What Are Patient Navigators Doing, For Whom, and Where? A National Survey Evaluating the Types of Services Provided by Patient Navigators

Abstract

Objective

A nationwide cross-sectional study was conducted to assess patient navigator, patient population, and work setting characteristics associated with performance of various patient navigation (PN) tasks.

Methods

Using respondent-driven sampling, 819 navigators completed a survey assessing frequency of providing 83 PN services, along with information about themselves, populations they serve, and setting in which they worked. Analyses of variance and Pearson correlations were conducted to determine differences and associations in frequency of PN services provided by various patient, navigator, and work setting characteristics.

Results

Nurse navigators and navigators with lower education provide basic navigation; social workers typically made arrangements and referrals; and individuals with higher education, social workers, and nurses provide treatment support and clinical trials/peer support. Treatment support and clinical trials/peer support are provided to individuals with private insurance. Basic navigation, arrangements and referrals, and care coordination are provided to individuals with Medicaid or no insurance.

Conclusion

Providing basic navigation is a core competency for patient navigators. There may be two different specialties of PN, one which seeks to reduce health disparities and a second which focuses on treatment and emotional support.

Practice Implications

The selection and training of patient navigators should reflect the specialization required for a position.

1. Introduction

Patient navigation (PN) is a barrier-focused intervention that assists patients in getting a defined episode of recommended health care [1–3]. Since 1990, PN programs have been widely implemented to improve outcomes for a variety of diseases [3–8]. Research indicates PN is effective in increasing rates of some types of cancer care, including cancer screening and diagnostic services [3, 4, 8].

There are currently three viewpoints regarding the best model of PN based on navigator training and background. The first model indicates that the most important qualification of a patient navigator is being a “cultural broker and interpreter” who is from communities served by the PN program [9]. This model indicates a “clinical degree” is not necessary to perform PN, but that navigators must have certain personal qualities (i.e., being personable) and be willing to improve the lives of others, provide education to health care providers, and advocate for expanded services [9]. A second model emphasizes that navigators who provide screening, diagnostic, treatment, and survivorship PN should have specific professional training [10]. A third model suggests that a multidisciplinary team of lay and professional navigators should provide PN [11–13], with one accreditation standard indicating nonprofessional staff must be able to document training in PN from a recognized professional organization [11].

Seven articles published in academic journals and trade magazines have proposed core competencies of patient navigators, with most focused on training competencies of nurse navigators [14–20]. There is some agreement across these core competency proposals, suggesting that some skills are indeed core competencies for patient navigators, such as being able to provide information or education to patients and others [15–20], having well developed communication skills [16–18, 20], and understanding professional role and practicing professionalism [14, 17, 18]. On the other hand, proposals describing core competencies also differed significantly, suggesting some competencies may be specialized for a particular professional field (e.g., nursing)[15–17], population (e.g., older adults)[19], or disease (e.g., cancer)[14–16, 18]. Additional information regarding activities that various patient navigators typically perform would help inform selection of core competencies and specialty areas in PN. The field has also not reached consensus regarding the most effective ways of training patient navigators. There are currently numerous PN training programs and curricula [14, 15, 20], but it is unclear which training approaches or methods are most effective. A review of PN research studies identified significant variation in training duration, format, learning strategies, content, and trainers [21].

The purpose of this study was to assess patient navigator, patient population, and work setting characteristics associated with performance of various PN tasks. Information gained from this study will help inform discussions regarding core and specialty competencies of patient navigators, selection of models of PN in particular circumstances, and training needs of patient navigators. Identifying characteristics associated with performance of various PN tasks may assist program managers in determining optimal training methods for navigators and may also assist training programs with determining areas of specialization in PN.

2. Methods

2.1. Study design

This cross-sectional survey of patient navigators was approved by the Institutional Review Board of the University of Illinois, Chicago.

2.2. Recruitment

To be included in the study, participants were required to: 1) self-identify as a patient navigator; 2) be ≥18 years; 3) be able to read English or Spanish; and 4) be willing to assent to study participation. Although potential participants were not provided a definition of patient navigator or PN, we defined a patient navigator as a person who provides PN to patients. PN was defined as “assisting a patient through the health care system to access health services.”

Participants were recruited using respondent-driven sampling (RDS). Research team members sent an electronic invitation to the first wave of survey respondents, which consisted of nurse and social worker associations, national and local public health agencies, health care institutions, community health worker coalitions, and disease-specific advocacy organizations. Within the email, there was a request to distribute a survey link to colleagues and associates (‘seeds’) who have access to patient navigators or who are patient navigators. The e-mail invitation provided a flyer in English and Spanish which introduced the study purpose, a link to the survey webpage, and a contact to complete the survey on paper or by phone. The introduction page described benefits and risks of the research, institutional review board approval, and information about the sponsor. Respondents provided assent when initiating the survey from the introduction webpage. Participants who completed the survey were provided the option of receiving a $25 gift card.

2.3. Data collection

Data were collected using Survey Monkey Inc. with a survey developed by a multi-disciplinary team [22, 23]. Respondents were not allowed to skip survey questions.

