What are patient navigators and how can they improve integration of care?

The European Observatory on Health Systems and Policies is a partnership that supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of health systems in the European Region. It brings together a wide range of policy-makers, academics and practitioners to analyse trends in health reform, drawing on experience from across Europe to illuminate policy issues. The Observatory’s products are available on its website (https://eurohealthobservatory.who.int). What are patient navigators and how can they improve integration of care? POLICY BRIEF 44 Hannah Budde Gemma A Williams Giada Scarpetti Marieke Kroezen Claudia B Maier World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 E-mail: eurocontact@who.int Website: www.euro.who.int HEALTH SYSTEMS AND POLICY ANALYSIS Print ISSN 1997-8065 Web ISSN 1997-8073 PolicyBrief_PB44_COVER.qxp_Cover_policy_brief 14/12/2021 11:38 Page 1 Keywords: Patient care management Patient-centered care Delivery of health care Health policy Innovation Health care reform This policy brief is one of a new series to meet the needs of policy-makers and health system managers. The aim is to develop key messages to support evidence-informed policy-making and the editors will continue to strengthen the series by working with authors to improve the consideration given to policy options and implementation. Joint Policy Briefs 1. 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Ivy Lynn Bourgeault, Ellen Kuhlmann, Elena Neiterman, Sirpa Wrede 9. Do lifelong learning and revalidation ensure that physicians are fit to practise? Sherry Merkur, Philipa Mladovsky, Elias Mossialos, Martin McKee 10. How can health systems respond to population ageing? Bernd Rechel, Yvonne Doyle, Emily Grundy, Martin McKee 11. How can European states design efficient, equitable and sustainable funding systems for long-term care for older people? José-Luis Fernández, Julien Forder, Birgit Trukeschitz, Martina Rokosová, David McDaid 12. How can gender equity be addressed through health systems? Sarah Payne 13. How can telehealth help in the provision of integrated care? Karl A. Stroetmann, Lutz Kubitschke, Simon Robinson, Veli Stroetmann, Kevin Cullen, David McDaid 14. How to create conditions for adapting physicians’ skills to new needs and lifelong learning Tanya Horsley, Jeremy Grimshaw, Craig Campbell 15. How to create an attractive and supportive working environment for health professionals Christiane Wiskow, Tit Albreht, Carlo de Pietro 16. How can knowledge brokering be better supported across European health systems? John N. Lavis, Govin Permanand, Cristina Catallo, BRIDGE Study Team 17. How can knowledge brokering be advanced in a country’s health system? John. N Lavis, Govin Permanand, Cristina Catallo, BRIDGE Study Team 18. How can countries address the efficiency and equity implications of health professional mobility in Europe? Adapting policies in the context of the WHO Code and EU freedom of movement Irene A. Glinos, Matthias Wismar, James Buchan, Ivo Rakovac 19. Investing in health literacy: What do we know about the co-benefits to the education sector of actions targeted at children and young people? David McDaid 20. How can structured cooperation between countries address health workforce challenges related to highly specialized health care? Improving access to services through voluntary cooperation in the EU Marieke Kroezen, James Buchan, Gilles Dussault, Irene Glinos, Matthias Wismar 21. How can voluntary cross-border collaboration in public procurement improve access to health technologies in Europe? Jaime Espín, Joan Rovira, Antoinette Calleja, Natasha Azzopardi-Muscat , Erica Richardson,Willy Palm, Dimitra Panteli 22. How to strengthen patient-centredness in caring for people with multimorbidity in Europe? Iris van der Heide, Sanne P Snoeijs, Wienke GW Boerma, François GW Schellevis, Mieke P Rijken. On behalf of the ICARE4EU consortium 23. How to improve care for people with multimorbidity in Europe? Mieke Rijken, Verena Struckmann, Iris van der Heide, Anneli Hujala, Francesco Barbabella, Ewout van Ginneken, François Schellevis. On behalf of the ICARE4EU consortium 24. How to strengthen financing mechanisms to promote care for people with multimorbidity in Europe? Verena Struckmann, Wilm Quentin, Reinhard Busse, Ewout van Ginneken. On behalf of the ICARE4EU consortium 25. How can eHealth improve care for people with multimorbidity in Europe? Francesco Barbabella, Maria Gabriella Melchiorre, Sabrina Quattrini, Roberta Papa, Giovanni Lamura. On behalf of the ICARE4EU consortium 26. How to support integration to promote care for people with multi- morbidity in Europe? Anneli Hujala, Helena Taskinen, Sari Rissanen. On behalf of the ICARE4EU consortium 27. How to make sense of health system efficiency comparisons? Jonathan Cylus, Irene Papanicolas, Peter C Smith 28. What is the experience of decentralized hospital governance in Europe? Bernd Rechel, Antonio Duran, Richard Saltman 29. Ensuring access to medicines: How to stimulate innovation to meet patients’ needs? Dimitra Panteli, Suzanne Edwards 30. Ensuring access to medicines: How to redesign pricing, reimbursement and procurement? Sabine Vogler, Valérie Paris, Dimitra Panteli 31. Connecting food systems for co-benefits: How can food systems combine diet-related health with environmental and economic policy goals? Kelly Parsons, Corinna Hawkes 32. Averting the AMR crisis: What are the avenues for policy action for countries in Europe? Michael Anderson, Charles Clift, Kai Schulze, Anna Sagan, Saskia Nahrgang, Driss Ait Ouakrim, Elias Mossialos 33. It’s the governance, stupid! TAPIC: a governance framework to strengthen decision making and implementation Scott L. Greer, Nikolai Vasev, Holly Jarman, Matthias Wismar, Josep Figueras 34. How to enhance the integration of primary care and public health? Approaches, facilitating factors and policy options Bernd Rechel 35. Screening. When is it appropriate and how can we get it right? Anna Sagan, David McDaid, Selina Rajan, Jill Farrington, Martin McKee 36. Strengthening health systems resilience: key concepts and strategies Steve Thomas, Anna Sagan, James Larkin, Jonathan Cylus, Josep Figueras, Marina Karanikolos 37. Building on value-based health care Peter C Smith, Anna Sagan, Luigi Siciliani, Dimitra Panteli, Martin McKee, Agnès Soucat, Josep Figueras 38. Regulating the unknown: A guide to regulating genomics for health policy-makers Gemma A Williams, Sandra Liede, Nick Fahy, Kristiina Aittomaki, Markus Perola, Tuula Helander, Martin McKee, Anna Sagan 39. In the wake of the pandemic: Preparing for Long COVID Selina Rajan, Kamlesh Khunti, Nisreen Alwan, Claire Steves, Trish Greenhalgh, Nathalie MacDermott, Anna Sagan, Martin McKee 40. How can we transfer service and policy innovations between health systems? Ellen Nolte, Peter Groenewegen 41. What are the key priority areas where European health systems can learn from each other? Johan Hansen, Alexander Haarmann, Peter Groenewegen, Natasha Azzopardi Muscat, Gianpaolo Tomaselli, Mircha Poldrugovac 42. Use of digital health tools in Europe: Before, during and after COVID-19 Nick Fahy, Gemma A Williams, COVID-19 Health System Response Monitor Network 43. European support for improving health and care systems Nick Fahy, Nicole Mauer, Dimitra Panteli The European Observatory has an independent programme of policy briefs and summaries which are available here: https://eurohealthobservatory.who.int/publications/ policy-briefs What is a Policy Brief? A policy brief is a short publication specifically designed to provide policy makers with evidence on a policy question or priority. 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The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. PolicyBrief_PB44_COVER.qxp_Cover_policy_brief 05/01/2022 12:59 Page 2 Editors Matthias Wismar Ewout van Ginneken Anna Sagan Series Editor Anna Sagan Managing Editors Jonathan North Lucie Jackson The authors and editors are grateful to the reviewers who commented on this publication and contributed their expertise. Contents Key messages 5 Executive Summary 7 Policy Brief 9 Introduction 9 Patient navigators: roles, tasks and examples 9 of patient navigator programmes How effective are patient navigator programmes? 15 What are the levers and barriers for the 17 implementation of patient navigator programmes? Conclusions 21 References 23 Authors Hannah Budde – Pathways Public Health Gemma A Williams – European Observatory on Health Systems and Policies, London School of Economics and Political Science Giada Scarpetti – Technical University of Berlin Marieke Kroezen – Trimbos Instituut, Utrecht Claudia B Maier – Technical University of Berlin page What are patient navigators and how can they improve integration of care? Print ISSN 1997-8065 Web ISSN 1997-8073 PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 1 2Policy brief Acknowledgements The authors are grateful to Matthias Wismar and Ewout van Ginneken of the European Observatory on Health Systems and Policies for initiating and steering this work and to Professor Gilles Dussault, Global Health and Tropical Medicine, Universidade NOVA de Lisboa, and Professor James Buchan, Human Resources for Health, Edinburgh, for reviewing this policy brief and providing very helpful comments. PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 2 3What are patient navigators and how can they improve integration of care? Acronyms AIDS acquired immunodeficiency syndrome CAPRI CAncérologie, Parcours, Région, Ile de France CDC Centers for Disease Control and Prevention COVID-19 SARS-Cov-2 CPD Continuing professional development FFS fee-for-service HIV human immunodeficiency virus HoMBReS Hombres Manteniendo Bienestar y Relaciones Saludables ICARE4EU Innovating care for people with multiple chronic conditions in Europe I-PaCS Integrated Primary Care and Community Support MiMi Mit MigrantInnen für MigrantInnen OECD Organisation for Economic Co-operation and Development OWL Ostwestfalen-Lippe PCCP Patient Care Connect Program SALUS Salzburger Gesundheitslotsinnen SELFIE 2020 Sustainable intEgrated care modeLs for multi- morbidity: delivery, FInancing and performance UK United Kingdom USA United States of America WHO World Health Organization List of figures and boxes Boxes Box 1: Methods 9 Box 2: How is integrated care defined in this policy brief? 9 Box 3: Who are patient navigators? 10 Box 4: Key tasks performed by patient navigators 10 Box 5: Limitations of the evidence on 15 the effectiveness of patient navigator programmes Box 6: Patient navigator training programmes in the USA 18 Box 7: Funding of a patient navigator programme 19 in Germany Box 8: Payment mechanisms for patient navigator 19 programmes in the USA Figures Figure 1: Patient navigators in cancer care: across 11 the care continuum Figure 2: Factors to be considered for the 17 implementation of patient navigator programmes Tables Table 1: Evidence on patient navigator programmes 15 PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 3 4Policy brief PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 4 5What are patient navigators and how can they improve integration of care? Key messages • The patient navigator role originated in the USA. It is designed to support patients in finding their way through health and social care systems, and to help them overcome barriers to accessing services. • Although evidence on the effectiveness of patient navigator programmes is limited, available studies indicate that they can contribute to improving access and continuity of care, seemingly offering a promising approach to better integration of care. • There are a number of patient navigator initiatives in Europe, albeit with varying levels of implementation. Both these and the USA experience offer opportunities for countries to learn from each other. • Existing patient navigator programmes typically focus on: o cancer care, where they help patients to move through the entire care continuum, from prevention to survivorship o transitional care, where they centre on helping (often older) patients to move between various settings (e.g. hospital and home) or sectors (e.g. health and social care) o care for vulnerable and disadvantaged populations, such as migrants, ethnic minorities, homeless or uninsured persons, where they can facilitate early detection of diseases and access to care. • Patient navigators are an example of a skill-mix innovation, whereby new tasks or ways of working are implemented. Navigators come from different backgrounds: they can be qualified health professionals, such as nurses or social workers, or trained lay persons, often recruited from the community that is being targeted. • Key roles of the patient navigators depend on their skills and experience. Typical tasks might include identifying individual needs and barriers to care, educating patients and communities, and linking patients with different care providers. Professional navigators may carry out more advanced (including clinical) tasks. • Policy-makers interested in introducing patient navigator programmes should consider macro-, meso- and micro- level factors, all of which will influence implementation. • Key issues to address include: developing appropriate educational standards; securing support from key stakeholders; putting in place long-term funding to ensure the sustainability of patient navigator programmes. PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 5 6Policy brief PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 6 7What are patient navigators and how can they improve