Breaking Down the Basics of Patient Navigation, Care Coordination

Provider versus payer patient navigation

Fundamental to understanding patient navigation is assessing what it means to both provider organizations and the payer industry. For both sides of the proverbial healthcare coin, patient navigation generally means helping patients work their way through the complexities of medicine, but there are key differences in the payer versus provider spaces.

According to the Centers for Medicare & Medicaid Services (CMS), patient navigators work in the payer space to help consumers understand their health plan options.

“Navigators play a vital role in helping consumers prepare applications to establish eligibility and enroll in coverage through the Marketplaces and potentially qualify for an insurance affordability programs,” the agency says on its website. “They also provide outreach and education to raise awareness about the Marketplace, and refer consumers to health insurance ombudsman and consumer assistance programs when necessary.”

These statewide patient navigator programs are funded by CMS grants and operate year-round, the agency added. Most recently, CMS awarded $80 million total in 2022-2024 marketplace navigator grants.

Individuals working as marketplace navigators must complete federal training, complete a criminal background check, and complete state training and registration if the navigator’s particular state requires such.

In a clinical setting, patient navigators help patients work their way through the complexities of disease management and care coordination.

“Patient navigators are staff members who work with patients to overcome barriers and understand the medical system,” the Centers for Disease Control & Prevention says on its website.

Patients often have access to clinical patient navigators when they have extremely complex illness, like cancer, although patient navigators can in some cases help navigate individuals with complex social determinants of health needs.

There is no set educational or credentialing requirement for patient navigators, leaving individual clinician offices or health systems to carve out a job description that meets the needs of their patient populations. In a sample job description, the CDC offers some example qualifications:

• Minimum high school degree or some college education
• Strong understanding of cultural competency with the target population
• Bilingual (English/Spanish) preferred
• Computer literacy desirable
• Exposure to issues of death and dying

Healthcare organizations may also be beholden to individual state requirements. Some healthcare organizations might consider deploying some of their nursing staff as patient navigators, while others should look into community health partnerships, employ social workers, or tap Community health workers.

Patient navigation and disease management

Patient navigators are common care team members for individuals with extremely serious or complex illness, including cancer. These patients need to see an array of clinicians, will likely undergo several procedures, and face serious social determinants of health needs and barriers to care.

“A patient navigator helps patients communicate with their healthcare providers so they get the information they need to make decisions about their health care,” the NIH National Cancer Institute says.

“Patient navigators may also help patients set up appointments for doctor visits and medical tests and get financial, legal, and social support. They may also work with insurance companies, employers, case managers, lawyers, and others who may have an effect on a patient’s healthcare needs. Also called patient advocate.”

Patient navigators are also common for individuals with serious or multiple chronic illnesses or individuals exploring or participating in clinical trials. These healthcare professionals work to guide the patient through these systems and reduce any administrative burden a patient might face herself. Ultimately, this should reduce the barriers to care the patient might face while paving a smooth patient experience.

These efforts are mostly successful when clinical teams have a strong understanding of individual patient needs, studies have shown. In 2015, researchers wrote in the Journal of Cancer Education that patient navigation services can improve patient satisfaction scores when navigators know exactly what a patient needs, particularly in terms of social needs.

To that end, successful patient navigation programs will include social determinants of health screening to assess patients and then tailor navigation services. Other qualities of successful patient navigation programs include:

• Cultural competency training for navigators
• Offerings in multiple languages
• Navigation services for financial, clinical, and social needs
• Focus on care coordination
• Focus on patient education

Patient navigation and social services

Some healthcare organizations may find some patients without serious illness or multiple comorbidities could benefit from patient navigation services. These patients usually have extremely complex social determinants of health needs.

Patients who might benefit from patient navigation include:

• Dual-eligible patients or patients without health insurance
• Patients experiencing multiple social determinants of health
• Patients who regularly utilize the emergency department due to limited low-acuity care access

In these cases, patient navigators may be more focused on care coordination with social services providers. Strong community health partnerships and a manageable social services referral system—whether that be manual or digital—will be essential to supporting patient navigation.

Building a patient navigation program

As the medical industry continues to promote patient-centered care and health equity, the need for a patient navigator program will likely grow. It will be important for healthcare organizations to consider specific needs of their patient populations and begin designing a clinical navigator program from there.

Designing your patient navigator program

According to CDC, healthcare organizations need to determine which types of staff to employ as patient navigators—social workers, nurses, community health workers—and how the organization will work with community partners to facilitate the program.

From there, organizations can outline key performance indicators and quality metrics.

Organizations will want to determine how the patient and the navigator will interact—phone calls, secure messaging, or in person?—and whether they will work as part of and within the health system or separately.

CDC did not advocate specific answers to those considerations. Rather, surveying the clinical staff and patients will help organizations determine the best fit for their needs.

Sustaining a patient navigator program

Healthcare organizations should also assess the resources they will need to support a patient navigator department, including the physical tools the navigators use and the personnel who manage the department.

Additional considerations may include funding support through state and federal grants as well as cost sharing across clinic or hospital departments working with clinical navigators.

Healthcare is poised for this level of team-based care. The push for more patient-centered care, the influx of patients managing multiple chronic illnesses, and the renewed focus on social determinants of health and social barriers to care have underscored the importance of clinical navigators.

By understanding organizational needs and current resources, clinics and hospitals can determine their best path toward building a strong patient navigator program.