The History and Principles of Patient Navigation · 4/3/2013 · 8 This discovery to delivery “disconnect ” is a key determinant of the unequal burden of cancer. Discovery Development

1

The History and Principles The History and Principles

of Patient Navigationof Patient Navigation

March 30, 2012March 30, 2012

Harold P Freeman, M.D.Harold P Freeman, M.D.President & CEO President & CEO

Harold P. Freeman Patient Navigation InstituteHarold P. Freeman Patient Navigation Institute

Report to the Nation on Cancer Report to the Nation on Cancer Report to the Nation on Cancer Report to the Nation on Cancer Report to the Nation on Cancer Report to the Nation on Cancer Report to the Nation on Cancer Report to the Nation on Cancer

and the Poorand the Poorand the Poorand the Poorand the Poorand the Poorand the Poorand the Poor

In 1989, the American Cancer Society, In 1989, the American Cancer Society,

conducted a series of hearings conducted a series of hearings

throughout the country to hear the throughout the country to hear the

testimony of poor Americans who had testimony of poor Americans who had

been diagnosed with cancer.been diagnosed with cancer.

American Cancer Society Cancer in the Poor a Report to the Nation 1989

Report to the Nation on Cancer and Report to the Nation on Cancer and

the Poorthe Poor, 1989, 1989FindingsFindings

�� Poor people meet significant barriers when Poor people meet significant barriers when

they attempt to seek diagnosis and treatment they attempt to seek diagnosis and treatment

of cancer.of cancer.

�� Poor people often do not even seek care if Poor people often do not even seek care if

they cannot pay for it.they cannot pay for it.

�� Poor people experience more pain, suffering, Poor people experience more pain, suffering,

and death because of late stage disease.and death because of late stage disease.

2

Report to the Nation on Cancer and the Report to the Nation on Cancer and the

PoorPoor, 1989, 1989

FindingsFindings

�� Fatalism about cancer is prevalent among the Fatalism about cancer is prevalent among the

poor and prevents them from seeking care.poor and prevents them from seeking care.

�� Poor people and their families must make Poor people and their families must make

extraordinary and personal sacrifices to obtain extraordinary and personal sacrifices to obtain

and pay for care.and pay for care.

�� Current cancer education programs are Current cancer education programs are

culturally insensitive and irrelevant to many culturally insensitive and irrelevant to many

poor people.poor people.

Related to these findings Related to these findings

the first the first ““Patient NavigationPatient Navigation””

program was conceived and program was conceived and

initiated in 1990 at Harlem initiated in 1990 at Harlem

Hospital Center.Hospital Center.

Supported by a grant from the Supported by a grant from the

American Cancer SocietyAmerican Cancer Society

Patient Navigation Patient Navigation

Historical Time TableHistorical Time Table

�� 1989 National Hearings on Cancer in the 1989 National Hearings on Cancer in the PoorPoor

�� 1990 1990 ““Excess Mortality in HarlemExcess Mortality in Harlem””, , NEJM 1990 NEJM 1990 McCord and Freeman HPMcCord and Freeman HP

�� 1990 Patient Navigator Program Initiated 1990 Patient Navigator Program Initiated at Harlem Hospitalat Harlem Hospital

�� 1995 1995 ““Expanding Access to Cancer Expanding Access to Cancer Screening and Clinical FollowScreening and Clinical Follow--up Among up Among the Medically Underservedthe Medically Underserved””, , Cancer Practice 1995, Cancer Practice 1995, Freeman HPFreeman HP

3

Patient Navigation Patient Navigation

Historical Time TableHistorical Time Table

�� 2004 National Cancer Institute funded 9 Patient 2004 National Cancer Institute funded 9 Patient

Navigator SitesNavigator Sites

�� 2005 Patient Navigator Outreach and Chronic 2005 Patient Navigator Outreach and Chronic

Disease Prevention ActDisease Prevention Act

�� 2006 Center for Medicare and Medicaid Funded 2006 Center for Medicare and Medicaid Funded

6 Patient Navigator Sites6 Patient Navigator Sites

�� 2008 Health Resources and Services 2008 Health Resources and Services

AdministrationAdministration–– Funded 6 Patient Navigator SitesFunded 6 Patient Navigator Sites

The Principles of Patient NavigationThe Principles of Patient Navigation

1.1. Navigation is a patientNavigation is a patient--centric health centric health

care service delivery model.care service delivery model.