integration of care? Executive summary Why patient navigators? The majority of countries in Europe are facing rising rates of chronic diseases, long-term conditions and multimorbidity, with patients’ health care needs becoming increasingly diverse and complex. As a result, patients may require various types of service, including health, social care and community services from different providers. Patient navigators have been introduced in some countries, usually on a small scale, with the aims of: helping patients to ‘navigate’ through the complexity of care and to overcome any barriers; enabling their timely access to the health and social care services they need; and – through these – contributing to better integration of care. What do patient navigators do and who can perform this role? Patient navigators may perform various tasks depending on the country, setting, the patients they serve, and their own professional level and background. Some typical tasks include: identifying individual needs and barriers to care; educating patients and entire communities; linking patients with different care providers; making appointments and setting reminders. Most patient navigators have face-to-face contact with the patient, but remote contact via phone or video can also be used, with telemonitoring becoming particularly relevant since the outbreak of the SARS-Cov-2 (COVID-19) pandemic. Both health and care professionals (including, for example, nurses, social workers and physician assistants) and lay persons (including, for example, community workers and former cancer patients) can be recruited as patient navigators. There is wide diversity across countries and settings with regard to who performs this role. The evidence to date has been limited as to the exact tasks and activities performed by patient navigators from different backgrounds. Where are patient navigators used? Patient navigator programmes first emerged in the USA in the 1990s. Since then, they have been introduced in other countries in Europe and beyond, with initiatives targeting different settings and patient groups, and achieving varying degrees of implementation. This policy brief identified three main areas where patient navigators have been used: • Cancer care: Patient navigators were first used in cancer care in the USA with the aim of addressing access barriers to health care services. Existing programmes target patients with different types of cancer (e.g. breast, cervical, colorectal) across the entire care continuum, from prevention (to increase the uptake of screening), throughout treatment and on to survivorship. Both lay and qualified health care professionals (e.g. nurses) provide cancer navigation. While these programmes are firmly rooted in the USA, pilot projects in Germany and France show that patient navigator programmes are becoming more popular in other countries too, with some that focus on remote care provision introduced during the COVID-19 pandemic. • Transitional care: Patient navigators have increasingly been implemented for patients suffering from various single and multiple chronic conditions. These patients repeatedly have to transition between inpatient and ambulatory care, as well as between different providers, and often need support in coordinating their care. Patient navigators can facilitate effective transitions (e.g. older patients transitioning from hospital to home, young patients transitioning from paediatric to adult care) and can reduce hospital readmissions. Most patient navigator programmes in transitional care employ health care professionals, predominantly nurses, who have both the clinical expertise and system experience to enable them to perform advanced tasks when navigating high-needs patients through their care paths. • Services targeted at vulnerable and socially disadvantaged patients: Most patient navigator programmes address patients with specific needs or with a certain level of vulnerability. This includes patients of low socioeconomic status, with limited health literacy, persons without insurance (in the USA), or from ethnic minority and migrant communities. Patient navigator programmes in cancer care often focus on addressing health inequalities but this is the focus of other programmes too, such as those targeting human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients. The aim of these programmes is to increase access to health services for hard-to-reach groups. Patient navigators may engage in outreach activities (e.g. by educating and involving communities) and in building bridges between communities and service providers (e.g. through language and cultural translations). How effective are patient navigator programmes? Overall, patient navigator programmes are associated with positive outcomes in terms of increasing access to care, including reducing waiting times for diagnosis and treatment, and increasing uptake of screening. Patient navigators have also been found to contribute to improving care coordination and continuity of care, as shown by: improved referrals and adherence to follow-up appointments; higher completion of screening and diagnostics; and reduced readmission and emergency visit rates. These results should be interpreted with caution though as evidence remains scarce, particularly outside the USA, and outcomes are highly context dependent. PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 7 8Policy brief Which facilitators and barriers should be considered when implementing a patient navigator programme? The specific context and settings of the intended programme, as well as its overall aims, should be taken into account when considering the implementation of a patient navigator programme. This means identifying the desired profile and scope of tasks of the patient navigators, including how they will interact and collaborate with other health professionals. Implementation barriers can be encountered at the macro, meso and micro levels. Such barriers might, for instance, result from specific policies and regulatory mechanisms around the scope of practice and minimum level of educational background required – factors that are key to ensuring uniformity, quality and minimum professional standards in patient navigator programmes. Securing sustainable funding can also be a problem, despite some evidence on the cost-effectiveness of patient navigator programmes. Funding for patient navigator roles often comes from short-term government funding or private grants from charities and foundations, and obtaining long- term funding has often proved to be a major challenge to implementation. Other important barriers to the implementation of patient navigators include: weak (or no) institutional arrangements and general infrastructure to support team collaboration; lack of buy-in from important stakeholders such as health professionals; and – at the micro level – deficiencies in communication and lack of effective working relationships across and within different settings, teams and providers. These should all be addressed to ensure the effective and sustainable implementation of such programmes. PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 8 9What are patient navigators and how can they improve integration of care? Introduction Strengthening coordination of care is crucial to delivering high-quality and person-centred care (Nolte, Knai & Saltman, 2014; Roland & Nolte, 2014; Nolte & Knai, 2015). With a growing number of people affected by chronic diseases, long-term conditions and multimorbidity, patients’ health care needs have not only increased but also become more diverse and complex. Patients require not just various types of health services but also social care and community services (OECD, 2019). This in turn requires engagement and collaboration across a range of different providers and settings, as well as a fit-for-purpose workforce (Hopman, Schellevis & Rijken, 2015; Dussault & Buchan, 2018). Faced with these challenges, health systems require effective solutions to meet the needs of their populations and to ensure delivery of quality care services. Implementation of integrated care models is one strategy to address major health systems challenges, such as the growing demand for health and social services (WHO, 2016). This can be supported by the adoption of new roles and tasks undertaken by various health professionals or lay workers (Looman et al., 2021). Among these new roles and tasks, patient navigators have emerged as a promising innovation to help patients navigate the complexities of the health care system, thus facilitating the integration of care. This policy brief aims to inform policy-makers about the roles performed by patient navigators in different countries and how they can contribute to improving the integration of care. In the following section, we start by outlining the key features of the patient navigator role, before presenting more detailed descriptions of selected patient navigator programmes from different countries. We then draw on work conducted in the context of a European Observatory on Health Systems and Policies’ study on skill-mix (see Box 1) to summarize current evidence on the impact of patient navigators on patient and broader health systems outcomes. In the final section we highlight important levers and possible barriers to implementing patient navigators and discuss the implications for policy and practice. Box 1: Methods This policy brief draws mainly on two publications, both of which were based on an overview of reviews, following a prespecified protocol (Maier et al., 2018): (1) a forthcoming study by the European Observatory on Health Systems and Policies on Skill-mix innovation, effectiveness and implementation (Maier et al., 2022); and (2) an article on The role of patient navigators in ambulatory care: Overview of reviews (Budde et al., 2021). Second, a comprehensive search of grey literature, including websites, was performed to identify case studies on patient navigator programmes in different countries. This was supplemented by material from relevant research projects, such as SELFIE 2020 (Sustainable intEgrated care modeLs for multi-morbidity: delivery, FInancing and performance) and ICARE4EU (Innovating care for people with multiple chronic conditions in Europe). Patient navigators: roles, tasks and examples of patient navigator programmes Roles and tasks Why patient navigators? Integrated care concepts have received considerable attention from policy-makers and have been promoted as a strategy to achieve accessible and quality care services (Valentijn et al., 2013) (see Box 2). Yet, it is often unclear how best to implement such approaches, including which strategies have been pursued and with what results in terms of enabling care integration (Goodwin, 2017; Berntsen et al., 2018). New types of skill-mix innovations present an important approach to help facilitate different levels of integrated care (Winkelmann et al, in press). Skill-mix innovations change the status quo by modifying skills, roles and competencies within and between health professionals (Sibbald, Shen & McBride, 2004). Introducing new tasks and roles (not to be confused with introducing a new profession) is one type of skill-mix intervention. Box 2: How is integrated care defined in this policy brief? There are various definitions and conceptual frameworks of integrated care (Armitage et al., 2009). This policy brief defines integrated care as an approach “to provide coordinated, pro-active, person-centred, multidisciplinary care by two or more communicating and collaborating care providers. Providers may work at the same organisation or different organisations, either within the health care sector or across the health care, social care, or community care sectors (including informal care)” (Struckmann et al., 2018). Integration of care can take place at different levels. At the micro level, it is characterized by a person-focused care perspective, i.e. a focus on the individual needs of a person or of a defined population, which is meant to facilitate comprehensive, continuous and coordinated services. Rather than being disease-focused, a person- centred perspective considers the broader health context and encompasses a range of services, including social or community care. This may be particularly relevant for vulnerable and disadvantaged population groups whose needs span across different service areas. At the meso level, integration of care involves collaboration between professionals within and between organizations. At the macro level, it requires a holistic strategy involving health and social systems as a whole (Valentijn et al., 2013). Patient navigators are one example of a skill-mix innovation whereby a new role or new tasks are implemented. We are not aware of any patient navigator programme whereby an entirely new profession has been introduced. The primary focus of patient navigators is on the individual person’s level, i.e. the micro level. They consider the individual needs of a patient in order to match them with the right services and providers. Their main purpose is to navigate patients through the complexity of health care systems, helping them to access health services and overcome any access barriers (see Box 3). Moving beyond that to the meso level, patient navigators may collaborate with other care and social service providers who are involved in patients’ health. At the macro level, they can work with decision-makers to achieve system change, although this is rare (Doucet et al., 2019). POLICY BRIEF PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 9 10 Policy brief