2.3.1. Patient navigator characteristics

Respondents were asked to self-identify their own racial and ethnic background (African-American/Black, Asian/Pacific Islander/Hawaiian, Hispanic, White, and other/multiracial), gender, highest educational level (high school/general equivalency diploma, some college/trade school, associate’s degree, bachelor’s degree, some graduate education, completed graduate or professional education), whether the patient navigator was bilingual (yes/no), whether the patient navigator was a cancer survivor (yes/no), whether the patient navigator had been the caregiver of a cancer survivor (yes/no), whether the patient navigator received training (yes/no), average weekly caseload, work setting (hospital, community-based organization, community health center, government organization), geographical location of work (urban, suburban, rural), and health conditions navigated (breast cancer, cervical cancer, colorectal cancer, diabetes, cardiovascular disease, asthma or chronic obstructive pulmonary disease [COPD], and human immunodeficiency virus [HIV]/acquired immunodeficiency virus [AIDS]).

Respondents were categorized into five categories of patient navigators. Lay patient navigators included those without a professional degree, medical licensure, or credentials and those with education at or below a bachelor’s degree. Allied health patient navigators included those with professional backgrounds (i.e., medical assistants) and with educational degrees greater than a bachelor’s degree that were not clinically focused. Nurse navigators included individuals with two-year or bachelor’s nursing degrees as well as registered nurses, advanced practice nurses, nurse practitioners, and individuals with other nursing backgrounds. The social worker/counselor category included individuals with at least a bachelor’s degree in social work, those with a master’s degree in counseling, and licensed mental health counselors. A fifth category included “other” health navigators who did not fit into the other four categories.

2.3.2. Population characteristics

Ten survey items assessed characteristics of patient populations that each patient navigator served. Participants were asked to describe how many of their patients, in a typical week, were members of various racial and ethnic groups (Hispanic/Latino, Black/African American, Asian, Pacific Islander, Native American/American Indian, White) or who had various types of health insurance (uninsured, Medicaid, Medicare, private insurance). Response categories for each item included “no patients,” “some patients,” “most patients,” and “all patients.” One survey item assessed the number of patients navigated each week on average, with response categories of: 1–5 patients, 6–10 patients, 11–15 patients, 16–20 patients, 21–30 patients, 31–40 patients, and more than 40 patients.

2.3.3. Frequency of patient navigation tasks

Participants completed 83 items assessing for how many patients navigators performed various PN activities, with possible responses on a four-point Likert scale (1=no patients; 2=some patients; 3=most patients; 4=every patient). We conducted a principal components analysis to obtain a parsimonious set of PN tasks. An exploratory principal components analysis indicated 17 potential PN task factors with Eigenvalues greater than 1. Examination of the scree plot indicated these factors could be reduced to 5, which explained 47.5% of the variance. A second principal components analysis was conducted with five components specified. The five factor solution pointed to five types of PN services provided: 1) basic navigation; 2) arrangements and referrals to services; 3) care coordination; 4) treatment support; and 5) clinical trials/peer support (see Table 1 for definitions), with one item not loading on any factor. A score for each subscale was derived by summing scores on each item in the subscale and then dividing by the number of items on each subscale. All five subscales demonstrated high internal consistency (all Cronbach’s α ≥.86; see Tables 1 and 2 for more information regarding each type of PN service).

Table 1.

Factor loadings for component items by factor name.

