If one day for any reason you stopped going to your job as a navigator, would the people who follow you be able to pick up where you left off, or would they be stuck trying to reinvent the wheel? Are you building a legacy with your role so that those who come after you can stand on your shoulders and go even further than you, or are you setting them up for failure? Navigators need to start thinking of how we can sustain the progress we have worked so hard to attain.

The way that you help patients overcome barriers to care may seem second nature to you, but you may well find that your common sense is quite uncommon, and the process is more complicated than you had imagined.

Experienced navigators need to write down our common processes. For example, you may refer all of your patients with head and neck cancer to a nutritionist as part of your care coordination. Write down exactly how you accomplish this, what information is required, and to whom the referral is sent. Include the referral form as an appendix, along with any common problems with the referrals and how you have overcome them. Be as detailed as possible, and try to make the language accessible so that anyone can read it.

Put together a binder of all of your processes, or make an electronic document if at all possible so that you can disseminate the knowledge efficiently to all who need it. Remember that process manuals are living documents. Be prepared to make changes as they come.

Navigators need to start thinking of how we can sustain the progress we have worked so hard to attain.

There seems to be a ubiquitous binder in every case manager, navigator, and social worker's shelf full of notes about resources that may or may not actually work. These binders often contain outdated information, making the binder an unreliable waste of space even though it may contain some useful resources.

Our team came up with a simple but effective replacement for the binder; we created a spreadsheet database. It wasn't the most elegant solution, but it was free, and we were able to distribute it across our entire state instantly.

First, we vet all of the resources before placing them in our approved resource list. We exclude resources that do not return our calls or emails. As we communicate with the resource agencies, we confirm and record eligibility information. For continuity's sake, we commit to vet the resources as a team every 6 months. It is surprising how many resources can become defunct within that time span.

Second, we take the approved resource list and enter all of the relevant information onto uniform factsheets created for each resource. The template includes space for contact information, eligibility requirements, nature of assistance offered, and any special notes that could be relevant to the navigator or patient. The factsheets are saved in an electronic folder.

Third, we enter the basic information created for each resource into a spreadsheet, organized across 3 columns: (1) resource name hyperlinked to its respective factsheet, (2) location, and (3) resource type, for example, transportation, support, non-medical bills, and housing. We restrict the resource types to 20 unique terms to make it easier for the navigator to sort the terms for the patient’s specific needs when looking for resources.

Fourth, we use zip software to combine the spreadsheet and resources into a single folder, making sure that all patient health information is deleted from the resource files to prevent violating HIPAA. We upload to a cloud service like Dropbox or Google Drive, enable sharing options, and send the link to all personnel who should access it.

If your hospital system employs database programmers, by all means, use them to create a more refined version, but always take the time to vet the resources periodically. This database can be an invaluable tool to your team and serve them well in case you are absent.

Manuals and databases sustain navigation by improving continuity, but revenue-generating programs will sustain navigation on many different levels. You could hire more staff, prove your monetary worth to corporate leaders, and give your patients better access to care.

 your navigation procedures in a way that they can be easily disseminated

 a centrally accessible list of patient resources by location and type

 all of the successful cases helped by deploying revenue-generating strategies

One of the strengths of navigation is that we can anticipate problems before they occur and arrange for the appropriate screening. In Georgia, we can screen patients with breast and cervical cancer who are self-pay for eligibility for the Women's Health Medicaid program. We also screen Medicare patients for eligibility for QMB (Medicaid’s Qualified Medicare Beneficiary program), as well as for the “Extra Help” program for individuals who need assistance paying for Medicare’s Part D drug coverage. See if your hospital offers any COBRA premium assistance programs to help the recently unemployed maintain their coverage for treatment. Copay and pharmacy replacement programs can also bring in revenue.

Availability of these programs will depend on your location. Sometimes our own organization's systems are so large and disconnected that they don't share patient insurance information. Share the information with your organization's billers. Sometimes you are referred insured patients that supposedly are not covered for certain services; make the call to the insurance company yourself with the proper ICD-10 and CPT codes to confirm this. I have found many times that patients are covered—by confirming coverage, we retain paying patients.

Keep a record of all of the successful cases you have helped, using these revenue-generating strategies and programs. It is a win—win for both your organization and the patient, who in many cases gains better access to care.