Box 3: Who are patient navigators? This policy brief defines ‘patient navigator’ as an individual whose role is to enable “timely movement of the individual patient through an often complex and fragmented health care system. Patient navigators can also serve to connect systems of care for individual patients by applying the core function of navigation, which is the elimination of barriers to timely care across all segments of the health care continuum” (Freeman, 2012). However, the literature shows that there is significant ambiguity around the definition of patient navigators as a new role as well as patient navigation as a new function. The role of a patient navigator is not always well defined and is sometimes also referred to as care navigators, community health workers, patient or case managers, or other. Patient navigation typically describes a function which can be undertaken by a qualified health care professional as a new component of their role, among multiple existing tasks (Kelly, Doucet & Luke, 2019; Reid, Doucet & Luke, 2020). Who can be a patient navigator? Various types of qualified health professional, including, but not limited to, nurses, social workers, physicians and physician assistants, can act as patient navigators. This role can also be performed by trained lay persons, including community workers and patients (e.g. former cancer patients) (Robinson-White et al., 2010; Glick et al., 2012; Roland et al., 2017; Kline, Rocque & Rohan, 2019; Reid, Doucet & Luke, 2020). Lay persons are often recruited from the communities targeted by a specific patient navigator programme as they are more likely to be trusted by and understand the needs of the local community, and can empower its population (National Academies of Sciences, Engineering, and Medicine, 2018). In most cases, lay workers working as patient navigators do so in close collaboration with trained professionals and are part of a multiprofessional team (Roland et al., 2017). What do patient navigators do? Tasks performed by patient navigators reflect the heterogeneity of patients’ needs, the context in which care is given (e.g. transitional care) and their own background and qualifications (Wells et al., 2018; Reid, Doucet & Luke, 2020). For example, professional patient navigators such as nurses usually carry out more advanced tasks compared to lay health navigators, which is linked to their clinical expertise, skills and system experience. Their existing knowledge of the health system allows them to navigate complex care processes and coordinate with different providers. Lay navigators may approach patients on a more personal level and are often seen as equals, particularly when coming from the same community and sharing similar experiences (Reid, Doucet & Luke, 2020). Common tasks performed by patient navigators are listed in Box 4. Patient navigators typically have face-to-face contact with the patient, but they can also set up appointments or reminders via telephone or video (McBrien et al., 2018). During the COVID-19 crisis, telemonitoring has become particularly important within patient navigator programmes, allowing patient navigators to continue serving their patients while avoiding the risk of infection (Nalley, 2020; Bigelow et al., 2021; Ferrua et al., 2021). Box 4: Key tasks performed by patient navigators • Identify individual needs for health and social care. • Identify individual barriers to accessing health and social services. • Link and coordinate between different levels of the health and social care systems. • Facilitate communication with different providers of health and social care services. • Facilitate referrals. • Assist with appointment scheduling and follow-up. • Set reminders (e.g. about upcoming appointments). • Support self-management. • Perform outreach activities. • Inform and educate patients and community members. • Educate and involve communities. • Translate and offer interpretation services. • Provide social and emotional support. • Assist with goal setting. • Link patients and clients to resources (social, financial, transport). Source: Authors, based on Desveaux et al. (2019) and McBrien et al. (2018). Examples of patient navigators across countries and settings Patient navigators originally emerged during the 1990s in the USA, starting in Harlem, New York, to address barriers encountered by underserved patients in cancer care (Freeman & Rodriguez, 2011). They have since expanded across different settings and countries (Peart et al., 2018), with some programmes well-established and others still in their piloting phases or implemented at regional level only. We have identified three main areas where patient navigators have been introduced across Organisation for Economic Co-operation and Development (OECD) countries: 1) cancer care; 2) transitional care; and 3) for vulnerable and disadvantaged patients. This section presents examples of patient navigator programmes from different countries, including Australia, Austria, Canada, France, Germany, the United Kingdom (UK) and the USA. Patient navigators in cancer care Ensuring high-quality services in cancer care presents several challenges, including access barriers for certain patient groups and difficulties in ensuring coordination of care across different providers and settings. These problems are reflected in health inequalities in cancer care that exist in many OECD countries (OECD, 2019). The positive impact of patient navigators on reducing disparities in cancer care has been well established in the PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 10 11 What are patient navigators and how can they improve integration of care? USA. This was recognized in the Patient Navigation Outreach and Chronic Disease Prevention Act passed in 2005 (H.R.1812-109th Congress 2005–2006). A funding mechanism was introduced to support research on the effectiveness of patient navigation programmes. Several policies have been introduced since then to help implement patient navigator programmes in cancer care. Most notably, in 2012, the American College of Surgeons’ Commission on Cancer required all health care facilities accredited by the Commission to have a patient navigation programme, and to put in place processes aimed at identifying and removing patients’ barriers to care in order to address existing health disparities in cancer care (Mercurio, 2016; Dixit, Rugo & Burke, 2021). Patient navigators in cancer care can provide their services across the entire continuum of cancer care, from prevention and early detection to treatment and survivorship (see Figure 1; National Academies of Sciences, Engineering, and Medicine, 2018). For example, the Patient Care Connect Program (PCCP) implemented by the University of Alabama in the USA recruited lay patient navigators to support patients throughout their entire pathway, from cancer diagnosis through survivorship and end-of-life care. The programme encompasses 12 cancer centres in five southern states and targets older Medicare patients (>65 years). The centres are located in both urban and rural regions. Patient navigators are required to have a minimum of a bachelor’s degree, but they are not licensed health care professionals. They undergo predefined training that has been developed and is delivered by a multidisciplinary team. The PCCP team also includes a registered nurse site manager, who supervises the team of lay navigators and is responsible for any clinical issues. Medical directors of cancer centres acting as site champions engage with the care teams to ensure that physicians and staff members integrate lay navigators within their teams. The evaluation of the programme showed high rates of patient satisfaction, with 83% of patients satisfied or very satisfied and 89.5% willing to recommend the programme to others (Rocque et al., 2016). Some patient navigation programmes are designed for cancer survivors and their families and address physical, emotional and practical concerns that patients encounter after treatment. The Livestrong Cancer Navigation Programme in Austin, Texas is such an example. Patient navigators start with a needs assessment and identify individual challenges of each cancer survivor and will then help patients to overcome these issues in a timely manner. Referrals to other organizations and facilitation of consulting with other providers are among the main tasks that patient navigators undertake (Livestrong, 2021). In 2015, the programme was evaluated to assess how well cancer survivors managed their health and practical concerns, and how the survivorship navigation contributed to self-efficacy. Results showed that self-efficacy of cancer survivors who participated in the programme increased, while their concerns and emotional distress decreased. Participating survivors also reported higher satisfaction (Hemingway et al., 2015; Treiman et al., 2015). Figure 1: Patient navigators in cancer care: across the care continuum Source: Authors, based on Freeman & Rodriguez Patient Navigators Prevention Early detection Diagnosis Treatment Survivorship PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 11 12 Policy brief Various cancer patient navigator programmes have also been developed in European and other OECD countries. In Germany, there are around 38 different pilot programmes introducing patient navigators either as the main intervention or one component among several interventions. They target patients across various settings, including cancer care (BMC Managed Care, 2021). Most of these cancer navigator programmes are implemented as pilots at the level of federal states. One example is the Onkolotse (German abbreviation of ‘oncology navigator’) programme in the federal state of Saxony, where cancer navigators join the patient at the time of cancer diagnosis and collaborate closely with medical staff. Trained nurses, other health care professionals, counsellors, psychologists and social workers who specialize in oncology can all work as cancer navigators (‘Onkolotsen’). Their training encompasses seven modules and more than 130 hours of tuition on cancer care relevant topics (e.g. service structures, processes and appropriate contact persons). They act as a permanent contact person to patients and their families throughout the cancer treatment and aftercare, guiding patients through the system of different providers in the inpatient and outpatient settings. Their tasks include patient education to facilitate self- management (Porzig et al., 2018). Although patient navigator programmes are becoming more popular in Germany, their widespread implementation is still limited. Evaluations from randomized studies looking at the effectiveness and economic impact are needed to increase acceptance but are currently missing (Porzig et al., 2018). The current COVID-19 pandemic has exacerbated health system challenges, particularly in cancer care. Not only are cancer patients at higher risk of developing serious complications from COVID infections, they have also encountered delays in surgery and treatment. Many support programmes for cancer patients were paused, increasing barriers to effective cancer care (Hanna et al., 2020). Nurse navigators were one answer to address the impact of COVID-19 on cancer care (Nalley, 2020; Bigelow et al., 2021; Ferrua et al., 2021). One example is the CAPRI (abbreviation for CAncérologie, Parcours, Région, Ile de France – Oncology Pathway in the Ile de France Region) COVID programme in France, which uses oncology nurses as patient navigators to ensure that patients continue to receive adequate health and social services. The CAPRI-COVID intervention was launched in March 2020 at the coordinating outpatient care unit of the Gustave Roussy Cancer Centre in Paris. This could be implemented rapidly because the centre already had a unit where nurses had been providing patient navigation services since 2016 and therefore had the necessary skills and experiences to monitor patients remotely. Nine nurses with a French nursing degree as well as a dedicated postgraduate diploma specializing in oncology act as patient navigators, guiding patients who are isolating at home due to a COVID-19 diagnosis through their cancer treatment. They use telemonitoring to provide remote assistance with organizing visits to different service providers and supervise transition between providers. They also educate patients on COVID-19 prevention measures and identify needs relating to home assistance. If patients’ symptoms worsen during their quarantine, the navigators consult an emergency physician (Ferrua et al., 2021). The CAPRI-COVID programme has shown positive effects. It has enabled patients to remain at home while following their cancer care pathways and has contributed to a reduction in unnecessary visits to health care facilities as well as to the early identification of special needs and vulnerabilities (Ferrua et al., 2021). Patient navigators in transitional care Moving between different ambulatory services and between out- and inpatient care may introduce different barriers to access and a high degree of care fragmentation (WHO, 2016). Transitions between multiple providers across different settings are challenging for many patients, particularly for older persons with multiple chronic conditions (Manderson et al., 2012; Balaban et al., 2015), but also for young patients with complex needs (Doucet et al., 2019; Samuel et al., 2019). Patient navigation has thus also become popular for such patients (McBrien et al., 2018). Using patient navigators to support care integration during transitional periods may be a strategy to overcome