Patient navigators becoming the norm in Canada.

Directions are readily available to navigate city roads but what about the road to cancer recovery? Where’s the map to direct patients through the twists, turns and unmarked pathways of the health care system? Increasingly, the North American solution isn’t a map but rather a personal guide known as a patient navigator. But unlike the United States, where patient navigation is a somewhat helter-skelter unregulated occupation, (www.cmaj.ca /lookup /doi/10.1503/cmaj.109-3973), in Canada, it’s slightly more regulated, with often-defined roles and responsibilities. That responsibility typically involves connecting patients who have cancer with the right doctors and ensuring that they have access to the host of available therapies and resources. Navigators are also there to ensure continuity of care and to get answers to questions patients have about their diagnosis. Although the profession is still somewhat embryonic in nature, navigators have been appointed in virtually all provinces, with Nova Scotia leading the way. They are largely the product of patient demand, says Sandra Cook, patient navigation project manager for Cancer Care Nova Scotia. The “overwhelming recommendation coming from the patients, the survivors and their families was that the system was extremely complex and they needed assistance in just transitioning through the maze.” Health care reforms in the 1990s, and the shift toward ambulatory care, limited the time a physician could spend with a patient and reduced the ability of a physician to offer information about the impact of a diagnosis and available treatment options, Cook adds. “In a half hour to hour appointment, if you don’t get it, who do you turn to because the next patients are waiting.” Cook asserts that a minimum of 13 (and a mean of 32) physicians are involved with patients who progress beyond stage one cancer. “When you think of the communication challenges with that, having someone who knows each of the phases that you’re transitioning through helps,” she adds. Navigators provide a measure of familiarity and security for patients, she adds. “Patients have described the experience as being on a conveyer belt, it stops, you fall off and then you crawl on to the next phase but there doesn’t seem to be a connection so they use the navigator as that bridge so they don’t have that sense of falling off the conveyer belt quite as quick but it’s continuous.” In addition to connecting patients to resources and specialists, navigators also help patients obtain financial resources to cover such costs as transportation to a cancer centre and chemotherapy. Even with universal health care, patients can’t “walk away from the issue of finance,” says Margaret Fitch, head of oncology nursing and co-director of the patient and family support program at the Odette Cancer Centre in Sunnybrook Health Sciences Centre in Toronto, Ontario. Treatment may also require time off work, which contributes to financial pressure, adds Fitch, who got involved with patient navigation after chairing a federally funded Canadian Partnership Against Cancer action group in 2007. “When I first started looking at all this, it just felt like a dog’s breakfast. There were so many different notions, so many different ideas,” she says. Unlike the US, where community and private models of patient navigation have flourished, Canada has adopted a more regulatory approach to the profession, although programs do vary from province to province. Most Canadian navigators are nurses. In Nova Scotia, a navigator must be certified in oncology and have at least five years’ experience working with patients who have cancer. Oncology certification is also a requirement in Quebec which has about 270 l’infirmière pivot en oncology. An Ontario navigation program is still in its project phase so there are no fixed certification News CMAJ