These simple and free strategies will help you to sustain your navigation program, build your legacy, and demonstrate that your team is beneficial to your organization.

Jace Longnecker, BA, MBA, CCL, is a lay navigator at Northside Hospital in Atlanta

Articles

Nurse navigators should consider sustainability strategies to ensure that their progress remains.

Sustainability Strategies for Navigation

The fear of undergoing cancer treatment is universal. Imagine, however, how it would feel to have a medical team that cannot speak a word of your language or even pronounce your name. Envision trusting all of your communication to a series of interpreters whose skill level you have no way to assess. When I lived abroad, I could barely summon up the courage to have my hair cut by the locals! When non-English speaking patients access our medical system, it can be an immensely stressful time.

The many layers and multiple staff members of the American healthcare system may be in stark contrast to the medical experiences for someone from another country, and the length of time to interpret communication for non-English—speaking patients may cause even more distress. We can see why these patients may feel lost in the maze of US healthcare and are confused. Moreover, these gaps in experience and understanding may lead to nonadherence and even a sense of distrust.

Navigators are well-positioned to add an element of relational trust into the healthcare experience for patients from other cultures by eliciting surprising patient histories, using their assessment and listening skills, and asking spot-on questions.

I recall a telephone call I once had with a Vietnamese patient, who through an interpreter, mentioned symptoms she was experiencing. I turned the call over to Debbie Bickes, RN, MN, OCN, my supervisor and an oncology nurse, who discovered that the patient had been effectively starving herself by eating only rice water soup for 30 days after her surgery because she was told to have a “light diet” after surgery. The patient also mistakenly believed that she was not allowed to walk downstairs and had stayed in her bedroom for 30 days.

Using her nursing assessment and communication skills, Debbie had taken the time to uncover a serious misconception. The time she took was invaluable and allowed for an appropriate intervention—connecting the patient with her physician, empowering her, and helping to dispel a cultural belief that one should refrain from asking a doctor questions.

Over the past decade, my goal has been to help people of other cultures receive the best healthcare possible, researching many groups and learning many languages along the way to improve communication with our international patients. Through this process, I have identified three strategies that have been very effective:

(1) View your culture from a newcomer’s perspective

. American Ways: A Guide for Foreigners in the United States

 by Gary Althen is a book designed for immigrants and explains the differences between the US and other global cultures that can lead to frustration and confusion on both sides. Reading about our own culture helps us to recognize key differences which may impact patient care and also help practitioners to maintain humility and prevent unhelpful stereotyping.

. In addition to using a qualified interpreter, clinicians can use open-ended communication and a “teach back” approach. Nurses understand these strategies by virtue of their training, but it is important for lay navigators and other nonlicensed healthcare staff to use these communication strategies as well when working with patients from other cultures. As a former interpreter in a healthcare clinic, I witnessed patients answering “yes” multiple times during conversations with physicians and realized that often patients would simply agree with the physician instead of actually respond to the questions.

To remedy this issue, we began asking open-ended questions, such as who, what, where, when, why, and how. We would ask patients to summarize their understanding in their own words by asking them to “teach back” to us. Using these strategies fortified our communication and relationships, improving patients’ understanding of their care plan.

(3) Assist non-English speaking patients with their written communications

. This is especially important for navigators working with patients experiencing financial barriers. It can be a daunting task to obtain completed patient grant applications or even a signature on a form from patients who cannot read English. Many have admitted to throwing away mail they receive when the envelope is not addressed to them in their language.

One strategy we have used successfully is to ask non-English speaking patients to call when they receive mail in order to examine it together. We have also asked our Vietnamese and Chinese patients to go to a local Asian community center to have their mail explained to them. These strategies have resulted in patients who have kept more of their appointments, signed and returned more forms, and alerted navigators when they have received bills they cannot pay. This strategy has also assisted patients in renewing food stamps and other forms of government assistance which prevented a lapse in their benefits.

As navigators, we can make a great difference in the healthcare of international patients. By working together, we can empower patients from other cultures to improve not only their access to care, but also their care experience and outcomes.

___________________________________________________________________________________

Jace Longnecker has been a lay navigator for more than 5 years, and cur&shy;rently works in that role at Northside Hospital Cancer Institute in Atlanta, Georgia. Debbie Bickes has more than 30 years of experience as an oncol&shy;ogy nurse serving in a variety of roles and is currently the CMS Program Coordinator at Northside.

