July 21, 2014 Standard Occupational Classification Policy Committee U.S. Bureau of Labor Statistics, Suite 2135 2 Massachusetts Avenue NE., Washington, DC 20212 To Whom It May Concern: The George Washington University Cancer Institute, in conjunction with the Academy of Oncology Nurse & Patient Navigators (AONN+), the Colorado Department of Public Health and Environment, the Patient Navigator Training Collaborative, the Cancer Patient Navigators of Georgia (CPNG), the Georgia Center for Oncology Research and Education, Inc., the `Imi Hale Native Hawaiian Cancer Network, the Virginia Cancer Patient Navigator Network, the Florida Coalition of Oncology Nurse Navigators (FCONN), the Cancer Community Network, the Social Work Program at the University of Houston-Downtown and Nueva Vida, are writing to request that the SOC Policy Committee (SOCPC) adopt the proposed definition of Patient Navigation as reviewed and supported by the American College of Surgeons’ Commission on Cancer for inclusion in the 2018 Standard Occupational Classification (SOC) system. A patient navigator is a healthcare expert who reduces and eliminates barriers to accessing care, empowers patients and their families and facilitates timely access to high-quality medical care across the healthcare continuum. Patient navigators work with medically underserved individuals, populations and communities to reduce disparities in health care. A growing amount of literature and research demonstrates the impact of patient navigation on at-risk individuals dealing with medically and culturally complex cases. Research has also shown cost savings to programs utilizing patient navigators. Furthermore, recent changes in national policy and accreditation standards have made clear that the field of patient navigation will continue to grow. Given these changes and the growing body of research to support the field, we feel it is critical that patient navigation be included in the 2018 SOC system. We strongly encourage the SOCPC to adopt the proposed definition of Patient Navigators for inclusion in the 2018 SOC system. Sincerely,

Mandi Pratt-Chapman, MA

Director, The George Washington University Cancer Institute Lillie Shockney, RN, BS, MAS Program Director, Academy of Oncology Nurse & Patient Navigators Elizabeth Whitley, PhD, RN Director, Prevention Services Division Colorado Department of Public Health and Environment Patricia Alvarez Valverde PhD, MPH Director, Patient Navigator Training Collaborative Angela Patterson Vice President, Georgia Center for Oncology Research and Education, Inc. & Cancer Patient Navigators of Georgia (CPNG) JoAnn Tsark Project Director, `Imi Hale Native Hawaiian Cancer Network, a program of Papa Ola Lokahi Christina Sheffield Director, Cancer Network at the University of Virginia Virginia Cancer Patient Navigator Network Delmarie Newman Butler, RN, CBHN, BSHSA President, Florida Coalition of Oncology Nurse Navigators (FCONN) Terri Salter, RN, MSN, MBA UAB Administrative Director, Cancer Community Network Dr. Stephen Wernet Director, Social Work Program, College of Public Service University of Houston-Downtown (UHD) Dr. Health Goltz, PhD, LMSW, Med Assistant Professor of Social Work, Social Work Program, College of Public Service University of Houston-Downtown (UHD) Margaret Darling Chief Evaluation and Advocacy Officer, Nueva Vida Organizations in Support of this Submission: American Cancer Society Cancer Action Network American College of Surgeon’s Commission on Cancer Avon Foundation Breast Cancer Crusade Capital City Area Health Education Center Carmella Rose Health Foundation Pacific Cancer Foundation Via Christi Health Systems (VCHS) Oncology Service Line

The Wisconsin Cancer Council Wisconsin Comprehensive Cancer Control Program Individuals in Support of this Submission: Amy Arnold Cancer Registrar Coordinator Onslow Memorial Hospital Jacksonville, NC Karli Bergheer, MBA Integrative Oncology Patient Navigator Pacific Cancer Foundation Wailuku, HI Jennie Boyer, BSN, RN Oncology Nurse Navigator Saint Agnes Cancer Institute Baltimore, MD Delmarie Newman Butler, RN, CBHN, BSHSA Breast Health Navigator Bethesda Women’s Health Center Boynton Beach, FL Angie Carr, LSCSW, ACSW, MBA Patient Navigator KU Wichita Center for Breast Cancer Survivorship Wichita, KA Darlene deManicor, PhD Patient Advocate Women’s Cancer Resource Center Oakland, CA Christine Economos, BS, BPS, Patient Navigator Los Angeles Center for Women’s Health California Hospital Medical Center Los Angeles, CA Ginamarie Farino, MPH, PA-C Cancer Program Administrator Methodist Hospital of Southern California Arcadia, CA Susan Ferdon Oncology Patient Navigator