Component Item	Factor 1 Loading	Factor 2 Loading	Factor 3 Loading	Factor 4 Loading	Factor 5 Loading
Making Arrangements and Referrals to Services
Refer patient to housing services	0.707
Refer patient to food resources (food bank, low-cost groceries)	0.696
Arrange for food	0.654
Arrange for housing	0.646
Refer patient to adult care services	0.645
Arrange adult care	0.622
Refer patient to health insurance coverage resources (Medicaid, disability, Medicare, etc.)	0.614
Provide information and help with applications for financial and drug assistance	0.613
Arrange for other community resources	0.608
Refer patient to financial and drug assistance services	0.604
Refer patient to services for client's other medical conditions/disabilities	0.600
Refer patient to other community services	0.596
Identify resources for legal issues	0.587
Identify resources to address child/elder/domestic abuse	0.587*
Report child/elder/domestic abuse	0.583*
Arrange services for client's other medical conditions/disabilities	0.570
Refer patient to other agency (e.g., hospital) resources	0.569
Identify resources for employment issues	0.551
Refer patient to transportation services	0.536
Identify resources for immigration issues	0.532
Arrange transportation	0.513
Arrange for health insurance coverage (Medicaid, disability, Medicare, etc.)	0.510*
Arrange for other agency (e.g., hospital) resources	0.501
Refer patient to child care services	0.484
Arrange child care	0.402
Refer client to other services	0.378
Provide/arrange for durable medical equipment/prosthesis/wigs	0.355*
Treatment Support
Discuss the treatment plan with the patient/caregiver		0.791
Discuss the treatment plan with provider		0.713
Discuss death and dying issues		0.711
Reinforce importance of following treatment plan and taking medications		0.680
Review and discuss medical results		0.679
Explain side effects of treatment		0.676
Provide support during patient's decision-making process		0.670
Coach patient on setting goals for healthy lifestyle		0.662
Discuss patient’s cultural/spiritual beliefs		0.648
Review and reinforce treatment plan with patient		0.647
Use assessment tool to assess patient’s mental health (e.g., distress thermometer, PHQ-9)		0.590
Provide emotional support		0.588
Provide information about complementary therapies		0.560*
Provide information on healthy lifestyle (nutrition, exercise)		0.533
Address patient fears		0.518*
Refer patient to counselor/mental health provider		0.478*
View medical charts, lab results, imaging results, etc.		0.439*
Work with clients to reduce mistrust of provider/healthcare system		0.300*
Care Coordination
Schedule appointment(s) for preventive screening			0.815
Schedule appointment(s) for diagnostic follow-up			0.806
Schedule medical appointment(s)			0.783
Remind patients of future appointments			0.720
Get medical records for the appointments			0.643
Prepare patients for doctor visits			0.574
Work with the patient to prepare list of medications for medical visits			0.550
Help patients find health care provider			0.548
Arrange language interpretation services			0.474
Provide language interpretation services			0.464
Work with patients to prepare list of symptoms			0.444
Go with patient to appointments			0.438
Work with the patient to prepare questions for provider			0.387*
Drive client to appointment			0.371
Coordinate communication between providers and family			0.330*
Basic Navigation
Assess/identify patient needs				0.800
Collect client information to identify barriers to care				0.796
Develop plan of action to minimize/address barriers to care				0.729
Problem solve with client related to client issues/needs				0.728
Enter client related data into database/file				0.643
Explain patient navigator services and program				0.610*
Listening to clients concerns				0.590*
Follow-up to see how client is doing				0.565
Learn about client's medical condition(s)				0.528
Teach patients how to navigate healthcare system				0.479
Call/visit to stay connected to clients				0.455*
Assess client literacy level				0.409
Provide disease specific health information				0.408*
Provide general health information (prevention, health promotion, etc.)				0.316*
Clinical Trials and Peer Support
Explain clinical trial					0.812
Encourage enrollment into clinical trials					0.773
Provide information about clinical trials					0.766
Refer patient to support group					0.641
Refer patient to individual peer support					0.594
Arrange for individual peer support					0.585
Arrange for support group					0.562
Consent and enroll patients into clinical trial					0.382

Note:

^*items that load onto more than one factor

Table 2.

Description and measurement of each type of navigation service and characteristics of the navigator, setting, disease targeted by navigation, and patient characteristics associated with each type of navigation service.

Types of Navigation Services	Description	# of items	Mean (SD)	Cron-bach’s Alpha	Navigator characteristics	Setting characteristics	Disease characteristics	Patient characteristics
Basic Navigation	Identifying and addressing patient needs and barriers; providing information; patient follow-up	14	3.19 (0.66)	.92	high school/GED; nurse; caregiver of cancer patient; received training	hospital	Breast cancer	Hispanic, White; patients with Medicaid
Making Arrangements and Referrals to Services	Making arrangements for services, referring patients to resources	27	1.79 (0.41)	.93	Hispanic; other/multiracial; graduate or professional degree; bilingual; social worker; received training	community- based organization	Cervical cancer; diabetes; cardiovascular disease; asthma; HIV/AIDS	Hispanic, Pacific Islander, Native American, White; patients who are uninsured; patients who have Medicaid
Care Coordination	Coordination of medical visits and medical appointment scheduling	15	1.93 (0.55)	.90	Hispanic; other/multiracial; bilingual; allied health; caregiver of cancer patient; received training	community health center	Breast cancer	Hispanic; patients who are uninsured
Treatment Support	Supporting treatment by providing information regarding the treatment plan; assessing and supporting emotional health and psychosocial concerns	18	2.46 (0.68)	.93	graduate or professional degree; bilingual; nurse or social worker; caregiver of cancer patient	suburban; hospital		Hispanic, Asian; patients with private insurance
Clinical Trials/Peer Support	Facilitation of clinical trials and arrangements for peer support	8	1.84 (0.59)	.86	bachelor’s degree; some graduate education; nurse; caregiver of cancer patient; cancer survivor; received training	suburban, urban; hospital	Breast cancer	Asian, Pacific Islander, Native American; patients with Medicaid; patients with private insurance

2.4. Statistical analyses

We calculated descriptive statistics for key variables using frequencies and measures of central tendency and variation. We used analyses of variance (ANOVAs) and independent samples t tests to evaluate whether there were differences in the frequency with which navigators reported providing various services by characteristics of the navigator (gender, race/ethnicity, whether or not navigator was bilingual, education), model of PN (social worker/counselor, lay, nurse, allied health, other), receipt of training, whether or not navigator was a caregiver for a cancer patient or survivor, work setting of navigator (type of organization, geographical location), and type of disease for which the navigator provided PN. When Levene’s test indicated sample variances were unlikely to have occurred based on random sampling from a population with equal variances, an independent samples Kruskal-Wallis test was performed instead of an ANOVA. When an ANOVA or Kruskal-Wallace test indicated a significant difference in the frequency with which navigators reported providing various services, Bonferroni post-hoc tests, which control for multiple comparisons, were conducted to evaluate which groups were significantly different.