these challenges and can reduce hospital admissions or readmissions, facilitate discharge processes and improve access and quality of care (Manderson et al., 2012). Most patient navigator programmes for older persons with chronic conditions focus on supporting them during transitions, e.g. between hospital and home, or between health, long-term and social care, with the aim of keeping individuals independent for as long as possible. They employ health care professionals such as nurses, often with advanced practice expertise, whose main tasks relate to the discharge process, including care planning and coordination, phone support and home visits, with the aim of enabling access to the services and providers needed during transitional periods (Manderson et al., 2012). In the UK, the Salford Together programme targets older patients with multiple chronic conditions, with the aim of providing more integrated care services and reducing hospital admissions. As part of the programme, a centre of contact was established to help patients access the support they need after hospital discharge and to provide a 30-days follow-up (SELFIE, 2016). Today, ‘care navigators’ facilitate social prescribing as one intervention among several other components within the programme. The aims of social prescribing are to keep patients in their community as long as possible and to link them with local services (for more details on social prescribing, see Winkelmann et al., in press). The care navigators act as gatekeepers and ensure that patients are referred to the right services (Salford Primary Care Together, 2018). Nurse navigators can provide critical navigation services to patients in need of a high degree of comprehensive and coordinated care (Harvey et al., 2019). In Australia, the Queensland Government established the first nurse navigator programme in 2015 as part of its Nursing Guarantee policy. The programme committed to employing 400 nurse navigators across Queensland over a period of four years and the role became permanent in 2019 (Queensland Government, 2019a). PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 12 13 What are patient navigators and how can they improve integration of care? The aim of the Queensland nurse navigator programme is to reduce hospital readmissions through navigating patients from the point of referral from the primary care provider, throughout hospital care and back home. The navigators are senior registered nurses who support patients with multiple chronic conditions and complex needs (Queensland Government, 2019b). They have clinical expertise and in- depth knowledge of the health system, which allows them to identify what services high-needs patients require before facilitating access to the right health and social services. Nurse navigators function as central contact and coordination point for the patient and work with a multidisciplinary team. They provide patient education, support self-management, develop care plans and coordinate care, which includes scheduling appointments and liaising with different service providers and sectors to achieve patient-centred care. Evaluation of the programme started in 2018 and is still ongoing (Harvey et al., 2019). A progress report identified first positive results of the evaluation, indicating cost savings through the reduction of hospital readmissions, as well as improved patient well-being and self-management (Harvey et al., 2019). In Canada, patient navigator programmes frequently focus on patients with complex needs who need additional health, social and educational services (Reid, Doucet & Luke, 2020). For example, the Centre for Research in Integrated Care at the University of New Brunswick established the NaviCare/SoinsNavi programme in 2017 in the province of New Brunswick to facilitate transitions from paediatric to adult care for young patients (Doucet et al., 2019). Young patients are often unprepared for the transition to adult care and can face several challenges during the transition process, requiring a high degree of care coordination (Reiss & Gibson, 2002; Kaufman et al., 2007; Samuel et al., 2019). To support these patients, the NaviCare/SoinsNavi recruited two bilingual patient navigators (French and English), one lay worker and a nurse. These patient navigators first identify barriers and individual needs, then reach out to service providers and community services to meet these identified needs. They have regular contact and build partnerships with the different services and stakeholders they refer to. Patient navigators work on a one-to-one basis with the families. The patient is first assessed by the professional navigator and then the lay navigator takes over, depending on the client’s needs. A Family Advisory Council is composed of seven parents who have experience with children with complex needs. They continuously advise patient navigators on the complex needs of children and adolescents. The NaviCare/SoinsNavi team is also actively reaching out to other patient navigator programmes in Canada to share lessons learned and best practices. After its first two and a half years, the programme had assisted more than 160 families (Doucet et al., 2019). In Germany, several pilot projects funded by the innovation fund (‘Innovationsfonds’ – see section on funding) have introduced patient navigators in transitional care, mostly supporting patients transitioning from hospital to home (IGES, 2018). Projects such as Stroke OWL (OWL is an abbreviation for Ostwestfalen-Lippe, a region in Germany; see Box 7) or Cardiolotse (abbreviation for cardiology navigator in German) show how transitions can effectively be supported by patient navigators for a specific patient group with complex needs. The latter targets patients with chronic heart diseases, who transition from hospital to ambulatory care in Berlin. Only patients from one sickness fund and who are being treated in one of the specified clinics can access the programme. The programme employs 11 patient navigators who are medical assistants or nurses, and will be the patient’s primary contact person for 12 months after hospital discharge. They have regular phone contact with the patient, ensure adherence to necessary follow-up care, and assist with appointment scheduling or finding rehabilitation services. Patient navigators undergo a two-month training to obtain their qualification. Training is delivered by cardiologists, nurses who are specialized in cardiology, and other specialists, with training modules including communication training, medical education, data management and coaching (Cardiolotse, 2021). Patient navigators for vulnerable and disadvantaged patients Vulnerable and socially disadvantaged persons may face large barriers when accessing or navigating through health care services. Consequently, they may experience higher rates of disease, reduced access and fewer treatment options (Natale-Pareira et al., 2011). Most patient navigator programmes focusing on vulnerable and disadvantaged patients either target a specific vulnerable community, such as ethnic minorities and/or migrants by offering language-tailored services (Shommu et al., 2016), homeless persons (Sarango et al., 2017) or uninsured persons (Bush, Kaufman & Shackleford, 2017), or address a specific disease that disproportionally affects vulnerable and disadvantaged communities, such as those with HIV/AIDS (McBrien et al., 2018). The early detection of cancer is an important intervention to prevent serious health impacts and improve survival rates (Huo et al., 2014; Redaniel et al., 2014). However, screening services are particularly underutilized among vulnerable patient groups as they encounter the largest barriers when accessing primary care services (Freeman, 2012). These barriers can relate to language, location, financial or structural factors (Waisel, 2013). Patient navigator programmes may address patients and communities with high needs and who are at risk for delayed cancer care or hardest to reach. Patient navigators targeting vulnerable groups may approach patients through outreach activities, set up structured phone calls, or meet face to face to identify individual barriers, for example to cancer screening services (De Mil et al., 2018). Through continuous follow-up, appointments and home visits, they help to prevent delays in follow-up after screening and enable early diagnosis and treatment initiation (Robinson-White et al., 2010; Glick et al., 2012; Bush, Kaufman & Shackleford, 2017). Lay patient navigators who are recruited from the communities can function as a bridge between the patient and the health system (National Academies of Sciences, Engineering, and Medicine, 2018). In the German city of Stuttgart, an ongoing patient navigator programme aims to educate migrant communities, through seminars in the PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 13 14 Policy brief community. The seminars cover topics such as healthy lifestyles, maternal health, long-term care, prevention of drug abuse; they also provide relevant information about the health care system in Germany. Twenty-five volunteers from migrant communities were recruited and trained as patient navigators. They speak the same language and have the same cultural background as the communities they serve. The patient navigators receive training consisting of two modules, the first of which provides all of them with a basic knowledge about the health care system as well as introducing them to the area of health promotion and prevention. In the second module, participants can choose one subject area on which to focus. The project started in 2018 and will be funded until the end of 2022 (vdek, 2019). Similar programmes have been initiated in Austria, including MiMi (Mit MigrantInnen für MigrantInnen – with migrants for migrants) in Vienna and SALUS (Salzburger Gesundheitslotsinnen – Salzburg’s health navigators) in Salzburg. The latter was initiated in 2014 and funded until 2016. Migrant women were trained to become patient navigators focusing on health promotion and prevention. The participatory approach, which included experts from migrant communities as well as health professionals to develop the programme and training for the patient navigators, was critical to its implementation. In 2016, the programme was awarded the title of ‘Best practice example’ in the region of Salzburg (Fund for Healthy Austria, 2017). Some programmes are aimed at increasing access to HIV/AIDS prevention services, treatment and care (Bradford, Coleman & Cunningham, 2007; McBrien et al., 2018; Mizuno et al., 2018; Shade et al., 2021). These usually target persons with a history of incarceration, AIDS diagnosis and substance use or mental health problems. Patient navigators in HIV/AIDS treatment and care accompany patients to appointments, coordinate these appointments, provide education and refer to health services. Most of these programmes are in the USA (McBrien et al., 2018; Mizuno et al., 2018). The HoMBReS (Hombres Manteniendo Bienestar y Relaciones Saludables – Men Maintaining Wellbeing and Healthy Relationships) and HoMBReS Por un Cambio (Men for Change) intervention is a community-level programme that addresses HIV/AIDS disparities among Hispanic men in the USA. Lay health workers (called ‘navegantes’), who belong to existing social networks such as recreational soccer teams, are recruited to promote safe use of condoms and to increase screenings for sexually transmitted diseases (Rhodes et al., 2016). Introducing lay advisors in this specific setting presents an important strategy to reach the population as they are members of the community themselves and are trusted within these social networks. Originally introduced in 2012, the programme expanded to address other population groups who may be at higher risk of exposure to HIV/AIDS, such as men who have sex with men or transgender persons. The programme was included in the Centers for Disease Control and Prevention (CDC)’s Compendium of Evidence-based Behavioural Interventions and Best Practices for HIV Prevention (Rhodes et al., 2016). There is also literature on patient navigation that focuses on vulnerable patients with other chronic conditions, including diabetes, cardiovascular diseases or multiple chronic diseases. Most of these studies come from the USA and have assessed patient navigator programmes for patients with low socioeconomic status or without insurance, or ethnic minority patients who have one or multiple chronic conditions. However, the evidence on their effectiveness considering patient and health system outcomes is limited (McBrien et al., 2018). PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 14 15 What are patient navigators and how can they improve integration of care? How effective are patient navigator programmes? This section presents an overview of the evidence on the effectiveness of patient navigator programmes across countries. The synthesis is based on an overview of systematic reviews on patient navigators in ambulatory care (Budde et al., 2021); this was conducted as part of a larger European Observatory on Health System and Policies’ study on skill-mix innovations (Maier et al., 2022). The systematic reviews identified by an overview of reviews (Budde et al., 2021) covered individual studies mostly from the USA and Canada, followed by studies from European countries (e.g. Austria, Germany, UK) and individual studies from Asia (e.g. Republic of Korea) and South Africa. Systematic reviews covered patients with cancer or other chronic conditions and multimorbidity, and patients in transitional care. Nine out of the 11 