Mapping variation in intervention design: a systematic review to develop a program theory for patient navigator programs

[Utilizing Patient Navigation Model in the Whole-Process Management of Lung Cancer in the Context of Medical Consortiums in China: Insights and Reflections]

Patient navigation is an effective intervention measure to promote the integration of medical systems and services. By providing individualized, coordinated, and continuous care, patient navigation offers a way to address the problem of fragmented services across institutions and levels of care in the whole-process management of lung cancer, providing assistance to patients with complex healthcare needs. Herein, we reviewed the origin, the development, the models, and the application status of patient navigation in China and other countries. We also analyzed the considerations regarding introducing patient navigation in the whole-process management of lung cancer against the background of medical consortiums in China, discussing why patient navigation should be introduced, how to introduce patient navigation, as well as potential challenges and coping strategies. Patient navigation meets the current needs for equitable, accessible, systematic, continuous, and integrated prevention and treatment services for chronic diseases in the context of the Healthy China Strategy. It helps fill the gaps in the continuity and coordination of whole-process management of lung cancer patients in the context of medical consortiums. However, introducing patient navigation in medical consortiums involving multiple institutions and levels of care may face challenges, including incompatibility between the health information systems of different institutions, poor cross-institutional collaboration and communication, and limited resources. Further improvement is needed in medical informatization, coordination and communication mechanisms, and benefit distribution mechanisms within the medical consortiums. In this paper, we intend to provide insights and suggestions for developing patient navigation models that suit China's local characteristics and for promoting the implementation and development of whole-process management of lung cancer in the context of the medical consortium system.

Telephone outreach by volunteer navigators: a theory-based evaluation of an intervention to improve access to appropriate primary care

BACKGROUND

A pilot intervention in a participatory research programme in Québec, Canada, used telephone outreach by volunteer patient navigators to help unattached persons from deprived neighbourhoods attach successfully to a family doctor newly-assigned to them from a centralized waiting list. According to our theory-based program logic model we evaluated the extent to which the volunteer navigator outreach helped patients reach and engage with their newly-assigned primary care team, have a positive healthcare experience, develop an enduring doctor-patient relationship, and reduce forgone care and emergency room use.

METHOD

For the mixed-method evaluation, indicators were developed for all domains in the logic model and measured in a telephone-administered patient survey at baseline and three months later to determine if there was a significant difference. Interviews with a subsample of 13 survey respondents explored the mechanisms and nuances of intended effects.

RESULTS

Five active volunteers provided the service to 108 persons, of whom 60 agreed to participate in the evaluation. All surveyed participants attended the first visit, where 90% attached successfully to the new doctor. Indicators of abilities to access healthcare increased statistically significantly as did ability to explain health needs to professionals. The telephone outreach predisposed patients to have a positive first visit and have trust in their new care team, establishing a basis for an enduring relationship. Patient-reported access difficulties, forgone care and use of hospital emergency rooms decreased dramatically after patients attached to their new doctors.

CONCLUSIONS

As per the logic model, telephone outreach by volunteer navigators significantly increased patients' abilities to seek, reach and engage with care and helped them attach successfully to newly-assigned family doctors. This light-touch intervention may have promise to achieve of the intended policy goals for the centralized waiting list to increase population access to appropriate primary care and reduce forgone care.

Patient Navigators for CKD and Kidney Failure: A Systematic Review

Rationale & Objective

To what degree and how patient navigators improve clinical outcomes for patients with chronic kidney disease (CKD) and kidney failure is uncertain. We performed a systematic review to summarize patient navigator program design, evidence, and implementation in kidney disease.

Study Design

A search strategy was developed for randomized controlled trials and observational studies that evaluated the impact of navigators on outcomes in the setting of CKD and kidney failure. Articles were identified from various databases. Two reviewers independently screened the articles and identified those meeting the inclusion criteria.

Setting & Participants

Patients with CKD or kidney failure (in-center hemodialysis, peritoneal dialysis, home hemodialysis, or kidney transplantation).

Selection Criteria for Studies

Studies that compared patient navigators with a control, without limits on size, duration, setting, or language. Studies focusing solely on patient education were excluded.

Data Extraction

Data were abstracted from full texts and risk of bias was assessed.

Analytical Approach

No meta-analysis was performed.

Results

Of 3,371 citations, 17 articles met the inclusion criteria including 14 original studies. Navigators came from various healthcare backgrounds including nursing (n=6), social worker (n=2), medical interpreter (n=1), research (n=1), and also included kidney transplant recipients (n=2) and non-medical individuals (n=2). Navigators focused mostly on education (n=9) and support (n = 6). Navigators were used for patients with CKD (n=5), peritoneal dialysis (n=2), in-center hemodialysis (n=4), kidney transplantation (n=2), but not home hemodialysis. Navigators improved transplant workup and listing, peritoneal dialysis utilization, and patient knowledge.