2.2. Patient Navigation serves to virtually Patient Navigation serves to virtually

integrate a fragmented healthcare integrate a fragmented healthcare

system for the individual patient.system for the individual patient.


3.3. The core function of patient navigation is the The core function of patient navigation is the

elimination of barriers to timely care across all elimination of barriers to timely care across all

segments of the healthcare continuum.segments of the healthcare continuum.

4.4. Patient Navigation should be defined with a Patient Navigation should be defined with a

clear scope of practice that distinguishes the clear scope of practice that distinguishes the

role and responsibilities of the navigator from role and responsibilities of the navigator from

that of other providers.that of other providers.

4


5.5. Delivery of patient navigation services should Delivery of patient navigation services should

be costbe cost--effective and commensurate to effective and commensurate to

navigate an individual through a particular navigate an individual through a particular

phase of the care continuum.phase of the care continuum.

6.6. The determination of who should navigate The determination of who should navigate

should be determined by the level of skills should be determined by the level of skills

required at a given phase of navigation. required at a given phase of navigation.


7.7. In a given system of care there is the In a given system of care there is the need to define the point at which need to define the point at which navigation ends.navigation ends.

8.8. There is a need to navigate patient There is a need to navigate patient across disconnected systems of care, across disconnected systems of care, such as primary care sites and tertiary such as primary care sites and tertiary care sites.care sites.

9.9. Patient Navigation systems require Patient Navigation systems require coordination.coordination.

Patient Navigation Across The Patient Navigation Across The

Health Care ContinuumHealth Care Continuum

Patient NavigationPatient Navigation

AbnormalResults

Diagnosis Treatment

Ab

no

rma

l F

ind

ing

Re

so

luti

on

Freeman, 2006.

PreventionPreventionEarly Early

DetectionDetection

Diagnosis/Diagnosis/

IncidenceIncidenceTreatmentTreatment

Post Post

Treatment/Treatment/

Quality of LifeQuality of Life

Survival and Survival and

MortalityMortality

OutreachOutreach Rehabilitation

Initial target in Harlem Initial target in Harlem

ModelModel

5

The The ““War on CancerWar on Cancer””

Signing of the National Cancer Act of 1971Signing of the National Cancer Act of 1971

Disease always occurs within a context Disease always occurs within a context

of human circumstances.of human circumstances.

These human circumstances are These human circumstances are

determinants ofdeterminants of

survival and quality of life.survival and quality of life.

Significant medical advances Significant medical advances

have improved health and have improved health and

quality of life for many quality of life for many

Americans.Americans.

6

The poor and underserved The poor and underserved

have not shared fully in have not shared fully in

these benefits, these benefits,

as evidenced by their high as evidenced by their high

cancer incidence, mortality, cancer incidence, mortality,

and lower survival.and lower survival.

Poor Americans have a Poor Americans have a

10% to 15 % lower 10% to 15 % lower

cancer survival rate cancer survival rate

compared to other compared to other

AmericansAmericansAmerican Cancer Society Report on Cancer in the Economically Disadvantaged 1986

Life Expectancy at Birth Life Expectancy at Birth –– USA USA

(1970(1970--2003)2003)(CDC/National Center for Health Statistics Report 2006)(CDC/National Center for Health Statistics Report 2006)

7

8

This This discovery to deliverydiscovery to deliverydiscovery to deliverydiscovery to deliverydiscovery to deliverydiscovery to deliverydiscovery to deliverydiscovery to delivery ““disconnectdisconnect””

is a key determinant of the unequal is a key determinant of the unequal

burden of cancer.burden of cancer.

