Cities for LifePatient Navigator Training

Overview• What is a Patient Navigator?• The Patient• Motivational Interviewing• The Practice • Organizing• Issues to Consider

Purpose of Patient Navigator• The patient navigator’s purpose is to decrease health disparities and

barriers.– A health disparity is a gap in the presence of disease, health outcomes or

access to health care between different population groups.• What are barriers to healthcare?

– Socioeconomic conditions– Logistical issues (how close they live to medical care, reliable transportation) – Language or culture– The healthcare system

• According to the National Cancer Institute, individuals from underserved populations are more likely to:– Die from preventable disease.– Receive no treatment or sub-standard treatment.– Die of diseases that are generally curable or controllable.

Role of Patient Navigator

• To help patients navigate through the healthcare system.

• Patient navigators are not healthcare providers. They work with the healthcare team to coordinate patient care and improve the patient experience. – Promote patient health and comfort.– Build awareness among the healthcare team and

outside patient resources.

Qualities of a Good Patient Navigator• Effective patient navigators…

– Build working relationships– Solve problems– Direct patients to resources – Manage information

• To improve coordination of patient care and reduce barriers, patient navigators must work effectively with patients, healthcare teams and resource providers.

• Patients require empathy and an understanding of the cultural and socioeconomic backgrounds in the community. The ability to help patients depends on the ability to establish effective, trusting working relationships with patients.

Tips• Be clear about your role so you can clearly communicate it to

patients.• Give only basic health information.• Do not discuss the experiences of other patients; give only

basic information about treatment and care.• Be sensitive to the type and amount of information they need.• Handle patients with patience.• Not all patients will use the information or resources you

provide, while others will choose to delay care or even refuse it. Remember that patients are ultimately responsible for their own health. Treat all patients with respect, understanding and patience, even when you get frustrated!

Professional Boundaries• Patient navigators work closely with patients, develop trust and

learn about patients’ personal lives. Because of this, the line between a professional and personal relationship can blur.

• Patients may ask you for help that is beyond your professional role as a patient navigator and it may be difficult to say no to their requests. It is important to understand your role’s boundaries and to clarify them to your patients so you can maintain a professional relationship.

• Avoid becoming personally involved with patients. Involvement beyond your professional role opens you up to personal liability and establishes unrealistic expectations that can quickly get out of control.

Patient Rights & ResponsibilitiesAccording to the Consumer Bill of Rights and Responsibilities, patients have a right to:• See their healthcare records.• Choose their healthcare providers and plans.• Be part of treatment decisions.• Have their health information kept private.• Complain about their healthcare.• Be treated with respect and without discrimination.

Patient's responsibilities• Patients are responsible for their own health.• Patients must disclose information.• Patients must be financially and administratively responsible.• Patients must be respectful of others.

What Not to DoA few things that patient navigators should avoid:

DO NOT provide healthcare services such as:• “Hands-on” patient care• Physical assessments, diagnoses or treatment• Counseling

DO NOT offer opinions or judgments about:• The quality of physicians or medical care• Diagnosis or treatment options• Any aspect of healthcare

Patient navigators are healthcare representatives, not healthcare providers. Even if you are a health care professional, do not provide direct care to patients or offer opinions about medical care.

Effective Relationships

• Building effective working relationships is important to successful patient navigation. If patients do not trust you, they may not discuss their needs with you, or accept your help.

• What builds patient trust? – Caring– Communication– Competence

Effective Patient Navigator• Creative problem solver

– Find solutions to unique patient barriers.

• Knowledgeable resource– Stay informed of changes in the healthcare organization.– Seek current information about available patient resources.– Maintain current disease information for patients.– It’s okay to say “I don’t know, but I’ll find out for you”.

• Be sensitive to information overload– Be sensitive to patients’ need for information and try not to overwhelm them with

too much information.

• Skilled communicator– Motivational Interviewing.

Motivational Interviewing• What is Motivational Interviewing (MI)?

– Style of communication – that shifts from prescriptive to collaborative.

– “A collaborative, person-centered form of guiding to elicit and strengthen motivation for change.” (http://www.motivationalinterview.org/)

• Who can use MI?– Physicians, nurses, medical assistants, referral coordinators,

anyone who has a conversation with a patient about their health.

