Navigation Across the Continuum of Care

  • Danelle Johnston
  • Tricia Strusowski
  • Cheryl Bellomo
  • Linda Burhansstipanov


Cancer care is complex and must incorporate patient- and family-centered care that meets the needs of the population served within the community. Navigators must develop competency around cancer healthcare disparities in order to be able to assess and evaluate the community they serve and implement interventions that meet the needs of patients. The Theoretical Model of Cancer Health Disparities serves as a framework to identify barriers to care that impact patient outcomes. The Chronic Care Model provides structure to the role of navigation, which drives quality and outcomes. This model highlights the value of care coordination within and across care settings with three overlapping domains: entire community, healthcare systems, and provider organizations. The phases of cancer care include prevention, screening/outreach, diagnosis, treatment, survivorship, or end-of-life services, and managing these transitions is an essential component of a successful navigation program. The goals of navigation are to provide patient- and family-centered care that includes a comprehensive assessment of the patient's and family’s needs, as well as appropriate education and coordination through masterful managing of transitions. The navigator on a daily basis works with the patient and their family to remove barriers and ensure timely access to medical and psychosocial care across the entire continuum. The roles and responsibilities of the navigator incorporate national standards, core competencies, and navigation certification domains. It is essential that each lay navigator (nonclinical), social worker, or nurse navigator (clinical) works within the scope of their license and incorporates navigator core competencies and national standards into their role.