DiscoveryDiscovery DevelopmentDevelopment DeliveryDelivery

Critical Disconnect

The DiscoveryThe DiscoveryThe DiscoveryThe DiscoveryThe DiscoveryThe DiscoveryThe DiscoveryThe Discovery--------Delivery DisconnectDelivery DisconnectDelivery DisconnectDelivery DisconnectDelivery DisconnectDelivery DisconnectDelivery DisconnectDelivery Disconnect

Voices of a Broken System: Real People, Real Problems, Voices of a Broken System: Real People, Real Problems, PresidentPresident’’s Cancer Panel, Freeman, s Cancer Panel, Freeman, September 2001September 2001

Access to information

and knowledge

and

Access to quality care

Critical DisconnectCritical Disconnect


DetectionDetection



Post Post




MortalityMortality

Delivery

Freeman, H.P., 2006

Causes of Health DisparitiesCauses of Health Disparities

Freeman, Adapted from Cancer Epidemiology Biomarkers & Prevention, April 2003

PreventionPrevention TreatmentTreatmentPost Treatment/Post Treatment/

Quality of LifeQuality of LifeSurvival and Survival and

MortalityMortality

Social InjusticeSocial Injustice

Early Early

DetectionDetection


IncidenceIncidence

CultureCulture

Poverty/Poverty/

Low EconomicLow Economic

StatusStatus

Possible Influence on Gene Environment InteractionPossible Influence on Gene Environment Interaction

9

The Meaning of PovertyThe Meaning of Poverty

�� Substandard housingSubstandard housing

�� Inadequate information and Inadequate information and

knowledgeknowledge

�� RiskRisk--promoting lifestyles, attitudes, promoting lifestyles, attitudes,

and behaviorsand behaviors

�� Diminished access to health careDiminished access to health care

CultureCulture

•• Shared communication systemShared communication system

•• Similar physical and social environmentSimilar physical and social environment

•• Common beliefs, values, traditions, and Common beliefs, values, traditions, and

world viewworld view

•• Similar lifestyles, attitudes, and Similar lifestyles, attitudes, and

behaviorsbehaviors

POVERTYPOVERTY

CULTURECULTURE

DECREASED SURVIVALDECREASED SURVIVAL

Inadequate physical and

social environment

Inadequate

information and

knowledge

Risk-promoting lifestyle,

attitude, behavior

Diminished

access to

health care

Freeman, H.P., Cancer in the socioeconomically disadvantaged. Cancer 1989

10

U.S. Census Bureau, 2003 to 2005 Annual Social and Economic Supplements; Income, Poverty, and Health Insurance Coverage in the U.S.: 2005

8.7

24.7 21.9

9

25.6 22.4

0

5

10

15

20

25

30

2004 2005

White:

2004=16.9M

2005=17.4M

Black:

2004=9.0M

2005=9.0M

Hispanic:

2004=9.1M

2005=9.3M

Poverty Rates by Race and Hispanic Origin: 2Poverty Rates by Race and Hispanic Origin: 2--Years Years

2004 and 20052004 and 2005

Health Insurance Coverage in the U.S.: 2002, U.S. Census Bureau, 2003; U.S. Census Bureau, 2005 and 2006 Annual Social and Economic Supplements

Percent of People Without Health Insurance Percent of People Without Health Insurance Percent of People Without Health Insurance Percent of People Without Health Insurance Percent of People Without Health Insurance Percent of People Without Health Insurance Percent of People Without Health Insurance Percent of People Without Health Insurance

Coverage by Race and Hispanic OriginCoverage by Race and Hispanic OriginCoverage by Race and Hispanic OriginCoverage by Race and Hispanic OriginCoverage by Race and Hispanic OriginCoverage by Race and Hispanic OriginCoverage by Race and Hispanic OriginCoverage by Race and Hispanic Origin

ThreeThreeThreeThreeThreeThreeThreeThree--------Year Averages: 2003Year Averages: 2003Year Averages: 2003Year Averages: 2003Year Averages: 2003Year Averages: 2003Year Averages: 2003Year Averages: 2003--------20052005200520052005200520052005

