Seamless Care: How Patient Navigators Help

Traversing the healthcare landscape after receiving a serious diagnosis or having to undergo a major surgery is far from easy. There are tests and treatments to schedule, physicians to speak to, visits to attend and big decisions to make. The list of to-dos can seem endless and the stress of the unknowns can be daunting.

Doylestown Health patient navigators know this. Their job is to be a reliable resource and help guide patients through an extra-challenging time.

Informed Guidance

For patients with breast cancer, Kathy Nellett, RN, OCN, CBCN, is there to help them at the time of diagnosis to whatever comes next. Usually their journey starts with surgery and then potentially, chemotherapy, radiation or both. It’s a lot to coordinate and handle for any patient.

“I’m here to help them get timely care in a safe manner. I guide them to all the other resources we have available here and make sure that the process goes as smoothly as it can,” says Kathy.

Part of what Kathy does is spend time advising patients on the phone and in person — she even stays with them while they’re having procedures performed.

Similarly, Marianne Haig, BSN, RN, works closely with patients who’ve been diagnosed with colorectal cancer. Some of what she helps with includes ensuring appointments are scheduled for CT scans or MRI, blood work or with medical oncology or radiation oncology. Then, she follows up with the patients after these appointments to make sure that no part of their care is “falling through the cracks,” she adds. “I follow along in their care and call them to check in on them to see how they’re doing and if they need anything.”

Different than Case Managers

While some of what navigators do sounds like case management, they are not case managers. Navigators tend to follow patients for the long run, not just while they’re in the hospital like case managers. They provide extra support and spend a lot of time sharing their health care knowledge and educating patients on their conditions and treatments.

Navigators also tend to have a close working relationship with physicians. The Doylestown Health navigators routinely meet with physicians, surgeons, oncologists and the like to ensure they don’t miss any aspect of care for the patient.

In orthopedics, the navigators follow patients who have elective surgeries, like joint replacements and spine surgeries, as well as patients who’ve experienced hip fractures. They get involved from the time of scheduling patient surgeries and work with them until after they are discharged. Navigators meet daily with surgeons, therapists, nurses and physician assistants to update them on the patient’s goals to coordinate a safe discharge plan. And every day, they make rounds with all the patients while they’re in the hospital and then follow them throughout their discharge.

Some of what they do after discharge is refer patients to rehab or home care. “We give them options. We can direct them to rehab or give them ratings for home care services and, we make the referral for what they might need at home,” says Pam DiPietro, MSW, orthopedic navigator.

One example of what an orthopedic navigator can do is anticipate the specifics of what patients will need. “I had a patient who was having a knee replacement and would need a lot of assistance, but didn’t have much family support. So I worked with her to problem solve and came up with a solution of hiring a private caregiver,” explains Kathy Johnson, LSW, orthopedic navigator. “When I talked to her after the fact, she was very grateful that we worked together to find that solution.”

More Specific Circumstances

In some cases, patients have very specific issues after undergoing cancer treatment that might require another type of navigator’s help. For example, some patients who are already undergoing cancer treatment can put them at greater risk for heart issues (like treatment for breast cancer on the left side) while others getting treated for cancer might have an underlying heart condition. A physician would then assign these patients to a cardio-oncology navigator like Kassie Richman, BSN, RN.

Kassie helps educate this specific patient population on how chemotherapy or radiation might affect their heart. “I touch base with patients regularly to make sure they’re not having any cardiac symptoms — like any shortness of breath, lightheadedness or dizziness. And I make sure they’re seeing a cardiologist while going through treatment,” Kassie says. “Once they see the cardiologist, sometimes medications are started and then I call the patient afterward and reinforce education on medications and answer any questions.”

Lessening Stress

Overall, a navigator is like an added layer of reassurance. Susan Keiper, BSN, RN, OCN explains she knows the value that navigators provide to patients from personal experience. Her father was diagnosed with cancer and had a navigator whom both of them could talk to about his treatment, which was a major benefit to the family.

“If you can just have someone to call and talk to, it’s a huge stress relief,” says Susan, who is a urology navigator. “So you could say that we navigators help provide a better outcome for our patients because we’re reducing that stress.”

Rachel Saks, MSS, LSW, OSW-C, director of the Doylestown Hospital Cancer Institute, agrees.

“Our navigators have a one-on-one relationship with their patients. There’s pretty much no limit to what they can do,” says Rachel. “They can be extraordinarily beneficial, even life-changing for some patients.”