Pearson correlations were conducted to evaluate whether frequency of provision of the five PN services was associated with the number of patients navigated in the past week from various racial and ethnic backgrounds or with various types of insurance. Analyses were performed using SPSS [24].

3. Results

3.1. Participant characteristics

Eight hundred nineteen participants completed all survey items (Table 3). Most participants were non-Hispanic white (71.2%), female (93.5%), and between 40 and 59 years (61.9%). Most participants reported having more than a high school education (95.1%), having received training as a patient navigator (69.1%), and having served as a caregiver for a cancer patient (55.4%). Participants were most likely to be nurses (35.3%), lay navigators (28.2%), or social worker/counselor navigators (20.0%). Most patient navigators (84.7%) indicated that they provided PN for cancer, were not bilingual (79.4%), and were not cancer survivors (84.7%). On average, most survey participants (64.7%) reported providing PN to 20 or fewer clients each week. Although participants were geographically distributed across the US[23], most worked in an urban setting (51.8%). Patient navigators most frequently performed basic navigation, with relatively less frequent provision of treatment support, making arrangements and referrals to services, care coordination, and clinical trials/peer support.

Table 3.

Differences between navigators in the frequency of provision of the types of patient navigation services.

Navigator Characteristic	Basic Navigation	Making Arrangements and Referrals to Services	Care Coordination	Treatment Support	Clinical Trials/Peer Support
Gender
Male (n = 53)	3.08 (0.77)	1.86 (0.47)	2.02 (0.63)	2.40 (0.69)	1.82 (0.69)
Female (n = 766)	3.20 (0.66)	1.79 (0.40)	1.93 (0.55)	2.47 (0.68)	1.84 (0.58)
P	0.208	0.221	0.251	0.468	0.813
Race/Ethnicity of patient navigator
African-American/Black (n=72)	3.05 (0.75)	1.67 (0.35)d,e	1.97 (0.50)f,g	2.29 (0.68)	1.77 (0.52)
Asian/Pacific Islander/Hawaiian (n = 37)	2.97 (0.90)	1.84 (0.63)	2.18 (0.78)c	2.36 (0.86)	1.93 (0.74)
Hispanic (n = 92)	3.37(0.53)	1.91 (0.54)c, d	2.24 (0.60)d,f	2.47(0.72)	1.81(0.66)
White (n = 583)	3.20 (0.64)	1.78 (0.36)c	1.84 (0.49) c,d,e	2.48 (0.66)	1.83 (0.55)
Other/multiracial (n=35)	3.19 (0.79)	1.97(0.52) e	2.29 (0.68) e,g	2.59 (0.76)	1.98 (0.78)
p	.063a	.018a	<.001a	.136	.668a
Education of patient navigator
High school/GED (n = 40)	3.43 (0.70)c	1.83 (0.41)	2.08 (0.58)	2.33 (0.69)	1.65 (0.56)
Some college/trade school (n = 100)	3.03 (0.80)c	1.75 (0.36)	1.99 (0.54)	2.25 (0.69)c,d	1.66 (0.56)c,d
Associate’s degree (n = 106)	3.28 (0.73)	1.67 (0.40)c	1.98 (0.51)	2.53(0.69)	1.81 (0.62)
Bachelor’s degree (n = 251)	3.23 (0.59)	1.80 (0.45)	1.94 (0.56)	2.49 (0.70) c	1.91 (0.59)c
Some graduate education (n = 60)	3.34 (0.62)	1.86 (0.43)	1.90 (0.58)	2.46 (0.67)	1.95 (0.63)d
Completed graduate or professional education (n = 262)	3.11 (0.64)	1.83 (0.37)c	1.86 (0.55)	2.51 (0.65) d	1.85 (0.55)
p	<.001a	.013	.086	.018	.002
Model of patient navigation
Nurse (n = 289)	3.31 (0.62)c,d	1.66 (0.32)c, e, f	1.99 (0.45)c,d	2.73 (0.58)c,f,g	1.99 (0.56)c,d
Social worker/counselor (n= 164)	3.09 (0.59)c	1.95 (0.36)c,d	1.76 (0.53) c,e	2.49 (0.64)c,d,h	1.72 (0.48)c
Lay (n = 231)	3.18 (0.70)	1.82 (0.44)d,e	1.91 (0.56)f	2.19 (0.67)d,e,f	1.72 (0.58)d
Allied health (n = 56)	3.19 (0.77)	1.82 (0.48)	2.22 (0.62)d,e,f,g	2.47 (0.74)e	1.84 (0.74)
Other (n = 79)	3.01 (0.71)d	1.84 (0.48)f	1.92 (0.73)g	2.21 (0.70)g,h	1.86 (0.64)
p	<.001a	<.001a	<.001a	<.001a	<.001a
Received training as a patient navigator
Yes (n = 566)	3.27 (0.62)	1.82 (0.41)	1.96 (0.56)	2.46 (0.69)	1.88 (0.61)
No (n = 253)	3.01 (0.72)	1.73 (0.41)	1.86 (0.52)	2.46 (0.67)	1.75 (0.53)
p	<.001b	.007	.014	.969	.003
Is patient navigator bilingual?
Yes (n = 169)	3.24 (0.64)	1.88 (0.49)	2.21 (0.63)	2.48 (0.72)	1.87 (0.68)
No (n = 650)	3.18 (0.67)	1.77 (0.38)	1.86 (0.50)	2.46 (0.67)	1.83 (0.56)
p	.255	.006b	<.001b	.650	.465b
Caregiver for a cancer patient
Yes (n = 454)	3.26 (0.64)	1.81 (0.43)	1.99 (0.55)	2.59 (0.65)	1.94 (0.62)
No (n = 365)	3.11 (0.68)	1.78 (0.39)	1.85 (0.54)	2.31 (0.69)	1.71 (0.52)
p	.001	.327	<.001	<.001	<.001b
Cancer survivor
Yes (n = 125)	3.09 (0.63)	1.81 (0.45)	1.92 (0.55)	2.44 (0.62)	1.95 (0.58)
No (n = 694)	3.21 (0.67)	1.79 (0.40)	1.93 (0.55)	2.47 (0.69)	1.82 (0.58)
p	.063	.720	.846	.659	.015