11.2

19.3

32.3

11.3

19.6

32.7

0

5

10

15

20

25

30

35

2004 2005

W hite: 2004=21.8M

2005=22.1M

Black: 2004=7.1M

2005=7.2M

Hispanic:

2004=13.5M

2005=14.1M

Race Race Perhaps the single Perhaps the single

most defining issue in most defining issue in

the history of the history of

American societyAmerican society

11

In this nation we see, value, and In this nation we see, value, and

behave toward one another behave toward one another

through a powerful lens of through a powerful lens of ““racerace””..

This lens can create false This lens can create false

assumptions that may result in assumptions that may result in

serious harm to members of some serious harm to members of some

racial and ethnic groups.racial and ethnic groups.

Findings of IOM Report on Unequal Findings of IOM Report on Unequal

Treatment, 2003Treatment, 2003

Bias, stereotyping, prejudice, and Bias, stereotyping, prejudice, and

clinical uncertainty on the part clinical uncertainty on the part

of healthcare providers may of healthcare providers may

contribute to racial and ethnic contribute to racial and ethnic

disparities in healthcare. disparities in healthcare.

Geographic Areas of Geographic Areas of

Excess Cancer MortalityExcess Cancer Mortality

12

A Black male in Harlem A Black male in Harlem has less of a chance of has less of a chance of reaching age 65 than a reaching age 65 than a male in Bangladesh.male in Bangladesh.

McCord and Freeman, NEJM January, 1990

An Analysis of An Analysis of

Excess Cervical Excess Cervical

Cancer Mortality Cancer Mortality

–– A Marker for A Marker for

Low Access to Low Access to

Health Care in Health Care in

Poor Poor

CommunitiesCommunities

US = 3.07/100,00011.4 - 23.89.50 - 11.47.99 - 9.496.70 - 7.985.83 - 6.694.40 - 5.823.72 - 4.393.18 - 3.712.62 - 3.171.19 - 2.61Sparse data (< 12 observed deaths; 1,490 counties; 7.04% of deaths)

Cancer Mortality Rates by County (Age-adjusted 1970 US Population)Cervix Uteri: White Females, 1970-98; Pooled White and Black Rates

NOTE: Shades of purple: ~ 100 counties eachShades of green: ~ 300 counties each

13


There is a critical window of There is a critical window of

opportunity to save lives opportunity to save lives

from cancer between the from cancer between the

point of an initial point of an initial

suspicious finding and the suspicious finding and the

resolution of the finding by resolution of the finding by

further diagnosis and further diagnosis and

treatment.treatment.

Source: National Cancer Institute INFORUM database

Central Harlem Central Harlem

Community CharacteristicsCommunity Characteristics

�� Ethnicity is predominantly AfricanEthnicity is predominantly African--American.American.

��Median household income in Central Harlem is Median household income in Central Harlem is

$22,367/year. $22,367/year.

��Median years of school completed is 12. Median years of school completed is 12.

––11% less than high school11% less than high school

––47% high school, no diploma47% high school, no diploma

––17% high school graduate17% high school graduate

––18% some college18% some college

––8% 4+ yrs. of college8% 4+ yrs. of college

14

East Harlem Community CharacteristicsEast Harlem Community Characteristics

•• EthnicityEthnicity

–– Puerto Rican, 51.8%Puerto Rican, 51.8% –– Central American, 3%Central American, 3%

–– Mexican, 9%Mexican, 9% –– Ecuadorian, 1%Ecuadorian, 1%

–– Dominican, 5%Dominican, 5%

•• Median household income in East Harlem is Median household income in East Harlem is

$23,309/year.$23,309/year.

