As a way to monitor this process, Utilization Review

was conducted. The definition of Utilization Review (UR) is a process for monitoring the use and delivery of services, especially one used by a managed care provider to control health care costs. There were “UR nurses” employed by insurance companies to perform (retrospective) medical record review and determine if there were inappropriate utilization of hospital or professional resources. Such days of hospitalization that occurred on  weekends when radiology services weren’t available or an extra night in the hospital because the patient didn’t have someone available to drive them home were closely scrutinized. This was especially an issue for patients needing transfer to a nursing home or rehabilitation center. Patients commonly waited days or even as long as week to be discharged to a lower level of care. Doctors and the hospital received “denial letters” from UR departments at managed care organization or the organizations overseeing Medicare and Medicaid (called Peer Review Organizations) informing the doctor (and hospital) that certain days of care or tests that were performed on the patient during her hospitalization would not be covered and it was hard to persuade the verdict to be reversed. There were situations in which patients were prematurely discharged from hospitals due to the realization they have reached their DRG limit. Money became the driver rather than quality of care. In an attempt to anticipate which patient’s records might result in the issuance of a denial letter, hospitals employed UR nurses as well to perform the same chart review task. These individuals would inform the finance department of potential risk of financial loss based on their medical record review. In some cases, the hospital UR department also sent letters to the doctors informing them of the same and requesting that they explain why care was delivered in a less than optimal manner. Bottom line was ,however, that the patient had gone home and the doctor was now busy taking care of new patients. His interest in explaining why the radiology department isn’t open on weekends or why the patient requested to stay an extra day was the least of his current worries. What was more concerning however was that there were situations in which patients were prematurely discharged resulting in poor care being provided. It clearly resulted in bad medical care. The tail was wagging the dog.

In the late 1980s, changed were made to this odd way of monitoring care and Utilization Management was introduced.  The definition of

Utilization Management

is the evaluation of the appropriateness, medical need and efficiency of health care services procedures and facilities according to established criteria or guidelines and under the provisions of an applicable health benefits plan. Though the overarching goal, according to the government and managed care organizations was to help ensure that patients were provided cost effective care, of high quality, delivered in an efficient manner, and which was medically necessary, the relationship between managed care organizations as well the government (PROs) overseeing Medicare and Medical Assistance, still had an adversarial relationship with doctors and hospitals. The mission was to avoid delays in treatment and delays in discharge from the hospital for inpatients receiving care, no matter what their disease or disorder was. DRGs were still the payment system. Insurance companies invested large dollars in performing, in a concurrent manner, medical record review while the patient was hospitalized. UM nurses monitored a patient’s hospitalization to ensure each day was medically necessary, there were no barriers to treatment or barriers to her being discharged to home or to a lower level of care, and she had a good clinical outcome.  (note I used the navigation word “barriers”) Hospitals now employed their own UM nurses (many of whom were previously UR nurses) to review the medical record documentation each day during the  patient’s hospitalization  and contact the doctor if there were any barriers to treatment or to her discharge she identified. The most common problem was lack of documentation in the medical records by the doctor to justify medical necessity for her to be there on a given day in the hospital. Keep in mind too that up to this point whether it was the UR process or the UM process being followed, neither the  review nurses working for the outside or the nurses doing chart review inside had any contact with the patient at all.  There were also situations in which the hospital UM nurse was responsible to contact the insurance carrier’s UM dept each day and report in on what specific care was being provided to the patient in order to justify her staying in the hospital “one more day.” Quality of care was getting more attention now however, and patient safety was starting to surface. PROs in particular were monitoring care from a quality perspective, raising flags when a complication would occur that was felt to be avoidable. Such instances could result in the team of doctors and nurses coming to the hospital and conducting focused reviews of specific patient populations. The war continued between payers of care and the deliverers of care.