Note:

^aKruskal-Wallis test,

^bLevene’s test of homogeneity of variances significant, t test does not assume equal variance,

^c–hindicates significant differences between groups (for example, model of patient navigation) performing a particular task (for example, arrangements) according to Bonferroni tests with correction for multiple comparisons

3.2. Differences in service provision by patient navigator demographic characteristics

There were no significant differences in frequency of each type of service delivered by the navigator’s gender (Table 3). There were significant differences by patient navigator race and ethnicity related to the frequency with which patient navigators made arrangements and referrals to services and provided care coordination. Follow-up Bonferroni tests indicated African-American/Black navigators reported making arrangements and referrals less frequently than navigators who indicated that they were Hispanic/Latino, multiracial, or other race/ethnicity. Furthermore, White navigators made arrangements and referrals less frequently than Hispanic/Latino navigators. Hispanic/Latino navigators more frequently provided care coordination when compared to those who identified as African-American/Black or White. Also, Asian/Pacific Islander/Hawaiian navigators provided care coordination to more patients than White navigators. Navigators who identified as other race/ethnicity or multiracial provided more care coordination than White or African-American/Black navigators.

Significant differences in frequency with which navigators provided clinical trials and peer support services were observed by education, with those who completed a bachelor’s degree or some graduate education providing these services more frequently than those with some college or trade school education. Those with more education provided treatment support and made arrangements and referrals more frequently. Finally, participants with the least amount of education reported more frequently providing basic navigation than those who completed some college or trade school.

With respect to the model of PN, there were significant differences in frequency of providing all five PN services. While nearly all navigators reported frequently providing basic navigation services, nurse navigators provided significantly more basic navigation than social workers and “other” navigators. Nurse navigators provided the most treatment support, providing significantly more than social worker/counselor navigators, lay navigators, and “other” navigators; social workers provided more treatment support than lay or “other” navigators. Lay navigators provided the least treatment support. Nurse navigators were significantly more likely to provide clinical trials/peer support when compared to social worker/counselor and lay navigators. On the other hand, social worker/counselor navigators made arrangements and referrals significantly more frequently than nurse and lay navigators. Nurse navigators were significantly less likely to make arrangements and referrals to services than social worker/counselor navigators, lay navigators, and “other” navigators. Allied health navigators were significantly more likely to provide care coordination than all other navigators, and nurse navigators were more likely to provide care coordination than social worker/counselor navigators. Participants who reported having received PN training reported providing more services related to basic navigation, making arrangements and referrals, care coordination, and clinical trials/peer support.

Some navigators possessed specialized skills and experiences that were associated with tasks they performed. Bilingual navigators were more likely to make arrangements and referrals to services and provide care coordination than monolingual patient navigators. Having previously been a caregiver for a cancer patient was associated with more frequently performing basic navigation, care coordination, treatment support, and peer and clinical trial support. Finally, navigators who reported being cancer survivors reported more frequent provision of peer and clinical trial support.

3.3. Differences in frequency of service provision by patient navigator’s work setting

There were significant geographical and health system differences in the frequency of provision of several types of PN services (Table 4). Treatment support was more frequently provided in suburban settings. Clinical trials/peer support was more frequently provided in suburban or urban settings. Navigators who worked in a hospital more frequently provided basic navigation, treatment support, and clinical trials and peer support. Participants who worked in community-based organizations were more likely to make arrangements and referrals to services and less likely to provide treatment support than those who did not. Patient navigators who worked in community health centers more frequently provided care coordination and less frequently provided clinical trials/peer support. Finally, navigators who worked in government organizations were less likely to provide basic navigation, make arrangements and referrals, treatment support, and clinical trials/peer support.

