System Cancer Services,
Memorial Hermann Hospital System
With the current economic strife we are facing in healthcare today, finding ways to deliver quality survivorship care for cancer patients has become a tremendous challenge for oncology nurse navigators (ONNs). It will become even more overwhelming with the estimated 20 million cancer survivors expected by the year 2020. Being willing to forge new relationships will help meet the expected increase in demand for cancer care.
In October 2010, I attended the 6th Annual Breast Health Summit of Texas and had the opportunity to participate in a roundtable session pertaining to the topic of community health workers (CHWs). CHWs are members of a community who have been chosen by various entities to provide basic healthcare within the community in which they reside.
The roundtable session was presented by faculty and CHW students from the Houston Community College (HCC) Coleman College for Health Sciences. Concepts related to disparate populations frequently having mistrust of hospital “white coat” workers and perceptions that hospital professionals often “talk down” to impoverished clientele were discussed.
Since CHWs frequently reside among the populations they serve, they have built trust with the members of their community. This can afford CHWs the opportunity to help decrease feelings of mistrust experienced by the populations they help.
Following the session, I was excited by all of the possibilities that could result from establishing a collaborative bond between the CHW and the ONN, not the least of which could be referral of community residents to a known entity—the ONN.
Having spent the last 32 years working primarily in hospital and home care settings in Pennsylvania, Louisiana, Nevada, and Texas, I had never heard of the CHW role. I was even more astonished to learn there was a CHW program in Houston that offered formalized college credit to CHW students and included a practicum option—the first such college program in the state. In fact, the current CHW cohort was even partially sponsored by the Houston chapter of Susan G. Komen for the Cure. Therefore, the curriculum was designed to provide some emphasis regarding the breast cancer patient population and the importance of breast health awareness.
The idea of a collaborative relationship between the ONN and the CHW began to formalize (in this case, through a preceptor/student practicum), but first, I had to learn more about the CHW role and also explain the ONN role to college faculty, who were not familiar with the position.
To start the process, I met with the program faculty lead instructor for the HCC CHW program and learned the following:
During the meeting, I provided a brief history of the patient navigator role as developed by Harold Freeman, MD, more than 20 years ago. I then presented the hospital system’s job definition of the ONN; required qualifications, which included being an oncology certified nurse; and the ONN’s role delineation/description. I further explained that there were 9 ONNs located at 7 out of the system’s 11 acute care facilities—the ones with cancer programs accredited by the American College of Surgeons Commission on Cancer.
Table. Community Health Workers and Their Delivery
|China||1940s||Barefoot Doctors||Initiated by Chairman Mao Zedong due to a lack of medical care for the rural population|
|Brazil||1990s||Community Health Agents||Family Health Program; used to reduce infant mortality rates|
|Iran||1984 – ongoing||Behvarz||Used to reduce infant mortality rates, monitor child growth, and for family planning in the underserved population|
|India||2010 – ongoing||Community Health Workers||Used to increase mental health service utilization|
|Tanzania||2004 – ongoing||Village Health Workers||Community-based safe motherhood approach; assisted pregnant women with safe birth planning|
But this was just the beginning. The information learned in the meeting with HCC faculty provided the impetus for a further review of the literature. In fact, I learned that CHWs had been utilized to help get necessary healthcare to rural populations all around the world. It also seemed that the CHW role was quite similar to the initial navigator role started by Freeman out of Harlem Hospital; both positions were dedicated to helping impoverished populations get the care they need. International examples of the use of CHWs are listed in the Table.
More recently, the US Department of Labor created a job line (DOL-21-1094) for the CHW. It defines the role to include “assisting individuals and communities to adopt healthy behaviors, and conducting outreach for medical personnel or health organizations to implement programs in the community that promote, maintain, and improve individual and community health. They also may provide information on available resources, provide social support and informal counseling, advocate for individuals and community health needs, and provide services such as first aid and blood pressure screening. Finally, they might collect data to help identify community health needs.”
The Texas Department of State Health Services (DSHS) defines the CHW as a person who may or may not receive compensation but whose duties include some or all of the following:
Using the 8 core competencies developed by DSHS—advocacy, capacity building, communication, interpersonal relations, knowledge, organization, service coordination, and teaching—the CHW can work within a community and collaborate with the ONN to assist cancer survivors or possible future cancer patients to navigate the healthcare system throughout the care continuum.
Additional articles were then reviewed to gain further knowledge about CHW interventions with successful outcomes. Examples of CHW-associated successes include:
I went on to query other healthcare providers within my hospital system to see if they were cognizant of this position. Of the individuals queried across 7 campuses, only 1 individual had heard of the CHW and that nurse had “worked with them down in the valley near Brownsville, Texas.” With self-education completed, I now felt more prepared to “pitch” the proposed CHW-ONN collaborative effort.