systematic reviews included patient navigator programmes primarily targeted at vulnerable and socially disadvantaged patient groups. Systematic reviews analysing patient navigator interventions primarily focus on assessing health system outcomes, such as access to care services, coordination of care, continuity of care or effectiveness. Some studies also report on patients’ clinical outcomes. Evidence on professional-related outcomes is largely missing (Budde et al., 2021) (other limitations are presented in Box 5). Box 5: Limitations of the evidence on the effectiveness of patient navigator programmes The evidence identified by the overview of reviews has several limita- tions. First, most of the available evidence on patient navigators came from the USA and focused on cancer care, and there was very limited evidence from European countries. Since outcomes at the system level are highly context dependent, generalizability of the out- comes to other countries and settings is limited. Second, the quality of the systematic reviews on patient navigators was generally low. There were only a few medium- to high-quality studies and meta analyses. Moreover, there was limited reporting on the training and qualification of patient navigators in the included studies, including lack of a detailed description of professional backgrounds or the length of training before undertaking patient navigation roles. Infor- mation about the scope of practice across different settings is also limited (Budde et al., 2021). Table 1 summarizes the key findings from the overview of reviews. At the system level, eight reviews showed improved access to health services for patients in the cancer setting. Two reviews reported reduced waiting times, one reported earlier treatment initiation, one shorter time to diagnosis and six studies demonstrated increased cancer screening updates. Five systematic reviews reported positive effects of patient navigation on care coordination and continuity of care, including improved referrals, adherence to diagnostic follow- ups and completion of screening and diagnostics. Effectiveness was demonstrated by reduced emergency department visits and readmission rates in two reviews for patients in transitional care. Three studies showed positive effects on patient-related outcomes, including mortality rates, clinical outcomes and quality of life (Budde et al., 2021). DIMENSIONS OUTCOME (SOURCE) COUNTRIES Access • Reduced waiting times and improved appointment scheduling with specialists (Robinson-White et al., 2010; Bush, Kaufman & Shackleford, 2017) • Earlier treatment and treatment initiation (Bush, Kaufman & Shackleford, 2017) • Shorter time to diagnosis and appointments (Ranaghan et al., 2016) • Increased screening uptake (Robinson-White et al., 2010; Glick et al., 2012; Genoff et al., 2016; Ali-Faisal et al., 2017; Roland et al., 2017; McBrien et al., 2018) Care coordination / continuity of care • Improved adherence to diagnostic follow-ups (Bush, Kaufman & Shackleford, 2017; McBrien et al., 2018) • Improved referrals (Roland et al., 2017) • Improved completion of screening and diagnostics (Glick et al., 2012; Roland et al., 2017) • Improved referrals or disease management, and positive effects on communication with pa- tients and caregivers (Manderson et al., 2012) Table 1: Evidence on patient navigator programmes • CA, USA • USA • CA, USA, ZA • AU, CA, USA • CA, FR, USA • AU, CA, USA • CA, KR, USA • BD, CA, USA Continued on next page >>> PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 15 16 Policy brief DIMENSIONS OUTCOME (SOURCE) COUNTRIES Effectiveness • Lower readmission rates (Manderson et al., 2012; Le Berre at al., 2017) • Fewer emergency department visits (Le Berre et al., 2017) • AT, AU, BE, CA, CH, CN, DE, DK, ES, FI, HK, IR, IT, JP, NL, NZ, SE, SL, UK, USA Health outcomes • Reduced mortality rates (Le Berre et al., 2017; McBrien et al., 2018) • Improved clinical outcomes (Manderson et al., 2012 McBrien et al., 2018; Desveaux et al., 2019) • Improved quality of life (Manderson et al., 2012) • AT, AU, BE, CA, CH, CN, DE, DK, ES, FI, HK, IR, IT, JP, NL, NZ, SE, SL, UK, USA, ZA • CA, USA, ZA • AU, CA, USA >>> Continued from previous page Country abbreviations: AT=Austria, AU=Australia, BD=Bangladesh, BE=Belgium, CA=Canada, CH=Switzerland, CN=China, DE=Germany, DK=Denmark, ES=Spain, FI=Finland, FR=France, HK=Hong Kong, IR=Iran, IT=Italy, JP=Japan, KR=Republic of Korea, NL=The Netherlands, NZ=New Zealand, SE=Sweden, SL=Slovenia, UK=United Kingdom, USA=United States of America, ZA=South Africa Source: Budde et al. (2021). PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 16 17 What are patient navigators and how can they improve integration of care? What are the levers and barriers for the imple- mentation of patient navigator programmes? Implementation of innovative workforce changes within existing health care structures is complex (Valaitis et al., 2017; Nolte, 2018; Nolte & Groenewegen, 2021). This section presents six main themes that emerge from the literature in relation to barriers and facilitators of the implementation of patient navigator programmes. At the macro level, these themes are policy, laws and professional regulation; education and training; and funding. At the meso level, they are organizational frameworks; and support and leadership. At the micro level, there is communication and working relationships (Figure 2). Figure 2: Factors to be considered for the implementation of patient navigator programmes Source: Source: Authors, based on Bourgeault et al. (2008); Maier et al. (2022); Scarpetti et al. (in press). MESO-LEVEL MACRO-LEVEL MICRO-LEVEL Policy, laws, professional regulation Funding Education and training Support and leadership Communication and working relationships Organizational frameworks PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 17 18 Policy brief Macro-level factors Policy, laws and professional regulation Policies on skill-mix and changes to regulatory mechanisms can act as either barriers or facilitators to the uptake of skill-mix innovations (Delamaire & Lafortune, 2010; Maier, Aiken & Busse, 2017). Clear definitions of the scope of practice of patient navigators can be a facilitator to successful implementation, but a barrier if not in place (Valaitis et al., 2017). In the USA, patient navigation has been included in health policies, accreditation standards and guidelines from professional organizations. In addition, the American College of Surgeons’ Commission on Cancer included patient navigation as a required standard for cancer programme accreditation in 2012 and in 2014, and the 2014 standards set by the National Accreditation Programme for Breast Centers require patient navigator processes to be in place. Both standards state that patient navigation may be provided by qualified professionals or trained lay persons. This is supported by joint position statements issued by professional organizations such as the Oncology Nursing Society, Association of Oncology Social Work and National Association of Social Workers (Ustjanauskas et al., 2015). Education and training The alignment of education and training is critical to ensure uniformity and a minimum educational and professional standard for patient navigators (Ustjanauskas et al., 2015; Kokorelias et al., 2021). Patient navigators perform different tasks, depending on whether they are lay persons or health care professionals. Within the group of health care professionals, educational backgrounds also vary considerably. Hence, it is important to agree on minimum standards of competencies, skills and knowledge across the professions, as well as between health professionals and lay workers (Ustjanauskas et al., 2015). Linking lay navigators to supervisors or qualified health care professionals has been described as a crucial factor in supporting them to perform their tasks (Hendren et al., 2012; Ustjanauskas et al., 2015; Guo et al., 2019; Kokorelias et al., 2021). In the USA, efforts have begun to develop standardized training programmes that provide training to different patient navigator programmes, such as those led by the Harold P. Freeman Patient Navigation Institute and the Patient Navigator Training Collaborative in Colorado (Ustjanauskas et al., 2015; see Box 6). Continuing professional development (CPD) ensures that patient navigators maintain and develop their competencies in line with the needs of the patients and communities they serve (Valaitis et al., 2017). Box 6: Patient navigator training programmes in the USA The Patient Navigator Training Collaborative in Colorado offers stan- dardized patient navigator training to new and experienced patient navigators from different professional backgrounds and provides free information material online. The course length varies, depending on the patient navigator’s existing experience. All participants receive a certificate of completion. While some of the courses are provided on- line, training can also be offered on site to meet an organization’s specific needs. Skills learned during the course include professional conduct, health promotion, motivational interviewing, communica- tion techniques, strategies to improve self-care and learn to over- come challenges, among others (Patient Navigator Training Collaborative, 2021). Another example is the training programme developed by the Harold P. Freeman (HPF) Patient Navigation Institute, located in New York City. Persons from various backgrounds can attend the programme, including lay workers and qualified health care professionals (HPF In- stitute, 2021). The programme comprises intensive two-day training, encompassing 10 theory-based modules, a practical module (interac- tion with patients), and case studies. Although the training curricu- lum is standardized and focuses on cancer care as the primary setting, it can be tailored to meet the needs of other programmes with different target populations. Lack of tailoring to the participants’ professional background and existing expertise may be an important drawback of this programme. Upon completion, all participants re- ceive a certificate. To our knowledge, there has not as yet been any evaluation of this or similar training programmes. Funding Implementing a patient navigator programme has cost implications. Funding is required to cover salaries, education and training, transport and office supplies, among others. Total costs will depend on the number of patients covered by the programme, the educational background of the navigator and the scope of the role (e.g. full-time, part- time). Lay patient navigators usually receive lower salaries than professional health care staff, although lay staff may also require supervision from health professionals. Moreover, lay workers’ roles are naturally limited primarily to non- clinical tasks, whereas nurses and other health professionals can naturally provide more holistic and integrated services, including for high-needs patients. There are also considerations over the optimal payment model (e.g. on a fee-for-services basis, salary or other) and its appropriate level. This requires an assessment not only of the costs of the role, but also the effort, qualifications, knowledge and skills needed to take on patient navigator roles or tasks. Funding for patient navigator programmes frequently comes from short-term government funding or private grants from charities and foundations (Osundina, Garfield & Downer, 2019). In Germany, for example, the innovation fund has provided yearly funding of EUR 200 million until 2024 for various innovative projects leading to more integrated care or improved quality, including patient navigator programmes, which have the potential to be integrated into the statutory health care (see Box 7). Cardiolotse, another project funded by the innovation fund (see section on transitional care) received approximately EUR 4.6 million in funding for its three-year pilot phase. First results from an ongoing evaluation showed positive effects on hospital readmission rates (Cardiolotse, 2021). Programmes can receive funding for a period of three to four years (Innovationsausschuss, 2021). The key challenge for PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 18 19 What are patient navigators and how can they improve integration of care? programmes is thus to secure long-term funding beyond this initial period and ensure the integration into regular health care. This initiative has provided funding for several pilot patient navigator programmes. Box 7: Funding of a patient navigator programme in Germany STROKE OWL is a patient navigator programme that is led by the German stroke foundation (Deutsche Schlaganfall-Hilfe) and aims to provide more integrated care services for stroke patients (Galle, 2021). The programme received a total of EUR 7.1 million between 2017 and 2021, and is currently undergoing its final evaluation. STROKE OWL is committed to finding a financial framework that will allow all patients to benefit from the patient navigator programme in the future. Some sickness funds considered stroke patient navigators to have the potential to reduce the overall burden on the health care system and to optimize patients’ care pathways; six of them have agreed to finance STROKE OWL for a transition period after 2021. To that end they entered into selective contracts with stroke clinics, thus allowing their patients continued access to the programme beyond the initial funding period (Galle, 2021). Examples of long-term funding from national budgets or direct reimbursement through insurance plans are less common. This acts as a