Fort Walton Beach Medical Center Fort Walton Beach, FL Charlene Forcier, RN, MS, CHPN Oncology Nurse Navigator Norris Cotton Cancer Center Manchester, NH Lorena Gayton Patient Navigator, Support Screen Department of Supportive Care Medicine Sheri & Les Biller Patient and Family Resource Center, City of Hope Duarte, CA Marc Hulbert, Ph.D. Executive Director Avon Foundation Breast Cancer Crusade Debra Jones, RN, BSN, MPH Oncology Patient Navigator Sentara Leigh Cancer Services Norfolk, VA Susan Krivacic Patient Advocate Judy McCree Carrington, B.A. Psychology, Certificate in Gerontology Community Clinical Linkages Coordinator Prevention Services Division Colorado Department of Public Health and Environment Melissa Mealy Patient Resource Navigator South Atlantic Division, American Cancer Society Wheeling, WV Susan T. Scott, RN, BSN, OCN Oncology Nurse Navigator Roy and Patricia Disney Family Cancer Center Burbank, CA

Robin Supinger Patient Navigator Dayton Physicians Network Dayton, OH Sarony Young Health Systems Policy Coordinator, Prevention Services Division Health Systems Unit Policy, Systems, and Analytics Branch Colorado Department of Public Health and Environment Maggie Ward, MSN, APRN Oncology Nurse Navigator Via Christi Health Systems (VCHS) Wichita, KS Jeanne Strickland Associate Researcher UW Carbone Cancer Center Wisconsin Comprehensive Cancer Control Proram Deborah Szabo, RN, MSN Nurse Manager, Site Disease Group University of Miami Sylvester Cancer Center

Standard Occupation Classification (SOC) System Patient Navigation

Input Requested by the SOC Policy Committee The healthcare system has become increasingly complex and difficult to navigate, particularly for poor, minority and other medically underserved populations. Fragmented care systems and barriers to accessing care such as reliable transportation, lack of childcare, language barriers and a lack of insurance often prevent people that need healthcare from receiving it. The growing field of patient navigation has developed out of a need to help patients with medically and culturally complex cases access timely, high-quality care across the healthcare continuum. Patient navigators are a new occupation developed as part of the transformation of care responsive to patient needs. Patient navigators reduce and eliminate barriers to accessing care, empower patients and their families and facilitate timely access to high-quality medical care across the healthcare continuum. Patient navigators work with medically underserved individuals, populations and communities to reduce disparities in health care. An increasing amount of literature and research demonstrates the impact of patient navigation on at-risk individuals dealing with medically and culturally complex cases. Research has also shown cost savings to programs utilizing patient navigators, making the field attractive for a variety of employers. Furthermore, recent changes in national policy and accreditation standards have made clear that the field of patient navigation will continue to grow. Given these changes and the growing body of research to support the field, we feel it is critical that patient navigation be included in the 2018 SOC system. Proposed definition: 21-109X Patient Navigators Reduce and eliminate barriers to access to care. May perform clinical duties as allowed under applicable licensure. Includes Nurse Navigators who primarily support adherence to treatment by eliminating barriers to accessing care. Excludes “Health Educators” (21-1091), “Social and Human Service Assistants” (21-1093) and “Community Health Workers” (21-1094). Illustrative Examples: Oncology Patient Navigator, Resource Navigator. 1. Nature of the work performed. *Addressing the nature of the work performed is the most important type of information the SOCPC will use when considering comments.

• What duties do the workers in the occupation perform? According to the Patient Navigator Outreach and Chronic Disease Prevention Act of 2005, duties of patient navigators include: (1) acting as contacts by assisting in the coordination of health care services; (2) facilitating the involvement of community organizations in helping

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individuals who are at risk for or who have cancer or other chronic diseases; (3) notifying patients of clinical trials and, upon request, aiding in enrollment of eligible individuals; (4) anticipating, identifying and helping patients overcome barriers within the health care system; (5) coordinating with the relevant health insurance ombudsman programs to provide information to individuals who are at risk for or who have cancer or other chronic diseases; and (6) conducting ongoing outreach to health disparity populations.1 In 2013 the Oncology Nursing Society identified competencies for Oncology Nurse Navigators.2 The George Washington University Cancer Institute has conducted research to better define the roles and responsibilities of Patient Navigators. The Institute has:

1. Conducted a literature and internet review to identify similarities and differences across patient navigator types.3

2. Conducted 6 focus groups with 21 non-clinically licensed Oncology Patient Navigators between March 27th and April 11th, 2014.

