Sharon Gentry, RN, MSN, AOCN, CBCN Breast Health Navigator Derrick L. Davis Forsyth Regional Cancer Center

1. Identifying and Removing Barriers to Care Sharon Gentry, RN, MSN, AOCN, CBCN Breast Health Navigator Derrick L. Davis Forsyth Regional Cancer Center

2. Objectives Identify common barriers to care all navigators may face Explore solutions to address barriers Share experiences among navigators on overcoming healthcare barriers

3. Defining Barriers Barriers to healthcare are obstacles within our healthcare system that prevent vulnerable patient populations from getting needed healthcare, or that cause them to get inferior healthcare compared with advantaged patient populations American Medical Student Association Foundation by the US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Medicine and Dentistry. www.amsa.org

4. The Patient Navigation Model Freeman HP, et al. Cancer Pract. 1995;3:19-30. The Cancer Care Continuum OUTREACH REHABILITATION PATIENT NAVIGATION Resolution Abnormal results Diagnosis Treatment Survivorship Suspicious Finding Conclude Navigation “The core function of patient navigation is the elimination of barriers to timely care across all segments of the healthcare continuum.”

5. Potential Barriers to Receiving Timely Healthcare Freeman HP, et al. Voices of a Broken System. Bethesda, MD: NIH, NCI; 2001.

6. Types Geographic/cultural barriers Socioeconomic barriers Organizational barriers ***Combinations

7. Geographic/Cultural Barriers Rural, suburban, inner-city… Baby boomer, generation X, generation Y… Health beliefs and behaviors Patient beliefs as well as practitioner beliefs

8. Cultural Barriers Language Bias Fears Care Information

9. Bias African Americans as a whole receive fewer cardiovascular procedures, organ transplants, orthopedic surgeries, C-sections, and lung operations for cancer American Indian and Alaskan Native women in the United States have a higher risk of death from cervical cancer than the general population due to low screening with Papanicolaou tests http://jama.ama-assn.org/issues/v283n19.http://www.idealibrary.com/links/doi/10.100/pmed.1999.0537.

10. Language Barriers http://factfinder.census.gov. In the United States, 1 in 5 people speak a language other than English

11. Language Barriers Non-English speakers have more difficulty understanding information from their doctor’s office

12. Methods Used in Hospitals to Provide Language Services Health Research and Educational Trust, 2006 Robert Wood Foundation.

13. Language Services Language Services Associates www.lsaweb.com American Language Services www.alsglobal.net

15. Lay Health Navigators Community leaders who educate community members about health-promoting behaviors REACH 2010 Initiative/PATH for Women Program Eng E, et al. BreastCancer Res Treat. 1995;35:23-29. Nguyen T, et al. SeminOncolNurs. 2008;24: 270-278.

16. Socioeconomic Barriers “Drivers of healthcare disparities” Lack of health insurance Inability to pay out of pocket – transportation, child care Poor education Employment

17. Socioeconomic Barriers The Institute of Medicine (IOM) report, Care Without Coverage: Too Little, Too Late, states that uninsured patients get about one half the health- care of insured patients and consequently die sooner than insured patients, largely because of delayed diagnoses. Another IOM report, Ensuring Quality Cancer Care, cites concerns about lapses in care that can lower the chances of survival and can compromise the quality of life of cancer patients.

18. Cancer. Aug 1, 2011:3546.

19. Patient Protection and Affordable Care Act (PPACA) Public Law 111-148 Goals – prioritize… affordability accessibility accountablilty tackle disparities Until then…

20. Uninsured/Underinsured CancerCarewww.cancercare.org800-813-HOPE Georgia Cancer Coalitionwww.georgiacancer.org404-584-7720 NeedyMedswww.needymeds.com Partnership for Prescription Assistancewww.pparx.org888-477-2669

21. Expenses National Patient Advocate Foundation www.npaf.org The Cancer Survival Toolbox www.cancersurvivaltoolbox.org 2011 Cancer Resource Guide www.curetoday.com Before treatment: Strategies to make sure you’re getting the most out of your insurance plan During treatment: Organization and help are crucial in managing your finances during treatment

22. Expenses therewithcare – Colorado www.therewithcare.org The WEPAC Alliance – Kansas www.wepacthehouse.org Patrick Dempsey Center for Hope and Healing – Maine www.dempseycenter.org Mautner Project www.mautnerproject.org Tigerlily Foundation – (888) 580-6523 www.tigerlilyfoundation.org Joe’s House – (877) JOESHOUSE (563-7468) www.joeshouse.org

23. Poor Education More than 20% of adults read at or below a fifth-grade level ̶ far below the level needed to earn a living wage Nearly half of America’s adults are poor readers, or “functionally illiterate.” They can’t carry out simply tasks, such as balancing a check book, reading a drug label, or writing an essay for a job 21 million Americans can’t read at all, 45 million are marginally illiterate, and one fifth of high school graduates can’t read their diplomas National Institute for Literacy, Fast Facts on Literacy, 2001.National Adult Literacy Survey.

24. ONS Connect. July 2011.

25. Employment “Those with jobs” Cancer and Careers www.cancerandcareers.org The CHAIN Fund www.thechainfund.com (203) 530-3439

26. Organizational Barriers Physical ̶ How accessible is your care? Can the patient find it? Communication Unspoken

28. Communication Insufficient culture-sensitive information. Drop out – give up in misunderstanding or frustration Being there…trust Negative research experiences

29. Information

30. System Politics of the system Squeaky wheel Favorite patients/cancers Outcome measures PROMIS FAMCARE Distress thermometer Tracking logs Patient satisfaction scales Supplement to Cancer. Aug 1, 2011.

31. Improve Patient Care Cancer Patient Navigation Programs are designed to help patients receive the best care possible. And they help the team that serves patients provide better care. Cancer Patient Navigation is not the cure for the disease, but it can be the lifesaver for the patient.

32. “broker” “key”contact person pivot nurse spoke of the wheel