•• Median years of school completed is 11. Median years of school completed is 11. –– 30% less than high school30% less than high school –– 13% some college13% some college

–– 31% high school, no diploma31% high school, no diploma –– 5% 4+ yrs. of 5% 4+ yrs. of

collegecollege

–– 22% high school graduate22% high school graduate

Source: National Cancer Institute INFORUM database

PRINICIPAL BARRIERS PRINICIPAL BARRIERS

TO HEALTH CARETO HEALTH CARE

�� FinancialFinancial

��CommunicationCommunication

��Health Care System BarriersHealth Care System Barriers

�� Fear and Distrust Fear and Distrust

Patient Navigation ModelPatient Navigation Model

OutreachOutreach Patient NavigationPatient NavigationPatient NavigationPatient NavigationPatient NavigationPatient NavigationPatient NavigationPatient Navigation Rehabilitation

Abnormal

Results Diagnosis TreatmentAb

no

rma

l F

ind

ing

Re

so

luti

on

Co

nc

lud

eN

avig

ati

on

Freeman, et.al., Cancer Practice, 1995.

15

Patient Navigator ModelPatient Navigator Model

The Patient Navigator Model promotes

timely diagnosis and treatment and aims

to ensure seamless, coordinated care

and services.

Patient navigators provide assistance to

patients and families to “negotiate” the

health care delivery system.

Harlem Hospital Center Breast Cancer Harlem Hospital Center Breast Cancer

Results Prior To InterventionResults Prior To Intervention

Screening Program Screening Program

Stage of DiseaseStage of Disease

19641964--19861986

Stage 0Stage 0 0%0%

Stage IStage I 6%6%

Stage IIStage II 45%45%

Stage IIIStage III 39%39%

Stage IVStage IV 10%10%*Freeman HP, Wasfie TJ (1989). Cancer of the breast in poor black women. Cancer, 63(12), 2562 – 2569.

Harlem Hospital Center Breast Cancer Harlem Hospital Center Breast Cancer

Results Prior To InterventionResults Prior To Intervention

39%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Five Year Survival Rate

Before accessto screening &patientnavigation(1964-1986)*

*Freeman HP, Wasfie TJ (1989). Cancer of the breast in poor black women. Cancer, 63(12), 2562-2569.

16

Impact of Harlem Hospital Center Breast Impact of Harlem Hospital Center Breast

Cancer Screening/Navigation Program Cancer Screening/Navigation Program

Comparison of FiveComparison of Five--year Survival Rates (%)year Survival Rates (%)

19641964--19861986 19951995--20002000

Stage 0Stage 0 0%0% 12%12%

Stage IStage I 6%6% 29%29%

Stage IIStage II 45%45% 38%38%

Stage IIIStage III 39%39% 14%14%

Stage IVStage IV 10%10% 7%7%Oluwale/Freeman, Journal of American College of Surgeons, 2003

Impact of Screening & Patient Navigation on Breast Cancer 5Impact of Screening & Patient Navigation on Breast Cancer 5--

year Survival Rates year Survival Rates

Harlem Hospital Cancer Control Center (BECH)Harlem Hospital Cancer Control Center (BECH)

39%

70%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Five Year Survival Rate

Before accessto screening &patientnavigation(1964-1986)*

After access tosceening &patientnavigaton(1995-2000)**

*Freeman HP, Wasfie TJ (1989). Cancer of the breast in poor black women. Cancer, 63(12), 2562-2569.

Oluwale/Freeman, Journal of American College of Surgeons, 2003

Patient Navigation Across The Patient Navigation Across The



AbnormalResults

Diagnosis Treatment

Ab

no

rma

l F

ind

ing

Re

so

luti

on

Freeman, 2006.


DetectionDetection



Post Post




MortalityMortality



ModelModel

17

Harold P. FreemanHarold P. Freeman

Patient Navigation InstitutePatient Navigation Institute

http://.www.hpfreemanpni.org

Ralph Lauren Center for Cancer Ralph Lauren Center for Cancer

Care & Prevention PN ModelCare & Prevention PN Model•Outreach: The outreach navigator is responsible for creating access to the Center. This individual utilizes remote access technology to create

real time appointments in the scheduling management system and

tracks potential patients through their scheduled appointment.

•Financial: The financial navigator is responsible for removing any

financial barriers or obstacles that present amongst the Centers patient population.