Table 4.

Differences in the frequency of provision of the types of patient navigation services by work setting.

Characteristic of Workplace	Basic Navigation	Making Arrangements and Referrals to Services	Care Coordination	Treatment Support	Clinical Trials/Peer support
Geographical setting of workplace
Rural (n = 189)	3.20 (0.71)	1.85 (0.47)	1.92 (0.58)	2.38 (0.66)c	1.68 (0.54)c,d
Urban (n = 424)	3.15 (0.66)	1.80 (0.41)	1.93 (0.57)	2.44 (0.69)d	1.87 (0.61)d
Suburban (n = 198)	3.29 (0.60)	1.72 (0.34)	1.94 (0.49)	2.61 (0.68)c,d	1.92 (0.55)c,
p	.059a	.075a	.953	.002	<.001
Navigator works in hospital
Yes (n = 316)	3.29 (0.58)	1.77 (0.38)	1.93 (0.51)	2.60 (0.63)	1.99 (0.58)
No (n = 503)	3.13 (0.71)	1.81 (0.42)	1.93 (0.58)	2.38 (0.70)	1.74 (0.57)
p	<.001b	.284	.956 b	<.001b	<.001
Navigator works in community based organization
Yes (n = 120)	3.12 (0.68)	1.90 (0.44)	1.93(0.68)	2.32 (0.69)	1.92(0.59)
No (n = 699)	3.20 (0.66)	1.78 (0.40)	1.93 (0.53)	2.49 (0.68)	1.82 (0.58)
p	.194	.003	.915b	.015	.093
Navigator works in community health center
Yes (n = 85)	3.30 (0.67)	1.84 (0.48)	2.19 (0.60)	2.54 (0.74)	1.67 (0.60)
No (n = 734)	3.18 (0.66)	1.79 (0.40)	1.90 (0.54)	2.45 (0.67)	1.86 (0.58)
p	.119	.245	<.001	.304 b	.006
Navigator works in government organization
Yes (n = 78)	2.94 (0.84)	1.69 (0.41)	1.92 (0.55)	2.23 (0.67)	1.52 (0.44)
No (n = 741)	3.22 (0.64)	1.80 (0.41)	1.93 (0.55)	2.49 (0.68)	1.87 (0.59)
p	.006b	.024	.793	.001	<.001b

Note:

^aKruskal-Wallis test,

^bLevene’s test of homogeneity of variances significant, t test does not assume equal variances,

^c–gindicates significant differences between groups (for example, geographical setting of workplace) performing a particular task (for example, arrangements) according to Bonferroni tests with correction for multiple comparisons

3.4. Differences in frequency of service provision by disease targeted by patient navigation intervention

There were significant differences in frequency with which various PN services were provided by type of disease that the PN intervention targeted (Table 5). Navigators who reported providing services to improve outcomes related to breast cancer were more likely to provide basic navigation, care coordination, and clinical trials/peer support, than those who do not provide PN for breast cancer. Navigators who provided PN to improve outcomes related to cervical cancer were more likely to make arrangements and referrals and less likely to provide treatment support than those who did not navigate for cervical cancer. Similarly, navigators who provide services to improve outcomes related to colorectal cancer provided treatment support less frequently than those who do not provide colorectal cancer-related PN. Navigators who provide services related to improving outcomes in chronic diseases reported more frequently making arrangements and referrals to services and less frequently providing clinical trials and peer support services. Similarly, navigators who provided services related to HIV/AIDS reported more frequently making arrangements and referrals to services than those who did not provide PN for HIV/AIDS.

Table 5.

Differences in the frequency of provision of the types of patient navigation services by disease for which navigation is provided.

