I am an Assistant Professor in Medicine at Harvard Medical School and a primary care physician at Massachusetts General Hospital. I received my MD and PhD from University of Zagreb School of Medicine in Croatia. After coming to the United States, I completed a fellowship in medical education at Harvard Medical School, internal medicine residency training at Newton-Wellesley Hospital in Newton MA, and a fellowship in geriatrics at Mount Sinai Hospital in New York City. I practice in a community health center located in Chelsea, Massachusetts, which serves ethnically diverse, low income, immigrant populations. My current research focuses on eliminating disparities in cancer care among vulnerable populations. As the MGH Center for Community Health Improvement Physician Leader for Cancer Outreach Programs, I coordinate all patient navigator programs for cancer prevention. I also serve on the steering committee of the Reduction of Cancer Risk and Disparities Program at Dana Farber/Harvard Cancer Center. In 2011, I received the Prevent Cancer Prevention Foundation Laurel for Innovative Programs for developing Colorectal Cancer Screening Patient Navigator Program at MGH Chelsea Health Center where I practice. I also designed the Komen Breast Cancer Screening patient navigator program that eliminated disparities in breast cancer screening in women refuges from Somalia, Bosnia and the Middle East. I am a co-investigator on an Agency for Healthcare Research and Quality funded grant evaluating a patient-centered, population-based information technology system for cancer screening within a primary care network. For this grant, I oversee the expansion of patient navigation for cancer screening across the entire MGH primary care network.
Questions and Answers
Patient navigator programs have been shown to improve cancer care in vulnerable populations. Although our program focused on colorectal cancer screening with an emphasis on colonoscopy, such programs are also effective for breast and cervical cancer screening. Our community health center serves a predominately poor, immigrant, underserved, Latino and non-English population, but the program can be adapted to different settings and other patient groups. We think the key is that the patient navigators come from the community they serve and are well-trained to provide culturally appropriate education and navigation. In our program, we exclude patients with dementia and severe mental disease such as schizophrenia as well as with ongoing serious, acute health issues where prevention is not appropriate.
An important factor in successfully implementing our program was obtaining ‘buy in’ from all the stakeholders in our community as well as local “experts” in gastroenterology, community engagement, assessing disparities and quality measurement and improvement. All my colleagues in the practice and community health team at the health center embraced the program and supported its implementation. The clinical research team helped us design a rigorous evaluation for the program.
Challenges in disseminating this work to other settings include getting support within your practice, funding to support the navigators, and coordinating with a local gastroenterology practice. Then a continuous evaluation process is needed to troubleshoot problems that develop. The patient related challenges are transportation, insurance issues, preparation for colonoscopy, etc.
One of the first steps is establishing a strong collaboration with your gastroenterologists. Language issues, facilitating scheduling and no shows are all issues that can derail getting scope procedures done. Identifying the right individual(s) as navigators, ones that are empathetic and can relate to the issues your patients are dealing with, and then training them so that they are comfortable with the clinical issues and local logistics is another key step.
During our study we developed and used a very simple questionnaire for patient navigators, our “Patient Contact Form”. The navigator used the form every time she/he contacted the patient to record the patient barriers to screening and interventions performed to overcome them. The form also creates data that the navigator’s supervisor can use to evaluate the PN work - information such as the number of contacts made, types of interventions, and the number of screenings completed. Patient navigators also keep separate records of completed CRC screenings/type of screening and results.
Building on this experience with our CRC screening program as well as other navigator programs for women with abnormal pap smear or mammography results, we designed a new patient centered navigator program for breast/cervical and colorectal cancer screening. This was developed as part of a new information technology (IT) system for population-based cancer screening within our entire primary care network. Using this newly developed IT system, the patient navigators are now able to reach vulnerable patients overdue for one or more cancer screening tests in any of our network’s practices.