•Diagnostic: The diagnostic navigator is responsible for tracking and barrier removal for patients with a suspicious finding.

•Treatment: The treatment navigator is responsible for tracking and barrier removal for patients undergoing treatment services at the Center.

Map of Harold P. Freeman Patient Navigation Institute Alumni

567 Alumni to date 283 Healthcare Sites 41 States

Number of Institutions per state: Alabama (3), Alaska (2), Arizona (1), Arkansas (4), California (24), Colorado (3), Connecticut (32), Delaware (1), Florida (4), Georgia (6), Hawaii (7), Idaho (1), Illinois (9), Indiana (2), Kansas (2), Kentucky (8), Louisiana (5), New Jersey (9), Maine (3), Maryland (8), Massachusetts (5), Michigan (4), Minnesota (3), Missouri (3), Montana (1), New Hampshire (1), New Mexico (4), New York (61), North Carolina (9), Ohio (5), Oklahoma (1), Oregon (1), Pennsylvania (9), Rhode Island (2), South Carolina (2), South Dakota (3), Tennessee (5), Texas (14), Virginia (1), Washington (2), West Virginia (1), Wisconsin (1) and District of Columbia (6)

St. Thomas, Virgin Islands (1), Bucharest, Romania (1), Toronto, Canada (1), London, England (1), Galway, Republic of Ireland (1) Updated as of January 24, 2012

18

Three Major Factors to Three Major Factors to

Improve ResultsImprove Results

1)1) Provide screening to patients Provide screening to patients

regardless of ability to payregardless of ability to pay

2)2) Establish patient navigation programEstablish patient navigation program

3)3) Increase outreach and public Increase outreach and public

educationeducation

Signed into law Signed into law

June 29, 2005June 29, 2005

"Patient "Patient "Patient "Patient "Patient "Patient "Patient "Patient Navigator Navigator Navigator Navigator Navigator Navigator Navigator Navigator

Outreach and Outreach and Outreach and Outreach and Outreach and Outreach and Outreach and Outreach and

Chronic Disease Chronic Disease Chronic Disease Chronic Disease Chronic Disease Chronic Disease Chronic Disease Chronic Disease

Prevention Act of Prevention Act of Prevention Act of Prevention Act of Prevention Act of Prevention Act of Prevention Act of Prevention Act of

2005" 2005" 2005" 2005" 2005" 2005" 2005" 2005" P.L. 109P.L. 109P.L. 109P.L. 109P.L. 109P.L. 109P.L. 109P.L. 109--------1818181818181818

National Legislation authorizing Patient National Legislation authorizing Patient

Navigation Program Navigation Program

How can we How can we

eliminate health care eliminate health care

disparities?disparities?

19

This This discovery to deliverydiscovery to deliverydiscovery to deliverydiscovery to deliverydiscovery to deliverydiscovery to deliverydiscovery to deliverydiscovery to delivery ““disconnectdisconnect””

is a key determinant of the unequal is a key determinant of the unequal

burden of cancer.burden of cancer.

Discovery Development Delivery

Critical Disconnect

The DiscoveryThe DiscoveryThe DiscoveryThe DiscoveryThe DiscoveryThe DiscoveryThe DiscoveryThe Discovery--------Delivery DisconnectDelivery DisconnectDelivery DisconnectDelivery DisconnectDelivery DisconnectDelivery DisconnectDelivery DisconnectDelivery Disconnect

Voices of a Broken System: Real People, Real Problems, Voices of a Broken System: Real People, Real Problems, PresidentPresident’’s Cancer Panel, Freeman, s Cancer Panel, Freeman, September 2001.September 2001.

We must apply what we We must apply what we

know know at any given timeat any given time to to

allall peoplepeople, irrespective of , irrespective of

their ability to paytheir ability to pay..

Freeman, HP, Cancer in the Economically Disadvantaged, CA, July 1 Supplement, 1999. Presented at the American Collegeof Surgeons/American Cancer Society Workshop on Quality Assurance in Cancer Care, 1988, published Cancer, 1989

Provide universal Provide universal

access to health access to health

care.care.

