The Unique Role of the Navigator as Agent of Health Justice

The Unique Role of the Navigator as Agent of Health Justice

by Steve Sunderland, PhD
Cover of the Urban League of Greater Southwestern Ohio report tiled"Two Cities"

Introduction: There is agreement about the health facts facing minorities and the poor in Cincinnati: A large number of people do not have access to health resources and a significant number of people are suffering and dying as a result. Basic health information about illness when it is critical is seriously lacking for this population. Basic information about how to negotiate the health care system in a timely way is missing. Health professionals are untrained in working with minorities and the poor about both their health and non-health needs; often financial reasons are used for denying care. Most importantly, there is shoddy care coordination between the patient and the health care system and the patient and the non-health care system. In sum, the minority individual in Cincinnati faces life threatening obstacles to receiving minimal guidance in health and non-health related concerns.

A navigator, placed at health centers throughout the city, or placed in social agencies that work with the poor, or based at hospitals can make a significant difference in the health outcomes for poor people. A better use of health care systems will occur if the navigator is permitted to coordinate both health and non-health related needs.  People, gaining access in a timely way to the “best” health or non-health service, can reduce both mortality and the waste of the citizen’s time and life.

The Cincinnati Health Crisis: Large numbers of minorities and low income people face a crisis in health care. Mortality rates for cancer, infant mortality, and other diseases are near or at the top of state and national surveys of poor health. In Cincinnati, the Cincinnati Health Department, the Hamilton County Health Department, the Urban League “Two Cities” report, and the recent reporting of the NY Times state the same conclusion: Life expectancy for minorities and the poor are generally 15-20 year lower than majority populations. Hospitals throughout Cincinnati do not reach out to the communities with the worst statistics. The outcome is that there is dramatic increase in mortality in those communities that have hospitals located in them. Going to the emergency room in any hospital is a difficult and often scary reality for citizens who do not know if they will be accepted and/or if they have sufficient financial resources. Often, due to extreme pain, the citizen winds up in an emergency room and is treated badly. Sadly, the citizen may have to go to the emergency room because they do not know another place to go with a sick family member, or to find temporary shelter, food, or safety. Hospitals are ill-prepared for non-health related crisis.

The Cancer Example: Minorities and the poor have greater mortality than majority populations. One of the reasons is that access to information about danger signals about cancer is very limited in this population. Also, failing to follow up with timely screenings increases the likelihood of the cancer advancing to a stage that cannot be treated. Added to this is that there is not a single program in Cincinnati to reach out to the minority community with either information about cancer or a way of getting screened. Another factor is physician discomfort with minority or poor citizens when they come for cancer treatment. Research indicates that health care professionals are frustrated by not being able to understand, be understood, or by implicit and explicit stereotypes of poor citizens.

Navigators Increase Life Expectancy: Research on navigator programs in minority populations indicate a doubling of life expectancy due to navigator involvement with citizens at the earliest stage of their cancer. Navigators provide assistance in overcoming obstacles to getting to the screening and treatment processes. Navigators that are community based have been documented as successful in helping the citizen a) face housing, transportation, and cultural obstacles, b) find resources to solve conflicts that may prevent compliance with screening and treatment times, c) assist the citizen in understanding how the health and non-health systems work so that citizen choices about overcoming obstacles can be accepted, and d) assist with citizen’s fears about taking necessary steps in both the health and non-health area. Navigators are trusted to work in both areas and need to demonstrate both competence and compassion for the difficulties facing the citizen. Being community based, well trained in finding and sharing resources, the navigator increases the possibility of successfully navigating both the health and non-health care systems.

As successful as navigators can be in getting citizens to the door of a health center, a hospital, or a social agency, the citizen has then to cope with the treatment by the agencies. Too often, the fears of the citizen are met with indifference, minimal treatment or worse: unnecessary or non-existent treatment. It is clear from some of the research on navigation that the citizen must have the navigator as a team member to see just how entry and information about service is offered. Poorly educated physicians, with little cultural competence, and poor communication skills, or overwhelmed by their schedules, challenge the citizen with their abrupt and confusing behavior. The navigator can serve as another pair of eyes and ears for the citizen, helping to decode both the behaviors and the information.

One Model: The Cancer Justice Network (CJN): The CJN is a network of agencies that work with the poor and minorities in Cincinnati. A navigator, placed at each agency, attends community events, i.e., dinners, health fairs, training sessions, employment discussions, pantries, and other related agency based experiences. The navigator is part of a team that includes a physician, and an American Cancer Society staff member. At the event of the agency, the agency staff member will introduce the team and encourage people who would like to learn more about cancer to join a brief 15-20-minute talk. At the talk, the navigator will be introduced, cancer materials will be left, and a time for navigator-citizen connection will be set, either at that event or at a mutually agreed upon time. The navigator will meet with the citizen and discuss both health and non-health related needs that connect to the citizen at that point. A schedule for screening and/or other agency resources will be shared. Another meeting may be scheduled with the citizen and their family to discuss concerns that have recently become evident to the citizen. Cancer can be a foreboding experience for anyone, even people familiar with the health system. For people new to health care, the diagnosis of cancer may seem like a death sentence. The navigator steps into this emotional confusion with skill, compassion, and some experience with other cancer survivors.

The major positive outcome of this approach is that it builds trust between the navigator and the citizen, begins the exploration of how the citizen can get their resources for either/or health or non-health concerns, and increases the probability of follow up. By being agency based, this model may have rapid access to resources for non-health related concerns. It is likely that the citizen will trust this navigation process because the navigator is based in the agency, the navigator is prepared to talk about and help with health and non-health concerns, and the navigator is prepared to work as a partner with the citizen at the “home base” of the citizen. In effect, the physician, the cancer information specialist, and the navigator have all come into the neighborhood of the citizen and thereby indicated that the agency where they are meeting is a good place to start.

The Compassionate Benefits of Navigator Role: Treating people sooner for both health and non-health concerns increases survival and well-being. The more advanced the problem, the more complicated may be the helping process. Facing the unknowns of disease and related crisis may understandably reduce the emotional and physical capacity of a citizen. There is no one best way of facing crisis; yet, facing a health or non-health crisis with a team member, a navigator, opens the possibility of expanding the strengths of both the navigator and the citizen. Compassionate care, having the time to listen to questions or the time to hear fears being spoken, ignites the feelings of strength and solidarity. Facing hard problems with a navigator may make solutions, financial, decision making, and spiritual, more visible. Changing to a navigator-citizen team process offers a new set of services to those in crisis. And, with these services, comes the possibility of restoring faith in human relationships that matter in terms of survival. The navigator, the more educated they are to handle knowledge about resources and personal coordination, can increase the chances of survival.