflict of interest

Author Karen M. Freund received funding from the American Cancer Society: American Cancer Society #CRP-17-112-06-COUN. The authors have no other funding or conflicts of interest to report.

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Appendix A. Clinical Advisory Panel Survey about Navigation Program

Appendix A. Clinical Advisory Panel Survey about Navigation Program

Name

Institution

Patient Navigation

  1. 1.

    Does your hospital provide patient navigation for any patients with breast cancer care during active treatment?

Navigators

  1. 2.

    Are there different navigators at different phases of care (e.g. screening, diagnostic care, cancer care?)

  2. 3.

    About how many clinical FTE patient navigators are focused specifically on breast cancer patients undergoing active treatment

  3. 4.

    What is the educational background of the navigator(s) at your practice involved with breast cancer patients?

  4. 5.

    What criteria are used to determine which patients are offered patient navigators?

  5. 6.

    Which is the most common point of the patient's care process when navigators are brought into care?

  6. 7.

    How are the navigators at your practice assigned patients during active cancer treatment?

  7. 8.

    What is the most common way navigators are assigned patients?

    1. a.

      By referral of clinicians (physicians, nurses, SW)

    2. b.

      From a list of new patients or referrals

    3. c.

      Tumor board

    4. d.

      Other

  8. 9.

    How many patients does each navigator typically follow?

  9. 10.

    What is the most common method by which patients are contacted?

  10. 11.

    Who supervises the navigators?

  11. 12.

    Supervisor's background

  12. 13.

    What department is the navigator appointed under?

  13. 14.

    What funding sources pay for breast cancer navigators at your practice?

Navigation tools

  1. 15.

    What tools do navigators use to keep track of who/what they are navigating?

  2. 16.

    What tools do navigators use to decide which patient to work with on a day to day basis?

  3. 17.

    What tools do navigators use to identify when a patient has not kept a scheduled appointment or test?

  4. 18.

    Does anyone else (besides the patient navigator) track patients to make sure they return for care?

  5. 19.

    How do navigators decide that a patient no longer needs navigation?

  6. 20.

    How does your practice determine if patients have left your practice and transferred care to another health care system?

  7. 21.

    Has your hospital implement sending ADT information on the Mass Information highway?

  8. 22.

    Is there a timeline planned for implementing this?

Social Determinants of Health

  1. 23.

    Do any breast cancer providers routinely screen for social determinants of health?

  2. 24.

    Who does the screening for social determinants of health among breast cancer patients?

  3. 25.

    Which patients are screened?

  4. 26.

    When are patients screened?

  5. 27.

    How often are patients screened?

  6. 28.

    Which domains are patients screened for?

  7. 29.

    How does your practice perform the screening?

  8. 30.

    Which electronic platform/EMR/website does your practice use?

  9. 31.

    Are referrals made based on these screenings?

  10. 32.

    Which domains are prioritized?

    1. a.

      Employee assistance

    2. b.

      Child/elder are assistance/parenting

    3. c.

      Transportation

    4. d.

      Mental Health

    5. e.

      Domestic Violence

  11. 33.

    How does your practice refer patients for social determinants of health?

  12. 34.

    How is the decision made on where to refer patients?

  13. 35.

    Where does your practice get a list of resources for potential referrals?

  14. 36.

    Do you have a system to track whether a patient has connected with a referral or needs further assistance?

  15. 37.

    Who follows up with the patient after they are referred?

  16. 38.

    If your practice is not currently screening, does your practice have any plans to start systematic screening in the next 12 months?

  17. 39.

    Which domains do you plan to prioritize? Please rank the top 5 domains based on priority?

    1. a.

      Housing instability

    2. b.

      Education/literacy

    3. c.

      Child/elder care assistance/parenting

    4. d.

      Transportation

    5. e.

      Immigration

    6. f.

      Legal

    7. g.

      Physical Activity

    8. h.

      Addiction and recovery

    9. i.

      Mental Health

    10. j.

      Health insurance

    11. k.

      Domestic Violence

    12. l.

      Community Violence

    13. m.

      Food instability

  18. 40.

    How does your practice plan to perform the screening?

  19. 41.

    Where does your practice plan to get a list of resources for potential referrals?

  20. 42.

    Will you have a system to track whether a woman has connected with a referral or needs further assistance?

  21. 43.

    Who will follow up with the patient after they are referred?

  22. 44.

    Any other comments or features about your clinical setting or patient navigation program that you think might be relevant to the current project to implement a standard patient navigation process across all Boston hospitals?

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LeClair, A.M., Battaglia, T.A., Casanova, N.L. et al. Assessment of patient navigation programs for breast cancer patients across the city of Boston. Support Care Cancer 30, 2435–2443 (2022). https://doi.org/10.1007/s00520-021-06675-y

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