20

We must develop a We must develop a

comprehensive, unified comprehensive, unified

approach to improving approach to improving

conditions rooted in conditions rooted in

poverty.poverty.

Delineate and target geographic Delineate and target geographic

areas with excess cancer areas with excess cancer

mortality with an intense mortality with an intense

approach to providing culturally approach to providing culturally

relevant education, appropriate relevant education, appropriate

access to screening, diagnosis access to screening, diagnosis

and treatment, and improved and treatment, and improved

social support.social support.

Develop Patient Navigation Develop Patient Navigation

Programs to provide personal Programs to provide personal

assistance in obtaining timely assistance in obtaining timely

and adequate diagnosis and and adequate diagnosis and

treatment.treatment.

21

Create a high level of Create a high level of

awareness among medical awareness among medical

trainees and professionals trainees and professionals

regarding their role in regarding their role in

eliminating bias in medical care eliminating bias in medical care

delivery.delivery.

Establish and implement Establish and implement

systems for monitoring systems for monitoring

treatment equity according treatment equity according

to standards of care to to standards of care to

diminish bias in the diminish bias in the

provision of health care.provision of health care.

Encourage each individual, Encourage each individual,

regardless of economic status, regardless of economic status,

to share in the responsibility for to share in the responsibility for

promoting his her own health promoting his her own health

and well beingand well being..

22

Final ThoughtsFinal Thoughts

Disparities in cancer are Disparities in cancer are

caused by the complex caused by the complex

interplay of low economic interplay of low economic

class, culture, and social class, culture, and social

injustice, with poverty playing injustice, with poverty playing

the dominant role.the dominant role.

Residents of poorer communities, Residents of poorer communities,

irrespective of race, have higher irrespective of race, have higher

death rates from disease.death rates from disease.

Within each racial/ethnic group, Within each racial/ethnic group,

viewed separately, those living in viewed separately, those living in

poorer counties have lower disease poorer counties have lower disease

survival.survival.

23

There is evidence that race, in There is evidence that race, in

and of itself, is a determinant and of itself, is a determinant

of the level of health care of the level of health care

received. received.

Health disparities exact an Health disparities exact an

extraordinarily high extraordinarily high

human cost and a human cost and a

significant economic cost significant economic cost

to this nation. to this nation.

People should not die from People should not die from

cancer because they are cancer because they are

poor.poor.

24

The unequal burden of The unequal burden of

disease in our society is disease in our society is

a challenge to science a challenge to science

and a moral dilemma and a moral dilemma

for our nation. for our nation.

““ Knowing is not enough;Knowing is not enough;

we must applywe must apply

Willing is not enough;Willing is not enough;

We must do.We must do.””

Johann von GoetheJohann von Goethe

No person in America with a No person in America with a

suspicious finding or cancer should suspicious finding or cancer should

go untreated.go untreated.

No person in America should No person in America should

experience delays in diagnosis and experience delays in diagnosis and

treatment that jeopardize survival.treatment that jeopardize survival.

No person in America should be No person in America should be

bankrupted by a diagnosis of cancer.bankrupted by a diagnosis of cancer.

Voices of a Broken System: President’s Cancer Panel 2002

25

Of all of the forms of inequality, Of all of the forms of inequality,

Injustice in health is the most Injustice in health is the most

shocking and inhumane. shocking and inhumane.

Dr. Martin Luther King Jr. Dr. Martin Luther King Jr.

Abnormal results Diagnosis Treatment ConcludeNavigation

Patient Navigation across the Patient Navigation across the



AbnormalResults

Diagnosis Treatment

Ab

no

rma

l F

ind

ing

Re

so

luti

on

Freeman, 2006.


DetectionDetection



Post Post




MortalityMortality



ModelModel

Documents

The History and Principles of Patient Navigation · 4/3/2013 · 8 This discovery to delivery “disconnect ” is a key determinant of the unequal burden of cancer. Discovery Development