In the early 1990s some evolution to this process occurred yet again. Case management was born. The definition and philosophy of

Case Management was quite different than what had been conducted previously under the UR or UM program models. Based on the needs and values of the patient and in collaboration with all her healthcare providers, the Case Manager (again a role fulfilled by a nurse) linked clients with appropriate providers, and resources through the continuum of health and human services and care settings, while ensuring that the care provided is safe, effective, patient centered, and delivered in an efficient manner. Finally the patient was involved and the nurse involved with the patient. The role went from adversarial to one of collaborative health care professional and the case manager was considered a vital member of the healthcare team taking care of the patient.  The case manager had hands on involvement with the patient and addressed these barriers by ensuring tests happening in a timely manner, the patient was educated about her disease and its treatment, consultations for planning the next phase of care was arranged,  the team members involved with delivering the care were communicating with one another, psychosocial and financial issues were addressed that might impact care or delay it, and home care arrangements were made if a patient needed additional medical care after discharge. A particular focus, initially, was on patients with medical disorders who needed to be managed in a less expensive environment (lower level of care)—either nursing homes, rehab centers, or at home with home health care nurses or aides. Finally the health care system was no longer just focusing on charts and dollars but were focusing on the patient. Granted, having the patient’s hospitalization not exceed the DRG limit was important, but greater emphasis was placed on improving efficiency in the care delivery process, engaging the patient in her care, and carrying the management of her care over into the outpatient setting.  There are even some who would say that case management and patient navigation are the same thing. System barriers and individual patient barriers to care were surfacing and beginning to be identified and managed in a systematic way.

As time progressed and more and more care became outpatient based, which was somewhat  better reimbursed and less expensive than inpatient hospitalization, the focus needed to change once again in how care would be managed and monitored. As you’re no doubt very aware, when a patient is in an inpatient bed today they are very sick.  Though utilization management programs are still in operation, justifying medical necessity for the patient staying in the hospital is rarely an issue today. And though more and more care is delivered in a more appropriate healthcare setting, it remains expensive and why the government and managed care organizations are continuing to look at alternative ways of delivering care, as well as paying for it.

During the time that utilization management was being established, attention was being paid to issues associated with access to care. Dr. Harold Freeman, who coined the term, patient navigation, brought to the attention of health care professionals some important information that changed once again the how the delivery of health care services, especially those for cancer care, would be conducted. The central issue he identified and campaigned about was that patients face a variety of barriers to standard cancer prevention information, screening, diagnosis, treatment and follow up care that inhibit timely access to health care services. These barriers include fragmentation of health care services; lack of health insurance or underinsurance; provide-and patient-related education barriers; communication barriers, particularly for patients who first language is not English; inadequate transportation to medical appointments; and missed appointment due to travel, child care, or employment barriers. Health disparities arise when the delivery system does not provide access to timely, standard cancer care to everyone who needs it. This was particularly evident among racial/ethnic minorities, people of low socioeconomic status, residents of rural area and members of other underserved populations. Working at Harlem Hospital at the time, he implemented patient navigation to address this health disparity issue. Note that now the spectrum of care was greatly broadened. Up until now the focus had been on patients who were already familiar and “in” the healthcare model, who had insurance coverage of some kind, and were undergoing treatment for a disease or disorder that had already been diagnosed. Now the focus would begin much sooner--- with routine screening, in the case of breast centers, mammography screening. Navigators were responsible for educating the community about breast cancer awareness and recruiting patients to come to the mammography facility for screening and if needed diagnostic evaluation. The goal of

Patient Navigation as Dr. Freeman defined it and which was also adopted by the National Cancer Institute is to facilitate timely access to quality, standard cancer care in a culturally sensitive manner for all patients. Examples of navigation services included: facilitating communication and information exchange for patients with a limited understanding of the English language; coordinating care among medical service providers; and arranging for financial support, transportation, or child care services. Navigators under his model could be community lay persons or health care professionals. Navigation was to span the period from cancer detection procedures (i.e., screening mammography) through cancer diagnostic test to completion of treatment. This issue was just not one isolated to Harlem Hospital of course. The Institute of Medicine (IOM) report, Care without Coverage: Too Little Too Late, states that uninsured patient get about one-half the health care of insured patients and consequently die sooner than insured patients, largely because of delayed diagnosis. Another IOM report, Ensuring Quality Cancer Care, cites concerns about lapses in care that can lower the chances of receiving standard of care and compromise the quality of life and survival of cancer patients.