Limitations

Many studies did not show benefits across other outcomes, were at a high risk of bias, and none reported cost-effectiveness or patient-reported experience measures.

Conclusions

Navigators improve some health outcomes for CKD but there was heterogeneity in their structure and function. High-quality randomized controlled trials are needed to evaluate navigator program efficacy and cost-effectiveness.

What do people with lung cancer and stroke expect from patient navigation? A qualitative study in Germany

OBJECTIVE

This qualitative study investigated patients' needs and wishes in relation to patient navigation.

DESIGN

A qualitative interview study was conducted. Participants were invited to take part in three in-depth interviews over a period of 6-12 months. Thematic analysis was used.

SETTING

Interviewees were sought in the Berlin metropolitan area of Germany in academic university hospitals, in rehabilitation clinics and through self-help organisations.

PARTICIPANTS

The sample consisted of individuals diagnosed with lung cancer (n=20) or stroke (n=20).

RESULTS

From the perspective of interviewees, patient navigators should function as consistent contact persons, present during the whole care trajectory. Their role would be to guide patients through an often confusing healthcare landscape, offering practical, advisory and emotional assistance corresponding to patients' needs. The study shows that-independent of the disease-participants had similar expectations and needs regarding support from navigators.

CONCLUSION

For chronic and complex diseases-as is the case with lung cancer and stroke-it appears less important for navigators to fulfil disease-specific tasks. Rather, they should ensure that patients' more general needs, in relation to social, practical and emotional support, are met in a way that suits their individual wishes. Following these results, patient navigation programmes might be designed to include generic elements, which should then be adapted to the infrastructure in a particular healthcare region and to the particularities of a specific healthcare system.

The role of patient navigators in ambulatory care: overview of systematic reviews

BACKGROUND

Patient navigators have been introduced across various countries to enable timely access to healthcare services and to ensure completion of diagnosis and follow-up of care. There is an increasing evidence on the the role of patient navigation for patients and healthcare systems. The aim of this study was to analyse the evidence on patient navigation interventions in ambulatory care and to evaluate their effects on individuals and health system outcomes.

METHODS

An overview of reviews was conducted, following a prespecified protocol. All patients in ambulatory care or transitional care setting were included in this review as long as it was related to the role of patient navigators. The study analysed patient navigators covering a wide range of health professionals such as physicians, nurses, pharmacists, social workers and lay health workers or community-based workers with no or very limited training. Studies including patient-related measures and health system-related outcomes were eligible for inclusion. A rigorous search was performed in multiple data bases. After reaching a high inter-rater agreement of 0.86, title and abstract screening was independently performed. Of an initial 14,248 search results and an additional 62 articles identified through the snowballing approach, a total of 7159 hits were eligible for title/abstract screening. 679  articles were included for full-text screening.

RESULTS

Eleven systematic reviews were included covering various patient navigation intervention in cancer care, disease screening, transitional care and for various chronic conditions and multimorbidity. Nine systematic reviews primarily tailored services to ethnic minorities or other disadvantaged groups. Patient navigators performed tasks such as providing education and counselling, translations, home visits, outreach, scheduling of appointments and follow-up. Eight reviews identified positive outcomes in expanding access to care, in particular for vulnerable patient groups. Two reviews on patient navigation in transitional care reported improved patient outcomes, hospital readmission rates and mixed evidence on quality of life and emergency department visits. Two reviews demonstrated improved patient outcomes for persons with various chronic conditions and multimorbidity.

CONCLUSIONS

Patient navigators were shown to expand access to screenings and health services for vulnerable patients or population groups with chronic conditions who tend to underuse health services.

An International Review to Characterize the Role, Responsibilities, and Optimal Setting for Health Literacy Mediators

Health literacy is a critically important determinant of health and is influenced by access to supportive social networks and services. Global investment in education throughout the life course is required to support health literacy development. The aim of this review is to characterize the role, responsibilities, and the optimal setting for the emergent role of a Health Literacy Mediator (HLM). A scoping review of recent literature was conducted. The review revealed a lack of consensus on who should be teaching health literacy, and variability in confidence when teaching health literacy. Professionals reported facing barriers such as a lack of time, a lack of knowledge, and recognized that the health literacy needs of children worldwide are not being met. Further research into the role of HLM is required to determine who is best suited to this role and what their responsibilities will be to ensure consistent health literacy education.