The fear of undergoing cancer treatment is universal. Imagine, however, how it would feel to have a medical team that cannot speak a word of your language or even pronounce your name.

Navigator Offers Strategies to Support Non-English Speaking Patients

We, as collaborative navigators, became the village that helped a patient and her family. The story started calmly enough. As the gyn/onc nurse navigator, I was alerted to the needs of a woman we will refer to as Alice (who, upon the unfolding of her story did, indeed, seem to have stepped through a looking glass). It appeared that Alice was in need of a generous measure of psychosocial support as she began her treatment for ovarian cancer.

I established a relationship with Alice and her daughter Irene (pseudonym) while she was an inpatient and then followed her as her adjuvant chemotherapy was initiated. I visited with Alice and Irene each chemotherapy cycle, and we easily bonded in conversation. They both also came to our LIFT (Ladies in the Fight Together) monthly support group where they bonded with the other women. Our then American Cancer Society navigator, Erin Elliott, was able to get Alice a lovely wig which she enjoyed wearing.

Alice also fit the qualifications for our CCL (Cancer Care Liaison) program (aged ≥65 years, with Medicare parts A and B), and thus Jace Longnecker became part of the team as her designated CCL. Jace was able to support Alice in many ways, including finding a source for gas cards for her to make it easier for her to get to treatment.

One morning Jace called me to say that in his extensive conversations with Alice, she had revealed to him that she had her microwave stuffed with hot dogs. This alerted the ever-vigilant Jace to what appeared to be significantly aberrant behavior, so he called me and I, in turn, made a referral to our behavioral health department. After interviewing the patient, they determined that there was evidence of psychological hoarding behavior which I reported to her gynecologic oncologist and his team.

During one of Jace’s CCL weekly follow-up calls, Alice reluctantly shared that she had become dizzy while working in her garden, fallen, and now had a significant infected facial bruise. She was having chemo- therapy at that time and was reticent to call her doctor, so Jace took the initiative and reported the situation to her gynecologic oncologist who immediately placed her on antibiotics and adjusted her chemotherapy cycles accordingly. Jace also touched base with me, so I could call the patient and remind her she could call me with any clinical issues that came up.

Our patient was subsequently readmitted to the hospital for an infection in her leg, and I visited with her and Irene who was with her mother daily, as did Kourtney Carter, our then navigation social worker.

One afternoon when Irene was leaving for the day, she, Kourtney, and I began to chat, and Irene began describing her childhood, and she tearfully recounted that her mother had been extremely emotionally distant to her and her siblings to the point of withholding food. She said she had become severely anemic at one point. Irene said none of her siblings were interested in helping with her mother’s care but that she, as a born-again Christian, was compelled by her faith to be present for her mother.

This was apparently an extremely cathartic moment for Irene, and Kourtney and I supported her emotionally as she wept for several minutes. She later shared with us that this was the first time in her life she felt totally safe to express her feelings about her mother.

Jace and our behavioral health department were informed and were better able to support our patient and her daughter going forward. I also shared this new information with the patient’s medical team.

Looking back, the care of this patient and her daughter was incredibly enhanced by those of us who collaborated in her care—each of us bringing our own unique skills to the table and sharing with each other so that we actually synergized each other’s efforts. Our individual contributions to her care created a safe and therapeutic environment&mdash;not only for Alice, but also for her daughter, who needed ongoing support in her caregiver role.

To me, this showcases our unique navigation program at Northside Hospital Cancer Institute where we are able to support our patients and their families with a truly holistic and healing approach. Many times when patients and families are catapulted into a cancer diagnosis, the complexities of care can send them into a seemingly parallel universe where they feel overwhelmed with emotions that heretofore had been tamped down in the hustle and bustle of everyday life.

As navigators, whether clinical (as in oncology nurse navigators), or logistical (as in the supportive care cancer care liaisons), we have an opportunity to give our patients a sustaining framework to regain a sense of self and purpose in their lives as they proceed through the maze of cancer treatment. This blended and collaborative care model is the foundation of patient navigation in cancer care.

Supporting patients and families with a truly holistic and healing approach.

Jace Longnecker, BA, MBA, CCL

Articles

Sustainability Strategies for Navigation

Navigator Offers Strategies to Support Non-English Speaking Patients

The Moving Parts of a Village