Disease for Which Navigation is Provided	Basic Navigation	Making Arrangements and Referrals for Services	Care Coordination	Treatment Support	Clinical Trials/Peer support
Provides navigation related to breast cancer
Yes (n = 427)	3.26 (0.66)	1.79 (0.40)	2.01(0.53)	2.51 (0.66)	1.90 (0.62)
No (n = 392)	3.12 (0.67)	1.79 (0.42)	1.85 (0.56)	2.42 (0.70)	1.76 (0.54)
p	.003	.948	<.001	.055	<.001a
Provides navigation related to cervical cancer
Yes (n = 226)	3.20 (0.66)	1.85 (0.40)	1.96 (0.54)	2.37 (0.68)	1.78 (0.60)
No (n = 593)	3.19 (0.67)	1.77 (0.41)	1.92 (0.55)	2.50 (0.68)	1.86 (0.58)
p	.758	.018	.321	.011	.069
Provides navigation related to colorectal cancer
Yes (n = 213)	3.18 (0.65)	1.82 (0.38)	1.95 (0.53)	2.36 (0.68)	1.80 (0.59)
No (n = 606)	3.20 (0.67)	1.78 (0.42)	1.93 (0.56)	2.50 (0.68)	1.85 (0.58)
p	.795	.277	.626	.009	.255
Provides navigation related to diabetes
Yes (n = 152)	3.18 (0.68)	1.92 (0.44)	1.95 (0.57)	2.45 (0.67)	1.58 (0.51)
No (n = 667)	3.19 (0.66)	1.76 (0.40)	1.93 (0.55)	2.47 (0.68)	1.90 (0.59)
p	.798	<.001	.637	.838	<.001a
Provides navigation related to cardiovascular disease
Yes (n = 136)	3.22 (0.65)	1.91(0.41)	1.93 (0.51)	2.47 (0.64)	1.57(0.48)
No (n = 683)	3.19 (0.67)	1.77 (0.41)	1.93 (0.56)	2.46 (0.69)	1.89 (0.59)
p	.583	<.001	.984	.960	<.001a
Provides navigation related to asthma
Yes (n = 102)	3.26 (0.66)	1.99 (0.40)	1.95 (0.54)	2.52 (0.67)	1.58 (0.48)
No (n = 717)	3.18 (0.66)	1.76 (0.40)	1.93 (0.55)	2.46 (0.68)	1.87 (0.59)
p	.286	<.001	.734	.394	<.001a
Provides navigation related to HIV/AIDS
Yes (n = 69)	3.13 (0.73)	1.94 (0.43)	1.93 (0.57)	2.49 (0.74)	1.71 (0.57)
No (n = 750)	3.20 (0.66)	1.78 (0.41)	1.93 (0.55)	2.46 (0.68)	1.85 (0.59)
p	.430	.002	.970	.713	.060

Note:

^aLevene’s test of homogeneity of variances significant, t test does not assume equal variances.

3.5. Correlations between frequency of patient navigation tasks and characteristics of navigated populations

There were significant positive correlations between more frequently providing PN to Hispanic patients and more frequently providing basic navigation, care coordination, treatment support, and making arrangements and referrals for services (Table 6). Navigators who reported providing services more frequently to Asian patients provided treatment support and clinical trials/peer support significantly more frequently. There was also a statistically significant positive correlation between frequency of making arrangements and referrals to service and providing clinical trials/peer support and both the number of Native American patients as well as the number of Pacific Islander patients that navigators served. Finally, providing services more frequently to White patients was significantly positively correlated with providing more basic navigation and more frequently making arrangements and referrals and significantly negatively correlated with providing more care coordination.

Table 6.

Correlations between frequency of patient navigation tasks and number of patients assisted in past week in each racial or ethnic group and with each insurance type.

	Basic Navigation	Making Arrangements and Referrals for Services	Care Coordination	Treatment Support	Clinical Trials/Peer support
Race/Ethnicity of patients
African- American/Black	0.06	−0.03	−0.04	0.01	0.01
Asian	0.03	0.03	0.04	0.08*	0.11**
Hispanic	0.08*	0.08*	0.15***	0.09**	0.06
Native American	0.00	0.11**	0.04	0.01	0.07*
Pacific Islander	−0.01	0.08*	0.03	0.04	0.11**
White	0.12**	0.08*	−0.12**	0.09	0.06
Insurance status of patients
Uninsured	0.05	0.15***	0.17***	−0.03	−0.02
Medicaid	0.10**	0.18***	0.03	0.06	0.13***
Medicare	0.04	0.03	−0.11**	0.02	0.03
Private Insurance	0.06	−0.06	−0.08*	0.13***	0.17***

Note:

^*p < .05,

^**p<.01,

^***p < .001

There were also significant correlations between frequency with which navigators provided various types of services to patients with various types of insurance (Table 6). Patient navigators who saw more patients with private insurance and Medicare reported providing significantly less care coordination. On the other hand, patient navigators who frequently provided services to uninsured patients also frequently provided arrangements and referrals to services. Patient navigators who assisted more uninsured patients also more frequently provided services related to care coordination. Participants who reported assisting more Medicaid patients provided significantly more basic navigation, clinical trials/peer support, and made more arrangements and referrals to services. Finally, patient navigators who saw more patients with private insurance provided more treatment support and clinical trials/peer support services.

4. Discussion and Conclusion

4.1. Discussion

This study examined differences in types of PN services provided by patient navigators with varying characteristics, working in various settings, and providing PN for various diseases. It also examined associations between frequency of providing different types of PN services and the frequency of providing care to patients of different racial and ethnic backgrounds and with different types of insurance. Findings from the study indicated patient navigators provide more basic navigation than any other type of PN service, indicating that the ability to: assess and address patients’ needs and barriers to care; learn about and educate patients on their medical condition or general health; and follow-up with patients are core skills that all patient navigators must possess. This finding supports some of the recommendations for PN core compencies in communication and provision of education and information [14–18, 20].

