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Navigating the health care maze

Yale Medicine Magazine, 2014 - Spring


After his service in the 82nd Airborne Division during the Vietnam War, Michael Joseph (not his real name) went into free fall. A one-two punch of PTSD and alcoholism left him chronically homeless and unable to take advantage of the health benefits available to veterans.

In 2012, when emergency room doctors sent Joseph to the VA Connecticut Healthcare System in West Haven for psychiatric treatment, he met Cheryl Eberg, a VA employee and fellow vet who found him shelter, scheduled his medical appointments, and got him bus passes. With Eberg’s help, Joseph, 58, is recovering. “She pretty much keeps up with all aspects of my daily living,” Joseph said. Without her assistance, he said, “I’d be outside in the streets, drinking.”

Patients overwhelmed by illness, bureaucratic tangles, or insurance problems can benefit from a professional companion like Eberg. She is a patient navigator whose job it is to be a human GPS as well as a motivator and cheerleader. As the name implies, patient navigators help patients find their way through the maze of medical care—they help schedule appointments, arrange referrals for specialty care, and go to bat for patients with Medicare and Medicaid. Navigators are liaisons between patients and health insurers and providers, who, in addition to scheduling appointments, try to ensure that patients have the means to keep those appointments, finding them a ride when necessary. They try to link homeless people, who often suffer from chronic health issues, with agencies that can help them.

Thanks to a program begun at Gateway Community College and inspired by Suzanne Lagarde, M.D., HS ’77, FW ’80, a Yale physician, Eberg is among the first certified patient navigators in Connecticut. She was one of 15 students who enrolled in Gateway’s initial Patient Navigator Training Program, which started in the fall of 2012 with a grant from the state’s Department of Public Health. Since then, four more sections of the class have been offered at Gateway, one offering training for work with cancer patients, two offering general training, and one offering general training with additional training in colorectal cancer screening. This fall the program will offer training in preventive cancer screenings and diabetes.

“You’re riding the crest of a huge wave,” Lagarde, who became director of the Fair Haven Community Health Center last year, told the students at the first session of the inaugural class. Lagarde, assistant clinical professor of medicine (digestive diseases), recognized the importance of patient navigators when she helped start Project Access-New Haven, which helps the uninsured and underinsured find pro bono specialty care. “Four years ago, I had never heard of the word. I’ve become a zealot.”

Patient navigation is the brainchild of Harold P. Freeman, M.D., who started a program in New York City in 1990 to clear barriers to detecting, treating, and comforting cancer patients. In 2007, with the help of a $2.5 million grant, the Harold P. Freeman Patient Navigation Institute was opened to establish standards and practices for the growing profession. Health care providers, Lagarde said, have come to understand that navigators are a cost-effective way to promote health. A navigator can help patients find treatment before they show up in the ER. “Save two or three hospitalizations, and you could have a person’s salary for a year,” Lagarde said.

Patient navigators can be especially helpful in dealing with patients who have problems above and beyond their medical conditions, such as the homeless. “People who are homeless cost the system three to six times as much,” said David Rosenthal, M.D., the doctor in charge of a patient-aligned care team that serves homeless veterans at the VA. “They’re frequent users. To try to address that from a medical standpoint without a navigator is to work with a hand tied behind your back.”

Clinics also realize savings, because navigators help patients keep appointments so that devices like MRIs aren’t idle, said Christopher Borgstrom, program coordinator of Project Access. The tandem of patient and navigator “leads to amazing compliance,” he said. No-show rates for the program’s patients have fallen from 30 to 40 percent to just 2 to 4 percent.

When Lagarde approached Gateway officials, they thought the class fit well with the school’s mission—addressing the “changing academic, occupational, technological, and cultural needs of a diverse population,” according to the school’s website. Discussions first centered on training people to help cancer patients through their grueling health care maze, but Victoria L. Bozzuto, Gateway’s dean of workforce development and continuing education, also wanted a class for generic navigators. “You may think you only want to work with cancer patients, but find you want to work with the homeless,” she said. Interest in the class was “viral,” said Erika Lynch, Gateway’s continuing education coordinator for workforce development.

The program consists of three eight-hour Saturday classroom sessions followed by 24 hours of shadowing patient navigators at work. What defines a patient navigator is “broad,” Lynch said. A navigator, said Lagarde, must be creative, caring, and persistent in dealing with problems that are critical but ancillary to medical care, especially with homeless and mentally ill patients. “You’ve got to accept that there will be many closed doors,” she said. In addition to finding a way through those doors, a navigator must also act “like an Aunt Tilly,” and convince reluctant patients to fill out forms, manage finances, take medications, and show up for appointments. Since many navigators aren’t medical professionals, they must also know their boundaries and not make such clinical decisions as helping patients interpret test results.

Navigators often “come from the same community as the patients they serve,” said Kevin Fiscella, M.D., M.P.H., a professor of family medicine at the University of Rochester and the author of studies showing the benefit of navigators. “This enables navigators to establish a rapport and even a trust—somebody who speaks their language.” Eberg, for instance, served with the National Guard in Iraq in 2006 and 2007. “I don’t need to know anything else about her,” said another VA outpatient who served in the Army in the Iraq and Afghanistan wars. In Iraq, Eberg was in charge of transportation support operations. Like the Radar O’Reilly character in the television series M*A*S*H, she’s skilled at procuring things, like a cellphone for the veteran.

Navigators also provide a shoulder to cry on. When a 48-year-old patient from the Dominican Republic had surgery for bladder cancer there, doctors found another tumor and said her best hope was to get treatment in the United States. She spoke no English, didn’t qualify for Medicaid, and any appointments were months in the future. She wound up in the ER. “I had no guidance, no idea of what to do,” she said.

Edna Cruz-Cedeño and Giselle Carlotta-McDonald, patient navigators at Project Access, found physicians who treated her cancer, which is now under control.

“I had two cancers,” the patient said, “one in the body, and one of just thinking and worrying. That kills you faster.”

“As soon as she walked in the door, I could see it in her face,” Cruz-Cedeño said. “At this point it’s not navigating. It’s just listening.”

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