1. Cancer Navigation: A Discussion on Barriers and Obstacles All Clinical Navigators Face Sharon Gentry RN, MSN, AOCN, CBCN Breast Nurse Navigator Derrick L Davis Forsyth Regional Cancer Center

2. Objectives Identify common types of barriers that healthcare clinical navigators may face. Explore solutions to address the barriers Share experiences among navigators on overcoming healthcare barriers

3. Defining barriers Barriers to health care are obstacles within our health care system that prevent vulnerable patient populations from getting needed health care, or that cause them to get inferior health care compared to advantaged patient populations. American Medical Student Association Foundation by the U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Medicine and Dentistry. http://www.amsa.org/programs/barriers/intro.html

4. Potential Barriers to Receiving Timely Health Care Freeman HP, Reuben SH. Voices of a Broken System. Bethesda, Md: NIH, NCI; 2001. Financial and economicLack of or inadequate insurance TransportationDifficulty arranging transportation CulturalCultural beliefs regarding treatment Communication and languageDifficulty telling desires/needs Health care systemFragmentation of care Bias based on race/age Fear and mistrust by patients; inadequate screening of the elderly FearDelay or refusal of care Examples Barrier

5. Types of Barriers Geographic/Cultural Socioeconomic Organizational/Systemic ***Combination of above factors are likely to increase disparities of care Navigator role specific

6. Geographic/Cultural

7. Veterans born prior 1946 Affected by wars Baby Boomers born between 1946 and 1964 * largest population Gen X was born between 1965 and 1979 “latchkey kids” Gen Y was born between 1980 and 1995 Millennium or Net Generation. Generation Z was born after 1995 Digital Natives Disciplined respect law & order. Consistency - do not like change. Fixed views on role gender and workplace. A directive, command & control management style. Youth = open- minded and rebellious. Adult = more conservative. Job status and social standing are important. Tend to be optimistic, ambitious, & loyal. Employment is for life. Both parents working. Daycare and divorce. Well-educated generation. Resourceful. Individualistic. Self reliant. Skeptical of authority. Focus on relationships, outcomes, their rights and skills. Technology wise. Comfortable with ethnically diverse groups. Optimistic, confident, sociable, and strong morals with sense of civic duty. Not brand loyal. Flexible and changing in fashion, style consciousness. Instant action and satisfaction. Smaller families with older Moms. Online communities and social media. Rather than personally meeting. not perform well in public speaking.

8. Geographic/Cultural Rural, suburban, inner-city….. Veterans, Baby boomers, generations X, Y & Z health beliefs and behaviors Patient beliefs as well as practitioner beliefs

9. Geographic/Cultural Care Language Information Bias Fears

10. Health Literacy “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” US Dept of Health and Human Sciences Teach back method http://minorityhealth.hhs.gov/templates http://www.jointcommission.org/assets/1/6/ARoadmapforHo spitalsfinalversion727.pdf

11. Examples

12. Following directions

13. Methods Commonly Used In U.S. Hospitals To Provide Language Services Source: Health Research and Educational Trust, 2006 Robert Wood Foundation

14. One solution

15. Implicit Bias in Healthcare Unconscious (Implicit) Bias and Health Disparities: Where Do We Go from Here? Perm J. 2011 Spring; 15(2): 71–78. https://implicit.harvard.edu

16. Socioeconomic barriers “drivers of healthcare disparities” lack of health insurance inability to pay out of pocket – transportation, child care Inadequate education Employment issues Psychosocial concerns

17. What is the socioeconomic status of the navigated population? Who are the people?  Community profile 2015 Commission on Cancer requirement  Komen report  Census data EMPLOYMENT STATUS COMMUTING TO WORK OCCUPATION INDUSTRY CLASS OF WORKER INCOME AND BENEFITS HEALTH INSURANCE COVERAGE BELOW THE POVERTY LEVEL http://factfinder2.census.gov/faces/tableservices/

18. Psychosocial Concerns Fear Mistrust Emotions Distress – * Distress monitoring for Commission on Cancer by 2015

19. Organizational/Systemic

20. Accessibility – How accessible is your care ? Can the patient find it? Physical barriers Accessible toilet and dressing rooms http://www.cdc.gov/ncbddd/disabilityandhealth/accessibility.html Timely access for all

21. Organizational/Systemic Communication “Removing Barriers to Health Care A Guide for Health Professionals” http://projects.fpg.unc.edu/~ncodh/rbar/ Insufficient cultural sensitive information Drop-out – give up in misunderstanding or frustration

22. Organizational/Systemic Unspoken rules Chain of command Guarded reactions

23. Navigation as a Solution Being there…trust Negative research (clinical trial) experiences

24. Unspoken Rules Family members are usually expected to keep problems a secret...

25. Navigator role specific Role definition Acceptance by leaders and peers Job sustainability

26. Barrier Solution Cancer Patient Navigation Programs are designed to help patients receive the best care possible. And they help the team that serves patients provide better care. Cancer Patient Navigation is not the cure for the disease, but it can be the lifesaver for the patient.