Navigation Across the Continuum of Care

Abstract

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.