disincentive for providers to implement patient navigators and undermines the sustainability of such programmes over time. Some initiatives have been observed in the USA where patient navigators are reimbursed through insurance plans, using different types and combinations of payment mechanism, with each having specific benefits and limitations in terms of incentivizing implementation (see Box 8). Box 8: Payment mechanisms for patient navigator programmes in the USA In the USA, patient navigators are often reimbursed through a fee- for-service (FFS) model (such as is used, for example, for diabetes ed- ucators in diabetes self-management training through Medicare and Medicaid). FFS helps to provide long-term funding for navigators at a predefined level, thereby incentivizing uptake. However, it may require legal/regulatory changes to be put in place, and may restrict the types of navigator that can be reimbursed, limiting the use of lay navigators. Moreover, FFS has received long-standing criticism over promoting inefficient and unnecessary care. Other mechanisms have also been used, such as capitation where service providers receive a capitated payment to deliver services to a patient for a defined period of time. The Molina Healthcare of New Mexico, for example, negotiated a new billing code for its Integrated Primary Care and Community Support (I-PaCS) initiative to cover the costs of patient navigators, who were reimbursed under a capitated payment structure (Osundina, Garfield & Downer, 2019). Recent ini- tiatives have also seen increased use of more bundled payments. The CMS Medicare Oncology Care Model, for example, has adopted bun- dled payments, with per-beneficiary, per-month payments provided to cover the costs of the navigation service over a six-month period. The South Carolina Nurse–Family Partnership and Oregon Coordi- nated Care Organizations meanwhile use a pay-for-performance model to provide funding, dependent on the level of success and with an agreed capped maximum payment. It should be noted that bundled payments and pay for performance do not explicitly pay or reimburse for patient navigators, but instead act to incentivize the use of navigators if a provider determines that the role may help to achieve specific aims, such as improving care quality and coordination or health outcomes, while reducing costs. Context-specific evidence on the impact of navigators on different outcomes (including eco- nomic evaluations of cost implications) is therefore important to guide decisions on implementation (Osundina, Garfield & Downer, 2019). Meso-level factors Organizational frameworks Patient navigators operate in collaboration with other health care and social service providers. Therefore, institutional arrangements and resources that favour multiprofessional work and a general infrastructure that supports team collaboration and workflows can be levers for successful implementation (Kokorelias et al., 2021). A shared health IT system between patient navigators and other care providers is beneficial to allow access to informational material and data (Haque et al., 2019). Training for patient navigators will be required to ensure they are able to operate IT systems (Haque et al., 2019). Physical resources, such as room availability, can also act as a barrier or facilitator, and need to be considered in the overall organizational structure (Kokorelias et al., 2021). Partnership within and between organizations is another important factor that will determine the successful operation of a patient navigator programme. Strong relationships with community services and organizations facilitate the integration of health and social services for the population targeted by the patient navigator programme. The lack of such partnerships can be a major challenge, particularly when serving patients with complex needs (Valaitis et al., 2017). Support and leadership An important facilitating factor in increasing the uptake of patient navigator programmes is the role of leadership. Clinical leadership, considered as “the process of influencing point-of-care innovation and improvement in both organizational processes and individual care practices to achieve quality and safety of care outcomes” (Joseph & Huber, 2015), is also relevant for patient navigators. Supportive and visionary leaders can help promote and implement a needed change (Kokorelias et al., 2021). Programme leaders can be individual physicians, organizational leads or hospital administrators, but some programmes have an implementation committee that supervises the implementation process (Kokorelias et al., 2021). Certain stakeholders, such as physicians, clinical leaders, not-for-profit organizations, researchers and patients, can act as champions and encourage buy-in. They can support the implementation and help gain acceptance of patient navigators within their environment, for example PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 19 20 Policy brief by providing information within their specific organization, facility or community. Stakeholders acting as champions usually have several years’ experience of working with patient navigators (Kokorelias et al., 2021). Some professional groups can have a strong influence on lobbying for patient navigator initiatives (Valaitis et al., 2017; Kokorelias et al., 2021). Scepticism and poor understanding of the patient navigator role by various health care professionals, most notably physicians, can impact the uptake of such programmes (Valaitis et al., 2017). Micro-level factors Communication and working relationships At the micro level, team dynamics and communication are pivotal to the successful integration of patient navigators within the existing care pathway (Valaitis et al., 2017). For example, a rigid hierarchy and lack of communication can create bottlenecks to introducing new tasks and roles. Resistance from clinicians can be especially difficult and the reluctance to share care responsibilities with patient navigators may create a challenging environment for the navigators as they try to establish trust in their role (Friedman et al, 2016). Therefore, a good relationship between patient navigators and other health professionals is crucial (Pescheny, Pappas & Randhawa, 2018). Clear, effective and regular communication (e.g. in the form of regular meetings) among those involved in patient navigator programmes, as well as a shared understanding of professional boundaries and an appropriate supervisory structure will all help to integrate new roles into existing team dynamics. The engagement of clinical leads in regular meetings can increase the importance and value of the programme among the team (Valaitis et al., 2017). A more detailed overview of the levels and factors that can influence the uptake of skill-mix changes in general is provided by Winkelmann et al. (in press). PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 20 21 What are patient navigators and how can they improve integration of care? Conclusions Patient navigators may play an important role in overcoming the many challenges that patients face when moving across the health care system. Patient navigator programmes originated in the USA, mostly focusing on cancer care, but have gained popularity in Europe and other countries, both in cancer care and other settings. Several pilot programmes from different European countries have demonstrated that patient navigators can support better coordinated care for patients with various chronic conditions, particularly during transitional periods. Patient navigators have also been used to improve access to health and social services for vulnerable and disadvantaged groups. Examples from Germany and Austria demonstrate that patient navigator programmes can not only help to overcome barriers to care, but may also be used to increase prevention and health promotion in hard- to-reach communities. Existing programmes vary in terms of: context and setting; overall aims; and practical implementation, including choosing the right person for the job (e.g. lay or qualified health professional), with the necessary experience and training to meet both the programme’s purpose and the needs of the population, as well as to perform the various required activities and tasks. They are thus not easily transferable across countries. While short-term funding may help in initiating a programme and can support its evaluation, longer-term funding models are needed to ensure the sustainable integration of patient navigator programmes into health systems. Other important factors to consider include institutional arrangements that allow patient navigators to be integrated into existing teams and collaborative structures. Identifying individual champions in the clinical setting, or within patient communities, may increase acceptance and buy-in from stakeholders and contribute to the success of a programme. Finally, several pilot patient navigator programmes are currently undergoing evaluations or are yet to be evaluated. The results of these evaluations will be important to inform policy-making about their effectiveness and to further guide the implementation of such programmes. PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 21 22 Policy brief PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 22 23 What are patient navigators and how can they improve integration of care? REFERENCES Ali-Faisal S et al. (2017). The effectiveness of patient navigation to improve healthcare utilization outcomes: A meta-analysis of randomized controlled trials. Patient Education and Counseling, 100(3):436–448; doi.org/10.1016/j.pec.2016.10.014. Armitage GD et al. (2009). Health systems integration: State of the evidence. International Journal of Integrated Care, 9(2); doi.org/10.5334/ijic.316. Balaban RB et al. (2015). A patient navigator intervention to reduce hospital readmissions among high-risk safety-net patients: A randomized controlled trial. Journal of General Internal Medicine, 30(7):907–915; doi.org/10.1007/s11606-015-3185-x. Berntsen G et al. (2018). A person-centered integrated care quality framework, based on a qualitative study of patients’ evaluation of care in light of chronic care ideals. BMC Health Service Research, 18(479); doi.org/10.1186/s12913-018-3246-z. Bigelow SM et al. (2021). A new proactive virtual resource center navigation model identifies patient risk factors to reduce barriers to cancer care during the COVID-19 pandemic. Supportive Care in Cancer, 29(10):6069– 6077; doi.org/10.1007/s00520-021-06147-3. BMC Managed Care (2021). Gesundheitslotsen (https://www.bmcev.de/gesundheitslotsen, accessed 13 October 2021). Bourgeault IL et al. (2008). How can optimal skill mix be effectively implemented and why? Health Systems and Policy Analysis. Copenhagen, European Observatory on Health Systems and Policies (https://www.euro.who.int/en/health-topics/Health- systems/health-workforce/publications/2008/how-can-o ptimal-skill-mix-be-effectively-implemented-and-why, accessed 28 November 2021). Bradford JB, Coleman S, Cunningham W (2007). HIV System Navigation: An emerging model to improve HIV care access. AIDS Patient Care and STDs, 21(s1):S-49 (https://doi.org/10.1089/apc.2007.9987, accessed 28 November 2021). Budde H et al. (2021). The role of patient navigators in ambulatory care: Overview of reviews. BMC Health Services Research, 21(1166); doi.org/10.1186/s12913- 021-07140-6. Bush ML, Kaufman MR, Shackleford T (2017). Adherence in the cancer care setting: A systematic review of patient navigation to traverse barriers. Journal of Cancer Education, 33(6):1222–1229; doi.org/10.1007/s13187- 017-1235-2. Cardiolotse (2021). Projektsteckbrief (https://www.cardiolotse.de/ueber-uns, accessed 25 July 2021). Delamaire M, Lafortune G (2010). Nurses in advanced roles: A description and evaluation of experiences in 12 developed countries. OECD Health Working Papers, 54. Paris, OECD Publishing (https://doi.org/10.1787/5kmbrcfms5g7-en, accessed 28 November 2021). De Mil R et al. (2018). Cost-effectiveness analysis of a navigation program for colorectal cancer screening to reduce social health inequalities: A French cluster randomized controlled trial. Value in Health, 21(6):685– 691; doi.org/10.1016/j.jval.2017.09.020. Desveaux L et al. (2019). Mapping variation in intervention design: A systematic review to develop a program theory for patient navigator programs. Systematic Reviews, 8(8); doi.org/10.1186/s13643-018-0920-5. Dixit N, Rugo H, Burke NJ (2021). Navigating a path to equity in cancer care: The role of patient navigation. American Society of Clinical Oncology Educational Book, 41:3–10; doi.org/10.1200/edbk_100026. Doucet S et al. (2019). Patient navigation as an approach to improve the integration of care: The case of NaviCare/SoinsNavi. International Journal of Integrated Care, 19(4):7; doi.org/10.5334/ijic.4648. Dussault G, Buchan J (2018). Noncommunicable diseases and human resources for health: A workforce fit for purpose. In: Jakab M et al., eds. Health systems respond to noncommunicable diseases: Time for ambition. Copenhagen, WHO Regional Office for Europe, 182–198 (http://www.euro.who.int/en/publications/abstracts/healt h-systems-respond-to-noncommunicable-diseases-time- for-ambition-2018, accessed 28 November 2021). Ferrua M et al. (2021). Nurse navigators’ telemonitoring for cancer patients with COVID-19: A French case study. Supportive Care in Cancer, 29(8):4485–4492; doi.org/10.1007/s00520-020-05968-y. Freeman HP (2012). The origin, evolution, and principles of patient navigation. Cancer Epidemiology Biomarkers & Prevention, 21(10):1614–1617; doi.org/10.1158/1055- 