  1. 1.
    Hendred S. Patient’s barriers to receipt of cancer care, and factors associated with needing more assistance from a patient navigator. J Natl Med Assoc. 2011;103(8):701–10.CrossRefGoogle Scholar
  2. 2.
    Coleman E. (n.d.). The care transitions program health care services for improving quality and safety during care hands-offs. Accessed 12 Aug 2017.
  3. 3.
    Lattimer C. When it comes to transitions in patient care, effective communication can make all the difference. J Am Soc Aging. 2011;35:69–72.Google Scholar
  4. 4.
    Bridges W. Transitions making sense of life’s changes. 2nd ed. New York: DaCapo Press; 2004. Scholar
  5. 5.
    Rancour P. Using archetypes and transitions theory to help patients move from active treatment to survivorship. Clin J Oncol Nurs. 2008;12:935–40.CrossRefGoogle Scholar
  6. 6.
    Coleman E, Smith J, Frank J, Min S, Parry C, Kramer A. Preparing patients and caregivers to participate in care delivered across settings: the care transitions intervention. J Am Geriatr Soc. 2004;52:1817–25.CrossRefGoogle Scholar
  7. 7.
    National Transitions of Care Coalition. Who we serve. 2008. Accessed 12 Aug 2017.
  8. 8.
    National Transitions of Care Coalition. Improving transitions of care, findings and considerations of care coalition. September 2010. Accessed 12 Aug 2017.
  9. 9.
    Ventura T, Brown D, Archibald T, Goroski A, Brock J. Improving care transitions and reducing hospital readmissions: establishing the evidence for community based implementation strategies through the care transitions theme. Remington Report. 2010; 24–30.Google Scholar
  10. 10.
    Oncology Nursing Society, The Association of Oncology Social Workers, and the National Association of Social Workers joint position on the role of oncology nursing and oncology social work in patient navigation. 2010. Accessed 12 Aug 2017.
  11. 11.
    Patient-centered cancer treatment planning: improving the quality of oncology care [Workshop Summary]. Washington, DC: The National Academies Press; 2011.Google Scholar
  12. 12.
    Case M. Oncology nurse navigator: ensuring safe passage. J Oncol Nurs. 2011;15:33–40.CrossRefGoogle Scholar
  13. 13.
    C-Change. Cancer patient navigation. 2005. Accessed 12 Aug 2017.
  14. 14.
    Institute of Medicine. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press; 2013. As adapted from National Cancer Institute. The Cancer Control Continuum. Adapted from David B. Abrams, Brown University School of Medicine.Google Scholar
  15. 15.
    Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1(1):2–4.PubMedGoogle Scholar
  16. 16.
    Gentry S. Overview of professional roles and responsibilities. J Oncol Navig Surviv. 2016;7(6):28–31.Google Scholar
  17. 17.
    Bellomo C. The effects of navigator intervention on the community of care and patient satisfaction of patients with cancer. J Oncol Navig Surviv. 2014;5(6):16–20.Google Scholar
  18. 18.
    Merriam-Webster. (n.d.). Accessed 13 Aug 2017 from
  19. 19.
    American College of Surgeons. 2016. Accessed 13 Aug 2017
  20. 20.
    Calhoun, E, & Esparza, A. eds. (2017). Patient navigation overcoming barriers to care. New York: Springer. Scholar
  21. 21.
    Oncology Nursing Society. 2013. Accessed 13 Aug 2017
  22. 22.
    Role delineation in oncology navigation. J Oncol Navig Surviv. 2017;8(8):374–5.Google Scholar
  23. 23.
    Fillion L, Cook S, Veillette AM, et al. Professional navigation framework: elaboration and validation in a Canadian context. Oncol Nurs Forum. 2012;39:E58–69.CrossRefGoogle Scholar
  24. 24.
    Cascella S, Kerren J. Mujer a mujer/woman to woman: using a unique venue for culturally appropriate outreach and navigation in an underserved area to increase screening. J Oncol Navig Surviv. 2012;3(2):20–6.Google Scholar
  25. 25.
    Koh C, Nelson JM, Cook PF. Evaluation of a patient navigation program. Clin J Oncol Nurs. 2011;15:41–8.CrossRefGoogle Scholar
  26. 26.
    Lagrosa D. Breast patient navigation program hopes to reduce disparities among Hispanic/Latina women. J Oncol Navig Surviv. 2011;2(3):20–1.Google Scholar
  27. 27.
    Arias J. Patient navigation: blending imaging and oncology in breast cancer. J Oncol Navig Surviv. 2012;3(1):16–21.Google Scholar
  28. 28.
    Eley RM, Rogers-Clark C, Murray K. The value of a breast care nurse in supporting rural and remote cancer patients in Queensland. Cancer Nurs. 2008;31(6):E10–8.CrossRefGoogle Scholar
  29. 29.
    Wilcox B, Bruce SD. Patient navigation: a “win-win” for all involved. Oncol Nurs Forum. 2010;37:21–5.CrossRefGoogle Scholar
  30. 30.
    Doll R, Barrroetavena MC, Ellwood AL, et al. The cancer care navigator: toward a conceptual framework for a new role in oncology. Oncol Exch. 2007;6(4):28–33.Google Scholar
  31. 31.
    American College of Surgeons Commission on Cancer Standards 2015. Cancer program standards 2012, version 1.2.1: ensuring patient-centered care (educational standards). 2014.
  32. 32.
    Wagner EH, Bowles EJA, Greene SM, et al. The quality of cancer patient experience: perspectives of patients, family members, providers, and experts. Qual Saf Health Care. 2010;19:484–9.PubMedGoogle Scholar
  33. 33.
    Goldsmith J, Ferrell B, Wittenberg-Lyles E, et al. Palliative care communication in oncology nursing. Clin J Oncol Nurs. 2013;17:163–7.CrossRefGoogle Scholar
  34. 34.
    National Coalition for Cancer Survivorship. Our mission. http://www.canceradvocacy.or/about-us/our-mission. Accessed 2 Aug 2017.
  35. 35.
    Hewitt M, Greenfield S, Stovall E, editors. From cancer patient to cancer survivor: lost in transition. National Cancer Policy Board. Institute of Medicine. Washington, DC: National Academies Press. Published 2006. Accessed 2 Aug 2017.
  36. 36.
    Mullen F. Seasons of survival: reflections of a physician with cancer. N Engl J Med. 1985;313(4):270–3.CrossRefGoogle Scholar
  37. 37.
    National Cancer Institute. National lung screening trial: questions and answers. Updated November 12, 2014. Accessed 6 Aug 2017.
  38. 38.
    Fleischner Society. Fleischner society recommendations for follow-up of small lung nodules detected incidentally on CT (patients ≥35 years of age). Accessed 6 Aug 2017.

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Danelle Johnston
    • 1
  • Tricia Strusowski
    • 2
  • Cheryl Bellomo
    • 3
  • Linda Burhansstipanov
    • 4
  1. 1.Academy of Oncology Nurse and Patient Navigators, The Lynx GroupCranburyUSA
  2. 2.Oncology Solutions LLCDecaturUSA
  3. 3.Oncology Nurse NavigatorIntermountain Cancer Centers, Cedar City HospitalCedar CityUSA
  4. 4.Native American Cancer Research CorporationPineUSA

Personalised recommendations