Patient Navigation, Community Based Participatory Research and Asian Health DisparitiesKaren Freund MD MPHProfessor and Vice Chair of MedicineTufts Medical CenterTufts University School of Medicine

Goal of today’s talk•Patient Navigation to address health

disparities•Why community participation in patient

navigation research was critical to its success

•What are the important health issues for Asian American women today?

Theoretical Model of Factors that Influence Disparities

Prevention Screening Treatment

PATIENT PROVIDER

SYSTEM

BIOLOGIC

Diagnosis

Morbidity and Mortality

Patient Navigation as a Systems Intervention to Address Diagnostic Delays

Prevention Screening Treatment

PATIENT PROVIDER

SYSTEM

BIOLOGIC

Diagnosis

Morbidity and Mortality

OUTREACH

PATIENT NAVIGATION

REHABILITATION

Ab

norm

al

Fin

din

g

Reso

lutio

n

Init

ial

Con

tact

Conc

lude

Nav

igati

on

• Abnormal finding/diagnosis to resolution

• Eliminate critical delivery gap for populations experiencing disparities

Abnormal results/ Diagnosis

Diagnosis Treatment Survivorship

General Framework of Patient Navigation

Patient Navigators Address Individual Patient Barriers

Translate medical next steps and what to expect into lay language

Promote understanding of healthcare system pathways

Understand the patient’s health belief system

Coaching and cultural, emotional and psychosocial support

Assistance with physical needs and other barriers to care

Facilitate referrals to community resources and social services

Pre Post In-tervention

Pre Post Con-trol

Pre Post In-tervention

Pre Post Con-trol

70

75

80

85

90

95

100

Percent of Subjects Who Reach Diagnostic Resolution

% R

eso

lved

Breast Screening Abnormalities Cervical Screening Abnormalities

Impact of Patient Navigation Intervention on those with Diagnostic Resolution in 1 Year

Does everyone need navigation?

0102030405060708090

100

0 50 100 150 200 250 300 350 400

Perce

nt Re

solve

d

Days

Cervical Abnormality Site A

Control Navigated

•Is there a subset of patients who benefit?

•Can we determine who benefits a priori

•Reduce resources for the same benefit

Who benefits the most from navigation?

•Navigation eliminated the gap for these vulnerable populations▫Low income▫Unmarried▫Unstable housing▫Unemployed

•Navigation also benefited those with:▫Multiple health care problems▫Social and legal barriers to care

Why was patient navigation successful?

•Partnership between the research team and community stakeholders

What is Community Based Participatory Research (CBPR)?

•A true community-academic partnership•Goal of improving health in the

community

Community Based Participatory Research•Asks the right questions•Advises on methods

that will work• Interprets the findings

based on knowledge of community

•Uses the findings to benefit the community

Researchers

Community members

Change

How was CBPR critical to success of patient navigation?•Helped understand barriers to care•Aligned important stakeholders to help•Helped design a study that could be

completed in multiple community health centers

•Once the results were in, we worked together to find resources for ongoing support

What do investigators need to do?•Ask questions•Support the community efforts in the

research▫Provide resources once the research is

funded•Ask for help to interpret the findings•Use the stakeholder group to

disseminate results

Asian Health Disparities in Women today

•What are the important health questions?

Boston’s Chinatown Cancer leading cause of death among Asian American women

Breast Cancer most common cancer in Chinese American women

High rates of liver and stomach cancer

Fifth largest Chinese population

Most densely settled neighborhood

56% foreign born

62% linguistically isolated

Asian Cancer Disparities•Foreign born Asian

populations have the greatest unmet needs during cancer care

•Foreign born Asian populations have greater miscommunication about goals of cancer treatment

Asian Diabetes Disparities•More diabetes,

metabolic diseases at lower weight▫Overweight and

obesity redefined for Asian populations

Asian Mental Health Disparities•Least likely to be screened for depression•Present with physical symptoms•Although patients understand their

symptoms to have emotional cause, less likely to receive treatment

Asian Health Disparities•Challenge of heterogeneity•One size does not fit all•Different challenges for different sub

populations•Barriers to care often greater in foreign born

Asian American women•Disease risks may or with place of birth

What we hope to gain today•Community perspective

▫Important health needs among Asian American women

▫Challenges▫Solutions

•Academic perspective▫Interventions to test solutions▫Methods to evaluate the interventions