Motivational Interviewing

• When should MI be used?– Anytime you want to have a conversation with a

patient about lifestyle change.

• Why should I use MI?– Increased job satisfaction – increased likelihood of

patient beginning to make changes.– Deepened relationship with patient – better

understanding of patient – and what may/may not be obstacles to improved health.

Motivational Interviewing

How do I use MI?

The OARS Technique: OARS is a brief way to remember the basic approach used in motivational interviewing.

O – OPEN ENDED QUESTIONS A – AFFIRMATIONSR – REFLECTIONSS – SUMMARY

The OARS Technique

• Open-ended questions are those that are not easily answered with a "yes/no" or short answer containing only a specific, limited piece of information. Open ended questions invite ‐elaboration and thinking more deeply about an issue. They create forward momentum used to help the patient explore the reasons for and possibility of change.

Ex. “Tell me about any concerns you have.”

Core Skill-Open Questions

• Cannot be answered with a yes or no.

• Cannot be answered with a number, place, or single word.

• Starts with, “how,” “in what ways,” “tell me more...”

• Invites discussion, expression of personal ideas, wishes, plans...

• Helps us become listeners.

The OARS Technique• Affirmations are statements that recognize patient

strengths. They assist in building rapport and in helping the patient see themselves in a different, more positive light. To be effective they must be congruent and genuine. They can help patients feel that change is possible even when previous efforts have been unsuccessful.

Ex. “It sounds like you have a lot to deal with right now, I can see why it would be hard to feel like you have the time to make a change.”

Core Skill-Affirmations

• Defined as finding people doing something right.• Builds collaboration and are encouraging.• Are positive and genuine.

– A statement by the listener that affirms the speaker in a personal and meaningful way.

– Often focused on intent, commitment and/or effort.

The OARS Technique• Reflections or reflective listening is a crucial skill in mi. By

careful listening and reflective responses, the patient comes to feel the doctor understands the issues from their perspective. The physician can guide the patient towards resolving ambivalence by focusing on the negative aspects of the status quo and the positives of making change.

Ex. “It sounds like you are very busy right now, you want to make changes and you’ve tried in the past but haven’t been successful. It’s frustrating for you because you don’t want to end up with heart problems like your mom.”

Core Skill-ReflectionsIt sounds like you are feeling...It sounds like you are not happy with...It sounds like you are a bit uncomfortable with...So you are saying that you are having trouble...So you are saying that you are conflicted about...

As you become more familiar, truncate...You’re not ready to...You’re having a problem with...You’re feeling that...It’s been difficult for you...You’re struggling with...

The OARS Technique• Summaries are a special type of reflection where the physician

recaps what has occurred during the visit. Summaries communicate interest, understanding and call attention to important elements of the discussion. Summaries can highlight both sides of a patient’s ambivalence about change and promote the development of discrepancy.

Ex. “We’ve talked about your concerns about your weight today and the challenges you face with your busy schedule and being the primary care giver for your father. Even small changes can be beneficial. Let’s talk about some that may work for you.”

Core Skill-Summaries

• Summaries are a series of reflections.• Use after 4 or 5 reflections and start with

– Let me see if I understand…– In general it seems…

• Note both sides of an issue (if stated).• End with an open ended question, such as:

– Is there anything else?– What are your next steps?

Additional Core Skills-Asking Permission

• Shows respect and creates a collaboration.• Gives them ownership of the decision.• Use before giving advice...

– Would it be OK if I...– Would you mind if I shared some information with you about our

programs...– There is something that concerns me here. Would it be OK if I gave

you some information about...– It seems like you might be stuck. I have some ideas that may or may

not help. Would you like to hear them?• A twist – give the option to disregard.

– What you do with this information is totally up to you...

Additional Core Skills-Offer Options• First, ask the patient what he or she has

considered.– “What have you thought of? What might work?

• Next, offer several options. This reinforces the ownership of the change process as being the speakers’ not the listeners’.