9965.epi-12-0982. Freeman HP, Rodriguez RL (2011). History and principles of patient navigation. Cancer, 117(S15):3537–3540; doi.org/10.1002/cncr.26262. Friedman A et al. (2016). Facilitators and barriers to care coordination in patient-centered medical homes (PCMHs) from coordinators’ perspectives. Journal of the American Board of Family Medicine, 29(1):90–101; doi.org/10.3122/jabfm.2016.01.150175. Fund for Healthy Austria/Fonds Gesundes Österreich (2017). Salus – Salzburger Gesundheitslotsinnen (https://fgoe.org/projekt/salus-salzburger- gesundheitslotsinnen, accessed 19 October 2021). PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 23 24 Policy brief Galle G (2021). Patientenlotsen: Die Innovation in der Versorgung der 2020er-Jahre. Case Management, 3 (https://navicare.berlin/wp- content/uploads//G.Galle_Patientenlotsen_Case-Manage ment_Zeitschrift_3:97–136._September-2021.pdf, accessed 13 October 2021). Genoff MC et al. (2016). Navigating language barriers: A systematic review of patient navigators’ impact on cancer screening for limited English proficient patients. Journal of General Internal Medicine, 31(4):426–434; doi.org/10.1007/s11606-015-3572-3. Glick SB et al. (2012). Cervical cancer screening diagnosis and treatment interventions for racial and ethnic minorities: A systematic review. Journal of General Internal Medicine, 27(8):1016–1032; doi.org/10.1007/s11606-012-2052-2. Goodwin N (2017) Change management. In: Amelung V et al., eds. Handbook integrated care. Cham, Springer, 253–275 (https://doi.org/10.1007/978-3-319-56103- 5_16, accessed 28 November 2021). Guo Y et al. (2019). The Wellness Incentive and Navigation Intervention improved health-related quality of life among Medicaid enrollees: A randomized pragmatic clinical trial. Health Services Research, 54(6):1156–1165; doi.org/10.1111/1475-6773.13235. Hanna TP et al. (2020). Mortality due to cancer treatment delay: Systematic review and meta-analysis. BMJ, m4087; doi.org/10.1136/bmj.m4087. Harvey C et al. (2019). The evaluation of nurse navigators in chronic and complex care. Journal of Advanced Nursing, 75(8):1792–1804; doi.org/10.1111/jan.14041. Haque S et al. (2019). Use of health information technology among patient navigators in community health interventions. Perspectives in Health Information Management, 16(Spring):1a–12a. Hemingway B et al. (2015). Self-efficacy through survivorship: Results from the LIVESTRONG Cancer Navigation Study. Journal of Clinical Oncology, 33(15_suppl): 9577; doi.org/10.1200/jco.2015.33.15_suppl.9577. Hendren S et al. (2012). Randomized controlled trial of patient navigation for newly diagnosed cancer patients: Effects on quality of life. Cancer Epidemiology, Biomarkers and Prevention, 21(10):1682–1690; doi.org/10.1158/1055-9965.EPI-12-0537. Hopman P, Schellevis FG, Rijken M (2015). Health-related needs of people with multiple chronic diseases: Differences and underlying factors. Quality of Life Research, 25(3):651–660; doi.org/10.1007/s11136-015- 1102-8. HPF Institute (2021). The Patient Navigator Program. New York, Harold P. Freeman Institute (https://hpfreemanpni.org/the-program, accessed 13 October 2021). Huo Q et al. (2014). Delay in diagnosis and treatment of symptomatic breast cancer in China. Annals of Surgical Oncology, 22(3):883–888; doi.org/10.1245/s10434- 014-4076-9. IGES (2018). Studie zum Versorgungsmanagement durch Patientenlotsen. Berlin, IGES Institut (https://www.bundesgesundheitsministerium.de/fileadmi n/Dateien/5_Publikationen/Praevention/Berichte/IGES_Ve rsorgungsmanagement_durch_Patientenlotsen_042018. pdf, accessed 28 November 2021). Innovationsausschuss (2021). FAQ-Liste für Antragsteller zu den Förderbekanntmachungen des Innovationsausschusses beim Gemeinsamen Bundesausschuss. (https://innovationsfonds.g- ba.de/downloads/media/249/2021-03-17-FAQ.pdf, accessed 13 October 2021). Joseph ML, Huber DL (2015). Clinical leadership development and education for nurses: Prospects and opportunities. Journal of Healthcare Leadership, 7:55– 64; doi.org/10.2147/JHL.S68071. Kaufman M et al. (2007). Transition to adult care for youth with special health care needs. Paediatrics & Child Health, 12(9):785–788; doi.org/10.1093/pch/12.9.785. Kelly KJ, Doucet S, Luke A (2019). Exploring the roles, functions, and background of patient navigators and case managers: A scoping review. International Journal of Nursing Studies, 98:27–47; doi.org/10.1016/j.ijnurstu.2019.05.016. Kline RM, Rocque GB, Rohan EA (2019). Patient navigation in cancer: The business case to support clinical needs. Journal of Oncology Practice, 15(11):585–590; doi.org/10.1200/jop.19.00230. Kokorelias KM et al. (2021). Factors influencing the implementation of patient navigation programs for adults with complex needs: A scoping review of the literature. Health Services Insights, 14; doi.org/10.1177/11786329211033267. Le Berre M et al. (2017). Impact of transitional care services for chronically ill older patients: A systematic evidence review. Journal of the American Geriatrics Society, 65(7): 1597–1608; doi.org/10.1111/jgs.14828. Livestrong (2021). Livestrong cancer navigation services. Livestrong.org (https://www.livestrong.org/videos/livestrong-cancer- navigation-services, accessed 19 August 2021). Looman W et al. (2021). Drivers of successful implementation of integrated care for multi-morbidity: Mechanisms identified in 17 case studies from 8 European countries. Social Science & Medicine, 277; doi.org/10.1016/j.socscimed.2021.113728. Maier CB, Aiken LH, Busse R (2017). Nurses in advanced roles in primary care: Policy levers for implementation. OECD Health Working Papers, 98. Paris, OECD Publishing (https://doi.org/10.1787/a8756593-en, accessed 28 November 2021). PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 24 25 What are patient navigators and how can they improve integration of care? Maier CB et al. (2018). Overview of systematic reviews: Outcomes of health workforce skill-mix changes in primary and ambulatory care. National Institute for Health Research, PROSPERO (https://www.crd.york.ac.uk/prospero/display_record.php ?ID=CRD42018090272, accessed 5 March 2021). Maier CB et al. (2022). Implementing skill-mix changes: Lessons for policy and practice. In: Maier CB et al., eds. Skill-mix innovation, effectiveness and implementation: Improving primary and chronic care. Cambridge, Cambridge University Press (www.cambridge.org/9781009013758, accessed 28 November 2021). Manderson B et al. (2012). Navigation roles support chronically ill older adults through healthcare transitions: A systematic review of the literature. Health & Social Care in the Community, 20(2):113–127; doi.org/10.1111/j.1365-2524.2011.01032.x. McBrien K et al. (2018). Patient navigators for people with chronic disease: A systematic review. PLoS One, 13(2); e0191980; doi.org/10.1371/journal.pone.0191980. Mercurio, A (2016). Navigating Standard 3.1. Chicago, IL, American College of Surgeons, Commission on Cancer (https://www.facs.org/~/media/files/quality%20program s/cancer/presentations/mercurio%20coc%20navigation. ashx, accessed 19 October 2021). Mizuno Y et al. (2018). Is HIV patient navigation associated with HIV care continuum outcomes? AIDS, 32(17):2557–2571; doi.org/10.1097/qad.0000000000001987. Nalley C (2020). Navigating the COVID-19 pandemic as an oncology nurse. Oncology Times, 42(8):11,18; doi.org/10.1097/01.cot.0000661864.55789.d7. Natale-Pereira A et al. (2011). The role of patient navigators in eliminating health disparities. Cancer, 117(15 Suppl):3543–3552; doi: 10.1002/cncr.26264. National Academies of Sciences, Engineering, and Medicine (2018). Establishing effective patient navigation programs in oncology: Proceedings of a workshop. Washington, DC, The National Academies Press (https://doi.org/10.17226/25073, accessed 28 November 2021). Nolte E (2018). How do we ensure that innovation in health service delivery and organization is implemented, sustained and spread? Health Systems for Prosperity and Solidarity, 3. Copenhagen, European Observatory on Health Systems and Policies (https://apps.who.int/iris/handle/10665/331980, accessed 4 December 2021). Nolte E, Groenewegen P (2021). How can we transfer services and policy innovations between health systems? Health Systems and Policy Analysis, 40. Copenhagen, European Observatory on Health Systems and Policies (https://eurohealthobservatory.who.int/publications/i/ho w-can-we-transfer-service-and-policy-innovations- between-health-systems, accessed 4 December 2021). Nolte E, Knai C, eds (2015). Assessing chronic disease management in European health systems: Country reports. Observatory Studies, 39. Copenhagen, European Observatory on Health Systems and Policies (https://eurohealthobservatory.who.int/publications/i/ass essing-chronic-disease-management-in-european- health-systems-country-reports-study, accessed 30 November 2021). Nolte E, Knai C, Saltman R, eds (2014). Assessing chronic disease management in European health systems: Concepts and approaches. Observatory Studies, 37. Copenhagen, European Observatory on Health Systems and Policies (https://eurohealthobservatory.who.int/publications/i/ass essing-chronic-disease-management-in-european- health-systems-concepts-and-approaches-study, accessed 30 November 2021). OECD (2019). Health at a Glance: Europe 2018 – State of health in the EU cycle. Paris, OECD Publishing (https://doi.org/10.1787/health_glance_eur-2018-en, accessed 30 November 2021). Osundina F, Garfield K, Downer S (2019). Patient navigation in cancer care: Review of payment models for a sustainable future. American Cancer Society (https://www.bms.com/assets/bms/us/en-us/pdf/Patient- Navigation-in-Cancer-Care-Review-of-Payment-Models_ FINAL.pdf, accessed 31 August 2021). Patient Navigator Training Collaborative. Navigate to new knowledge and skills. Courses (https://patientnavigatortraining.org/courses, accessed 13 October 2021). Peart A et al. (2018). Patient navigators facilitating access to primary care: A scoping review. BMJ Open, 8(3); e019252; doi.org/10.1136/bmjopen-2017-019252. Pescheny JV, Pappas Y, Randhawa G (2018). Facilitators and barriers of implementing and delivering social prescribing services: A systematic review. BMC Health Services Research, 18(1); doi.org/10.1186/s12913-018- 2893-4. Porzig R et al. (2018). Evaluation of a cancer patient navigation program (“Onkolotse”) in terms of hospitalization rates, resource use and healthcare costs: Rationale and design of a randomized, controlled study. BMC Health Services Research, 18(1); doi.org/10.1186/s12913-018-3226-3. Queensland Government (2019a). 400 nurse navigators here to stay in Queensland. Brisbane, The Queensland Cabinet and Ministerial Directory (https://statements.qld.gov.au/statements/87522, accessed 9 October 2021). Queensland Government (2019b). Nurse navigators: Information sheet. Brisbane, Queensland Health, Clinical Excellence Queensland (https://www.health.qld.gov.au/__data/assets/pdf_file/00 32/666437/nn-info-sheet.pdf, accessed 9 October 2021). PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 25 26 Policy brief Ranaghan C et al. (2016). Effectiveness of a patient navigator on patient satisfaction in adults patients in an ambulatory care setting. JBI Database of Systematic Reviews and Implementation Reports, 14(8):172–218; doi.org/10.11124/JBISRIR-2016-00304. Redaniel MT et al. (2014). The association of time between diagnosis and major resection with poorer colorectal cancer survival: A retrospective cohort study. BMC Cancer, 14(642); doi.org/10.1186/1471-2407-14-642. Reid AE, Doucet S, Luke A (2020). Exploring the role of lay and professional patient navigators in Canada. Journal of Health Services Research & Policy, 25(4):229–237; doi.org/10.1177/1355819620911679. Reiss J, Gibson R (2002). Health care transition: Destinations unknown. Pediatrics, 110(6 Pt 2), 1307–1314. Rhodes SD et al. (2016). The HoMBReS and HoMBReS Por un Cambio interventions to reduce HIV disparities among immigrant Hispanic/Latino men. Mortality and Morbidity Weekly Report (MMWR) Supplements, 65(1):51–56; doi.org/10.15585/mmwr.su6501a8. Robinson-White S et al. (2010). Patient navigation in breast cancer: A systematic review. Cancer Nursing, 33(2):127– 140; doi.org/10.1097/NCC.0b013e3181c40401. Rocque GB et al. (2016). The Patient Care Connect Program: Transforming health care through lay navigation. Journal of Oncology Practice, 12(6):e633–e642; doi.org/10.1200/jop.2015.008896. Roland M, Nolte E (2014). The future shape of primary care. British Journal of General Practice, 64(619):63–64; doi.org/10.3399/bjgp14X676960. Roland K et al. (2017). Use of community health workers and patient navigators to improve cancer outcomes among patients served by federally qualified health centers: A systematic review. Health Equity, 1(1):61–76; doi.org/10.1089/heq.2017.0001. Salford Primary Care Together (2018). Care navigation comes to Salford. spctogether.co.uk (https://www.spctogether.co.uk/care-navigation-comes- to-salford, accessed 2 August 2021). Samuel S et al. (2019). Pragmatic trial evaluating the effectiveness of a patient navigator to decrease emergency room utilisation in transition age youth with chronic conditions: The Transition Navigator Trial protocol. BMJ Open, 9(12); e034309; doi.org/10.1136/bmjopen-2019-034309. Sarango M et al. (2017). The role of patient navigators in building a medical home for multiply diagnosed HIV- positive homeless populations. Journal of Public Health Management and Practice, 23(3):276–282; doi.org/10.1097/phh.0000000000000512. SELFIE (2016). Work Package 2 Report: United Kingdom (https://www.selfie2020.eu/wp- content/uploads/2016/12/SELFIE_WP2_UK_Final-thick-d