3. Conducted a national survey of patient navigators, their supervisors, researchers and others in the oncology patient navigation field (the survey closes August 11, 2014).

Based on the literature and internet review and the focus groups, we identified the following duties for non-clinical patient navigators: Identify and address challenges and barriers to care.

o Assist patients in identifying social, practical and system-based challenges to accessing care.

o Organize and prioritize responsibilities and steward resources to ensure access to care across the healthcare continuum for the most vulnerable.

o Identify, vet and acquire resources responsive to patient needs. o Continually identify, analyze and implement new knowledge to mitigate barriers

to care. o Apply knowledge of health insurance, copay programs, patient assistance

programs and financial assistance to help patients access care. o Understand how various health care delivery settings and systems work and

adapt to meet patient needs. o Help patients optimize time with their doctors and treatment team.

Provide education to patients, providers and communities.

o Orient and educate patients on the health care system and members of the multi-disciplinary team.

o Customize patient and family education based on linguistic, educational, social and cultural needs and preferences.

o Participate in the education of patients and health care professionals. o Educate providers on patients’ individual preferences of care and needs,

including relevant community considerations and cultural appropriateness of approaches and educational materials.

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Empower patients, families and communities.

o Support patients to participate in their wellness by providing self-management and health promotion resources and referrals.

o Know and support patient rights. o Apply Culturally and Linguistically Appropriate Services (CLAS) standards in

health care.

Provide services across the care continuum. o Support a smooth transition of patients across screening, diagnosis, treatment,

disease management and survivorship and/or end-of-life care, working with the patient’s clinical care team.

o Participate in patient-centered care planning with the multi-disciplinary team, assisting the patient with timely follow-up to adhere to treatment and supportive care recommendations.

o Facilitate timely scheduling of appointments, diagnostic testing and procedures to expedite plan of care and promote continuity of care.

o Follow up with patients to support adherence to treatment through continued assessment of barriers and referrals to supportive services.

Document and evaluate patient encounters, interventions, programs and systems. o Obtain and utilize information about individual patients, populations of patients

or communities from which patients are drawn to improve care. o Participate in tracking of metrics to document and evaluate navigation program

and report findings to stakeholders. o Use evaluation data (barriers to care, patient encounters, resource provision,

population health disparities data and quality indicators) to improve navigation process and participate in quality improvement.

o Maintain comprehensive, timely and legible records capturing ongoing patient barriers, patient interactions, barrier resolution and other metrics

Advocate for patients, families, communities and better systems to serve them. o Enhance communication among members of multidisciplinary team to prevent

fragmented or delayed care that could adversely affect patient outcomes. o Advocate on behalf of patients within the community and health care system to

promote optimal care and outcomes. o Advocate for quality patient care and optimal patient care systems.

• Which duties are common to all jobs in the occupation and would therefore

appear in the “required” duties statement in the occupation definition.

Based on the aforementioned literature and internet review, the following similarities across patient navigation roles emerged:

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o Identifying and addressing barriers to care and reducing health disparities as defined by age, disability, education, ethnicity, gender, sexual identification, geographic location, income or race in populations that often bear a greater burden of disease than the general population.4

o The knowledge base and skills needed to perform job-related duties and tasks, including supporting program evaluation efforts.

o Establishing trust and good patient rapport. o Ongoing identification, coordination, and referral to resources such as

individuals, organizations, and services in the community. o Identifying problems and resources to help patients solve problems and facilitate

patient-centered care.

o Ensuring appropriate communication with patient, healthcare and service providers and community.

o Promoting healthy behaviors and lifestyle, including integrative and wellness approaches.

o Understanding scope of practice and professional boundaries, assuring confidentiality and following legal requirements. Maintaining and adhering to the profession’s standards. Bringing accountability, responsibility and trust to the individuals the profession services.

o Supporting healthcare services that recognize, respect, and respond to cultural and social differences within the context of beliefs, practices, behaviors and needs of diverse community and/or population served.5

o Implementing a method of organizing patient care activities to facilitate the appropriate delivery of healthcare services.6

o Connecting patients to resources for psychosocial support services. o Advocating on behalf of patients within the community and healthcare system.