As suggested in a review of five PN programs [9], there was significant variation in the provision of PN services according to characteristics of the navigator, setting of navigation, disease outcomes targeted by navigation, and patient population (Table 2). With respect to characteristics of navigators who provided each type of PN, the present study found that navigators who identified as Hispanic or multi-racial/other race most frequently made arrangements and referrals to services and provided care coordination, potentially providing support for the model of navigation that indicates that cultural background and familiarity with a specific population are key aspects in hiring a navigator. Nurse navigators and those with low levels of education were most likely to provide basic navigation; highly educated social worker/counselor navigators were more likely to make arrangements and referrals to services and provide treatment support; and highly educated nurse navigators were more likely to provide clinical trials/peer support. Thus, it is clear that tasks performed by these types of navigators correspond with skills obtained through training. Study findings also indicated that certain life experiences, such as being a cancer survivor, were associated with providing certain types of PN services. Thus, caregivers and cancer survivors may apply their life experiences to obtain employment as a navigator.

The type of PN services provided also varied by the setting in which PN was delivered. In suburban areas and hospitals, navigators more frequently delivered treatment support and clinical trials/peer support, reflecting a stronger focus on providing emotional support and supporting a patient in treatment who is interacting within a healthcare system. On the other hand, in community-based organizations and health care centers, navigators more frequently made arrangements and referrals to services and provided care coordination services, reflecting the fact that PN tasks were performed to assist patients with obtaining basic needs and addressing barriers which prevented them from obtaining health care.

The frequency of providing PN services also differed by the disease outcomes the PN intervention was targeting. Navigators who reported more frequently providing PN for health care related to breast cancer screening, diagnosis, treatment, or survivorship, also reported providing more frequent services for clinical trials/peer support, care coordination, and basic navigation, indicating that breast health navigators seem to be hired to provide a unique form of PN that focuses on ensuring patient well-being as the patient moves through the healthcare system.

Finally, the present study found interesting correlations between characteristics of patients and frequency of delivering various types of PN services. These findings may help employers understand the skill set required to care for certain patient groups, which can be useful in hiring and training of a navigator. In addition, patient navigator training programs can better focus on providing appropriate skills to patient navigators working with specific populations. For example, navigators who frequently provided care to patients without insurance or with Medicaid also more frequently provided basic navigation and care coordination and made arrangements and referrals to services; thus, it is clear that these specific skills are needed for this particular PN workforce.

Several conclusions can be drawn from these findings. First, providing basic PN services is a core competency of all patient navigators; thus, all patient navigator training curricula should train patient navigators to perform basic navigation. Second, making arrangements and referrals to various services and providing care coordination are tasks frequently performed for ethnically and racially diverse patients and for patients who lack insurance, as well as by navigators who work in community-based clinics and organizations. This suggests that care coordination and making arrangements and referrals to services are being applied to reduce disparities in health care, which was the original goal of PN [25]. On the other hand, it appears providing treatment support, clinical trials support, and peer support are specialty services within PN often delivered by highly educated patient navigators, nurse and social work navigators, in hospital and surburban settings, and to patients with private health insurance. Thus, there may broadly be two areas of specialization in the field of PN, one which focuses on reducing health disparities, and another which focuses on disease treatment and emotional support. PN training programs should consider specific skills the navigator will need for his or her particular job and provide specialized training according to the area of specialization. Furthermore, models of patient navigation which suggest that all navigators should be lay or professional do not represent the actual practice of navigation. Instead, navigators should be selected based on the tasks they will be expected to perform with consideration given to the setting and population in which navigation will be conducted.

Although this is the largest study of the delivery of PN services to date, it is not without limitations. First, we assesed PN services with a new measure that has limited psychometric information. While this new measure assessed frequency of provision of 83 PN services, it is possible that some services may not have been assessed. Second, while the study included a diverse group of patient navigators providing services in various locations, patient populations, and diseases, it is not clear whether the sample is representative of the population of patient navigators. Third, this study did not evaluate efficacy of various types of PN services in improving disease outcomes or patient-reported outcomes, nor did it evaluate whether these services were effective in reducing health disparities. Fourth, this study was conducted prior to implementation of the Affordable Care Act. Since 2013, PN has included efforts to reduce hospital readmission, improve healthcare quality, and reduce costs. Fifth, the survey was conducted using RDS as there was no registry of patient navigators available that could be sampled. Thus, the study may be affected by selection bias.

4.2. Conclusion

Findings indicate basic navigation services are most frequently provided by all types of patient navigators, and there is significant variation in provision of PN according to characteristics of the patient navigator, setting of navigation, disease outcomes targeted by the PN intervention, and patient population. Future research should evaluate effectiveness of various approaches to core and speciality training on outcomes (i.e., timeliness of care) of PN.

4.3. Practice implications

PN training curricula and competencies should include both basic navigation and specialty navigation, as needed. All patient navigators should be trained to provide basic navigation services. Additional specialty PN training may be required in providing care to certain populations and certain settings.

Highlights.

• There are multiple proposed core competencies for patient navigators.

• No study has evaluated navigator tasks associated with context of navigation.

• Basic navigation services are provided by all models of patient navigation.

• There is significant variation in provision of other types of patient navigation.

• Training curricula and competencies should include basic and specialty navigation.