With the transference of care from an inpatient setting to an outpatient setting, and managed care dictating where a patient can have their treatment, more and more of the burden of keeping the schedule straight, understanding the sequence of care and treatment that lies ahead, and figuring out how to go from step 1 to step 2, etc. rests on the shoulders of the patient.  Whether the patient has cultural barriers, financial barriers, racial barriers, etc, the health care system has become incredibly complex. For someone diagnosed with a new cancer, figuring out what happens next, what to expect, and how to ensure she is getting appropriate care is overwhelming to accomplish without help.  Patients and their families are so scared and shocked by the diagnosis that imagining they can navigate through decision making about treatment options as well as actually receive the multimodality treatment in a reasonably smooth way is viewed as nearly possible. So in the early 2000s the patient navigator role was expanded to be utilized by all patients and not just those who fit a specific underserved definition. This doesn’t mean to say that it’s only been in the last few years that breast cancer patients have had someone to help them along this journey. Technically, everyone involved in her care and treatment has always had some role in navigating her along the decision making/treatment pathway but this process has been fragmented without a way to ensure that it really is happening. Each healthcare provider has focused on their specific portion of care, not necessarily looking across the continuum as the patient needs to have done. Having a designated person who is referred to as a navigator has become a new buzz word in the last few years and particularly popular in a breast center setting. Therefore the patient has expectations of what such an individual can do for her once she has become diagnosed with breast cancer.

A strong focus remains however on addressing the needs of the underserved, recognizing that their need for patient navigation is the highest among all populations. The President’s Cancer Panel (2001) reported on barriers including system barriers (fragmentation of care), financial barriers (lack of insurance or underinsurance), physical barriers (excessive distance from treatment facilities), information and education barriers (both provide and patient related), and the issues of culture and bias. Other barriers that were identified that must be overcome include insufficient culturally sensitive information and educational materials for cancer patients and their families; inadequate transportation assistance to get to medical appointments; missed appointments due to travel or childcare barriers; patients’ fiscal inability to take time off from work for screening and wellness care; and failure of providers to obtain patients’ medical test or laboratory results in a timely fashion. Cultural and language barriers usually affect members of underserved population. The cumulative effect of these barriers is unequal delivery of cancer prevention services and delays in detection, diagnosis and quality treatment of cancers. Many racial/ethnic minorities, people of low socioeconomic status, residents of rural area and other underserved populations facing such barriers simple give up out of frustration or misunderstanding and drop out of cancer care services.

This has resulted in various navigation models being developed in cancer centers. there may be navigators in a breast center for example who function similarly to that of a case worker, helping to sheppard underserved women in for screening mammograms and education about breast cancer and breast health. The case worker may be physically located at an office outside of the breast center space itself. Community based where she can reach the masses daily. This individual may remain involved in a navigation role through her diagnosis or treatment or more often might transition the patient over to another navigator (commonly a nurse) whose focus is on the diagnosis portion or treatment portion of breast cancer care. So your institution may be doing both types of navigation—pre diagnosis and post diagnosis.  As you see, these functions are rarely done by the same person, with one being based in a community setting having a liaison role with the breast center and the other being based physically at the breast center. There are also breast centers that have Mammography Technicians within their imaging facility who fulfill the role of navigator from point of the patient coming in for her screening mammogram through to the patient of her being diagnosed by having a biopsy done in breast imaging.

In April of 2008, C-Change, a national cancer coalition comprised of key national leaders from the government, business and nonprofit sectors, hosted an educational briefing for members of Congress at the US Capital. C-Change is a national cancer collaborative comprised of leaders from the public, private and not for profit sections. The vision and mission of C-Change is to eliminate cancer as a public health problem at the earliest possible time, by leveraging the expertise and resources of its members. The organization strives to accelerate cancer research, improve the timely access to the full continuum of quality cancer care services and support State, Tribe and Territory comprehensive cancer control efforts. (for more information go to www.c-changetogether.org)  The Cancer Patient Navigation Act was discussed. At this historic meeting, cancer patient navigation was discussed at length and its importance in helping to ensure that cancer patients receive patient focused care that is coordinated and of high quality.  Patient navigation was referred to as the individualized assistance offered to patients, families and caregivers to help overcome health care system barriers and to facilitate timely access to quality medical and psychosocial care from pre-diagnosis through all the phases of the cancer experience. Navigators guide a patient through the physical, emotional and financial challenges that come with a cancer diagnosis. The Cancer Navigation Act which was signed into law in June 2005 proposing $25 million over 5 years for demonstrating programs to provide navigator services to improve health outcomes. C-Change and other cancer leaders asked for the full $25million in funding of the Act in FY 09.

So you now can see where navigation began—through retrospective chart review in an adversarial environment—to now being a collaborative process that involves the patient and everyone who takes care of that individual. We’ve come a long way—finally addressing the needs of the most important thing of all—the patient.