escriptions.pdf, accessed 19 October 2021). Scarpetti G et al. (in press). Implementing skill-mix innovations: Role of policy and financing. In: Maier CB et al., eds. Skill-mix innovation, effectiveness and implementation: Improving primary and chronic care. Cambridge, Cambridge University Press (www.cambridge.org/9781009013758, accessed 28 November 2021). Shade SB et al. (2021). Outcomes and costs of publicly funded patient navigation interventions to enhance HIV care continuum outcomes in the United States: A before-and-after study. PLoS Medicine, 18(5), e1003418; doi.org/10.1371/journal.pmed.1003418. Shommu NS et al. (2016). What is the scope of improving immigrant and ethnic minority healthcare using community navigators: A systematic scoping review. International Journal for Equity in Health, 15(1); doi.org/10.1186/s12939-016-0298-8. Sibbald B, Shen J, McBride A (2004). Changing the skill-mix of the health care workforce. Journal of Health Services Research & Policy, 9:28–38; doi.org/10.1258/135581904322724112. Struckmann V et al. (2018). Relevant models and elements of integrated care for multi-morbidity: Results of a scoping review. Health Policy, 122(1):23–35; doi.org/10.1016/j.healthpol.2017.08.008. Treiman K et al. (2015). Cancer support services outside of clinical settings: An evaluation of LIVESTRONG Foundation’s Cancer Navigation program. Survivorship Navigation Services (https://www.livestrong.org/sites/default/files/what-we- do/reports/trieman_lsf_nav_study_jons_2015.pdf, accessed 28 November 2021). Ustjanauskas AE et al. (2015). Training in patient navigation: A review of the research literature. Health Promotion Practice, 17(3):373–381; doi.org/10.1177/1524839915616362. Valaitis RK et al. (2017). Implementation and maintenance of patient navigation programs linking primary care with community-based health and social services: A scoping literature review. BMC Health Services Research, 17(116); doi.org/10.1186/s12913-017-2046-1. Valentijn PP et al. (2013). Understanding integrated care: A comprehensive conceptual framework based on the integrative functions of primary care. International Journal of Integrated Care, 13(1); doi.org/10.5334/ijic.886. vdek (2019). Pressemitteilung: Gesundheitslotsen für Migrantinnen und Migranten der Stadt Stuttgart startet – Krankenkassen unterstützen das Projekt mit 216 Euro (https://www.vdek.com/LVen/BAW/Presse/Pressemitteilun gen/2019/PraeventionundGesundheitsfoerderungvdekfo erdertGesunheitslosten.html, accessed on 13 October 2021). Waisel DB (2013). Vulnerable populations in healthcare. Current Opinion in Anaesthesiology, 26(2):186–192; doi.org/10.1097/ACO.0b013e32835e8c17. PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 26 27 What are patient navigators and how can they improve integration of care? Wells KJ et al. (2018). What are patient navigators doing, for whom, and where? A national survey evaluating the types of services provided by patient navigators. Patient Education and Counseling, 101(2):285–294; doi.org/10.1016/j.pec.2017.08.017. WHO (2016). Integrated care models: An overview. Working document. Copenhagen, WHO Regional Office for Europe (https://www.euro.who.int/__data/assets/pdf_file/0005/3 22475/Integrated-care-models-overview.pdf, accessed 25 July). Winkelmann J et al. (in press). How can skill-mix innovations be drivers for implementation of integrated care for people with chronic conditions and multimorbidity? Copenhagen, European Observatory on Health Systems and Policies. Policy Brief (forthcoming). PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 05/01/2022 13:18 Page 27 28 Policy brief PolicyBrief_PB44_FINAL_PRINT.qxp_Policy_brief_A4 06/01/2022 14:51 Page 28 Keywords: This policy brief is one of a new series to meet the needs of policy-makers and health system managers. The aim is to develop key messages to support evidence-informed policy-making and the editors will continue to strengthen the series by working with authors to improve the consideration given to policy options and implementation. Joint Policy Briefs 1. How can European health systems support investment in and the implementation of population health strategies? David McDaid, Michael Drummond, Marc Suhrcke 2. How can the impact of health technology assessments be enhanced? Corinna Sorenson, Michael Drummond, Finn Børlum Kristensen, Reinhard Busse 3. Where are the patients in decision-making about their own care? Angela Coulter, Suzanne Parsons, Janet Askham 4. How can the settings used to provide care to older people be balanced? Peter C. Coyte, Nick Goodwin, Audrey Laporte 5. When do vertical (stand-alone) programmes have a place in health systems? Rifat A. Atun, Sara Bennett, Antonio Duran 6. How can chronic disease management programmes operate across care settings and providers? Debbie Singh 7. How can the migration of health service professionals be managed so as to reduce any negative effects on supply? James Buchan 8. How can optimal skill mix be effectively implemented and why? Ivy Lynn Bourgeault, Ellen Kuhlmann, Elena Neiterman, Sirpa Wrede 9. Do lifelong learning and revalidation ensure that physicians are fit to practise? Sherry Merkur, Philipa Mladovsky, Elias Mossialos, Martin McKee 10. How can health systems respond to population ageing? Bernd Rechel, Yvonne Doyle, Emily Grundy, Martin McKee 11. How can European states design efficient, equitable and sustainable funding systems for long-term care for older people? José-Luis Fernández, Julien Forder, Birgit Trukeschitz, Martina Rokosová, David McDaid 12. How can gender equity be addressed through health systems? Sarah Payne 13. How can telehealth help in the provision of integrated care? Karl A. Stroetmann, Lutz Kubitschke, Simon Robinson, Veli Stroetmann, Kevin Cullen, David McDaid 14. How to create conditions for adapting physicians’ skills to new needs and lifelong learning Tanya Horsley, Jeremy Grimshaw, Craig Campbell 15. How to create an attractive and supportive working environment for health professionals Christiane Wiskow, Tit Albreht, Carlo de Pietro 16. How can knowledge brokering be better supported across European health systems? John N. Lavis, Govin Permanand, Cristina Catallo, BRIDGE Study Team 17. How can knowledge brokering be advanced in a country’s health system? John. N Lavis, Govin Permanand, Cristina Catallo, BRIDGE Study Team 18. How can countries address the efficiency and equity implications of health professional mobility in Europe? Adapting policies in the context of the WHO Code and EU freedom of movement Irene A. Glinos, Matthias Wismar, James Buchan, Ivo Rakovac 19. Investing in health literacy: What do we know about the co-benefits to the education sector of actions targeted at children and young people? David McDaid 20. How can structured cooperation between countries address health workforce challenges related to highly specialized health care? Improving access to services through voluntary cooperation in the EU Marieke Kroezen, James Buchan, Gilles Dussault, Irene Glinos, Matthias Wismar 21. How can voluntary cross-border collaboration in public procurement improve access to health technologies in Europe? Jaime Espín, Joan Rovira, Antoinette Calleja, Natasha Azzopardi-Muscat , Erica Richardson,Willy Palm, Dimitra Panteli 22. How to strengthen patient-centredness in caring for people with multimorbidity in Europe? Iris van der Heide, Sanne P Snoeijs, Wienke GW Boerma, François GW Schellevis, Mieke P Rijken. On behalf of the ICARE4EU consortium 23. How to improve care for people with multimorbidity in Europe? Mieke Rijken, Verena Struckmann, Iris van der Heide, Anneli Hujala, Francesco Barbabella, Ewout van Ginneken, François Schellevis. On behalf of the ICARE4EU consortium 24. How to strengthen financing mechanisms to promote care for people with multimorbidity in Europe? Verena Struckmann, Wilm Quentin, Reinhard Busse, Ewout van Ginneken. On behalf of the ICARE4EU consortium 25. How can eHealth improve care for people with multimorbidity in Europe? Francesco Barbabella, Maria Gabriella Melchiorre, Sabrina Quattrini, Roberta Papa, Giovanni Lamura. On behalf of the ICARE4EU consortium 26. How to support integration to promote care for people with multi- morbidity in Europe? Anneli Hujala, Helena Taskinen, Sari Rissanen. On behalf of the ICARE4EU consortium 27. How to make sense of health system efficiency comparisons? Jonathan Cylus, Irene Papanicolas, Peter C Smith 28. What is the experience of decentralized hospital governance in Europe? Bernd Rechel, Antonio Duran, Richard Saltman 29. Ensuring access to medicines: How to stimulate innovation to meet patients’ needs? Dimitra Panteli, Suzanne Edwards 30. Ensuring access to medicines: How to redesign pricing, reimbursement and procurement? Sabine Vogler, Valérie Paris, Dimitra Panteli 31. Connecting food systems for co-benefits: How can food systems combine diet-related health with environmental and economic policy goals? Kelly Parsons, Corinna Hawkes 32. Averting the AMR crisis: What are the avenues for policy action for countries in Europe? Michael Anderson, Charles Clift, Kai Schulze, Anna Sagan, Saskia Nahrgang, Driss Ait Ouakrim, Elias Mossialos 33. It’s the governance, stupid! TAPIC: a governance framework to strengthen decision making and implementation Scott L. Greer, Nikolai Vasev, Holly Jarman, Matthias Wismar, Josep Figueras 34. How to enhance the integration of primary care and public health? Approaches, facilitating factors and policy options Bernd Rechel 35. Screening. When is it appropriate and how can we get it right? Anna Sagan, David McDaid, Selina Rajan, Jill Farrington, Martin McKee 36. Strengthening health systems resilience: key concepts and strategies Steve Thomas, Anna Sagan, James Larkin, Jonathan Cylus, Josep Figueras, Marina Karanikolos 37. Building on value-based health care Peter C Smith, Anna Sagan, Luigi Siciliani, Dimitra Panteli, Martin McKee, Agnès Soucat, Josep Figueras 38. Regulating the unknown: A guide to regulating genomics for health policy-makers Gemma A Williams, Sandra Liede, Nick Fahy, Kristiina Aittomaki, Markus Perola, Tuula Helander, Martin McKee, Anna Sagan 39. In the wake of the pandemic: Preparing for Long COVID Selina Rajan, Kamlesh Khunti, Nisreen Alwan, Claire Steves, Trish Greenhalgh, Nathalie MacDermott, Anna Sagan, Martin McKee 40. How can we transfer service and policy innovations between health systems? Ellen Nolte, Peter Groenewegen 41. What are the key priority areas where European health systems can learn from each other? Johan Hansen, Alexander Haarmann, Peter Groenewegen, Natasha Azzopardi Muscat, Gianpaolo Tomaselli, Mircha Poldrugovac 42. Use of digital health tools in Europe: Before, during and after COVID-19 Nick Fahy, Gemma A Williams, COVID-19 Health System Response Monitor Network 43. European support for improving health and care systems Nick Fahy, Nicole Mauer, Dimitra Panteli The European Observatory has an independent programme of policy briefs and summaries which are available here: https://eurohealthobservatory.who.int/publications/ policy-briefs What is a Policy Brief? A policy brief is a short publication specifically designed to provide policy makers with evidence on a policy question or priority. Policy briefs • Bring together existing evidence and present it in an accessible format • Use systematic methods and make these transparent so that users can have confidence in the material • Tailor the way evidence is identified and synthesised to reflect the nature of the policy question and the evidence available • Are underpinned by a formal and rigorous open peer review process to ensure the independence of the evidence presented. Each brief has a one page key messages section; a two page executive summary giving a succinct overview of the findings; and a 20 page review setting out the evidence. The idea is to provide instant access to key information and additional detail for those involved in drafting, informing or advising on the policy issue. Policy briefs provide evidence for policy-makers not policy advice. They do not seek to explain or advocate a policy position but to set out clearly what is known about it. They may outline the evidence on different prospective policy options and on implementation issues, but they do not promote a particular option or act as a manual for implementation. © World Health Organization 2021 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies) Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site (http://www.euro.who.int/pubrequest). All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the  delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organi- zation in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. PolicyBrief_PB44_COVER.qxp_Cover_policy_brief 14/12/2021 11:38 Page 2 The European Observatory on Health Systems and Policies is a partnership that supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of health systems in the European Region. It brings together a wide range of policy-makers, academics and practitioners to analyse trends in health reform, drawing on experience from across Europe to illuminate policy issues. The Observatory’s products are available on its website (www.healthobservatory.eu). What are patient navigators and how can they improve integration of care? POLICY BRIEF 44 Hannah Budde Gemma A Williams Giada Scarpetti Marieke Kroezen Claudia B Maier World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 E-mail: eurocontact@who.int Website: www.euro.who.int HEALTH SYSTEMS AND POLICY ANALYSIS Print ISSN 1997-8065 Web ISSN 1997-8073 PolicyBrief_PB44_COVER.qxp_Cover_policy_brief 06/01/2022 14:52 Page 1