• Check-in and ask an open-ended question:– “How does that sound? Which of these do you think

might work for you?”• Immediately reflect responses and ask for any

elaboration.• “So that seems like a good option. How would that

work?”

End on good terms

• Always thank the person for talking.• Find something to affirm.

– Appreciate efforts– Appreciate intentions

• Follow-up!

Practice Basics• Practice personnel

– Primary care physicians (family doctors, nurse practitioners) oversee a patient’s general health and their treatment. They refer patients for screening or diagnosis, and follow them through the process of treatment.

– Specialists are doctors who concentrate on diagnosing and treating specific diseases.

– Nurses are usually in charge of implementing the plan of care the doctor has set up. They are trained to administer medications and monitor side effects.

– Administrators such as clinic coordinators, schedulers, medical records specialists, case managers, and medical billing coordinators are a few of the administrators that coordinate and facilitate patient care.

• Practice workflow– Who is the main practice point of contact?– Who will refer patients to PN?– Who should receive patient reports?

Learning about the Practice

• 3 tips for learning about your healthcare team:– Search web sites or read other published

information.– Keep a copy of the organizational chart to learn

about the relationships between the associates on the patient's team.

– Visit healthcare team members in their offices or clinics.

Patient Resources• Local diabetes resources

– Who?– Location?

• National diabetes resources– Who?– Access?

• Other resources – Transportation services – Counselors– Language translators– Representatives who assist with financial support

OrganizationPatient navigators manage and track a large amount of information such as: • Patient profiles

– This information must be kept confidential and secure. It is important that navigators stay organized and use a systematic approach to information management.

• Appointments • Interactions with patients and practices

Find a system that works for you to organize patient information, coordinate care, or track “to do” items. Some tools that can keep you on track are:• A bound calendar with space to keep notes.• A tickler system to remind you of important dates as they come up (ex.

the Task feature on Outlook ).• Files for each patient.• A system for keeping patient information private.

Navigation Plan1. Receive referral from practice.2. Upload patient information and referral form into

information system.3. Contact patient.4. Explain program, process and interview patient.5. Direct patient to a community resource.6. Notify community resource of the referral.7. Update referring practice.8. Follow up with patient in 1-2 weeks.9. Note all correspondence.

 

Patient Flow Chart

Practices  

Patient Navigators

Neighborhoods

 

Patient Flow2. PHYSICIAN refer patient w/ pre-diabetes or type 2 diabetes to patient navigator

3. PATIENT NAVIGATOR assesses physician referral, patient needs and options 

  

 

 

 

1. PATIENTS go to a participating practice to receive care

4. Navigator runs a query based on assessment and matches referred patient to community-based resource

5. Patient guided by navigator participates in identified diabetes community programs

Practice-based Research Network

(Coordinating Center)

 

 

Community Resource Website

Resource flow to help practices to

optimize referrals

Community-based Diabetes

Management/Healthy Lifestyle

Programs

6. Navigator monitors patient’s progress and sends report back to physician

Commun-ity based Diabetes Manage-

ment/Healthy Lifestyle Programs

Project Issues to Consider• Primary Care Practices

– Should be familiar with workflow, reimbursement constraints, patient population, some knowledge of practice roles & EMRs, quality improvement, etc.

– Patient navigators should help practices integrate referral process into workflow.

– No two practices are the same.• Patient engagement component can be challenging.

How can patients be more engaged?– How to assess readiness to change in patients?– Motivational interviewing – Goal-setting

Tracking Patients• A tracking system is very useful for managing

information about people involved in Cities for Life.

• In the Birmingham project, the team used a customer relationship management system. The tracking system incorporated the data elements and the workflows to provide a working system for patient navigation and referral tracking.

Tracking Patients• The information on community resources,

data elements, workflow, necessary documentation, templates, and processes was included in tracking database development and testing.

• The system was used for tracking referred patients and maintained by patient navigators thorough the duration of the navigation process.

Issues to Consider cont’d• Do not underestimate the power of visual

cues & triggers. – Visual cues are really important; brainstorm ways

to make the referral process explicit and apparent to the very busy clinician.

– Posters work well. What else would work? Screen saver displays on the EMR? Pens?

– All practices have different rules about displaying information.