Patient Navigators may focus on a specific disease, such as Cancer, HIV/AIDS7,8 Mental Illness9, Diabetes10 , Cardiology11 or specific populations, such as drug-involved prisoners12, patients in an emergency room13, the elderly14,15 or those at risk for chronic conditions.

• What duties are frequent but not performed by all workers and might be identified in “may” statements in the occupation definition?

Some Patient Navigators may have another professional licensure, such as that of a registered nurse or a social worker. While their primary function may be reducing and eliminating barriers to care, these licensed professionals may perform clinical duties in accordance with their licensure while working as patient navigators. Other duties that may be performed by some, but not all, Patient Navigators include:

o Assess patient capacity to self-advocate.

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o Act as a liaison between patients/families and providers to optimize patient outcomes.

o Provide education and support to patients to identify their preferences and priorities for treatment; facilitate shared decision making in the patient’s health care.

o Provide healthcare education to individuals and communities that address health disparities.16,17

• Are there supervisory or management duties? No

• For revisions to existing occupations, is the work described in the SOC definition

accurate and up to date? N/A 2. How the work performed is distinct from other detailed occupations in the SOC.

• Does the same or similar work appear in other SOC definitions? Yes. “Registered Nurses” (29-1141) and some Community and Social Service Occupations (21-0000) include some similar duties, but no single occupation encompasses all of the duties.

• “Registered Nurses” (29-1141) o May advise patients on health maintenance and disease prevention or provide

case management.

• “Health Care Social Workers” (21-1022) o Services include advising family care givers, providing patient education and

counseling, and making referrals for other services. May also provide care and case management or interventions designed to promote health, prevent disease, and address barriers to access to healthcare.

• “Health Educators” (21-1091)

o Collect and analyze data to identify community needs prior to planning, implementing, monitoring, and evaluating programs designed to encourage healthy lifestyles, policies, and environments.

• “Social and Human Service Assistants” (21-1093)

o May assist clients in identifying and obtaining available benefits and social and community services.

• “Community Health Workers” (21-1094)

o May provide information on available resources, provide social support and informal counseling, advocate for individuals and community health needs, and provide services such as first aid and blood pressure screening.

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• If so, how is the occupation distinct?

There is no occupation that currently incorporates all of the duties of a Patient Navigator. Nor is there one that recognizes the specific focus of Patient Navigators on a particular disease area or unique population. Registered nurses are licensed professionals authorized to provide medical care to ill, injured, convalescent or disabled patients. Registered nurses may advise patients on health care issues and provide medical case management, but these are medically focused services requiring licensure and/or registration. This type of medical case management is beyond the scope of practice of a non-licensed patient navigator who does not advise patients but may provide educational materials and resources or provide case management services to support patient adherence to treatment. The role of a Patient Navigator is very different from that of a Health Care Social Worker because Patient Navigators do not provide any type of advice, counseling or psychosocial interventions for individuals, families or other groups. Social workers providing these services are focused on improving psychosocial health, increasing quality of life and providing other mental health services and supports for patients and families, whereas Patient Navigators connect patients with resources and provide referrals for services such as social work. The primary function of a Patient Navigator is to eliminate barriers to care in order to support patient adherence to treatment and reduce disparities in healthcare. Patient Navigators differ from Health Educators in that they are providing a very limited, specific amount of health education based on the individual’s condition, the individual’s or family’s health literacy needs and the setting in which the Patient Navigator works. Patient Navigators do not manage health education programs nor do they administer fiscal resources for health education programs. Health education is one duty of a Patient Navigator in the larger context of removing barriers to care for individuals on a case-by-case basis. Unlike Social and Human Service Assistants, Patient Navigators assist patients with obtaining benefits and community services as a means to addressing barriers and increasing access to care. Patient Navigators may or may not be licensed professionals able to fulfill other duties in the clinical care setting. Moreover, assisting with obtaining benefits and community services is one duty of a Patient Navigator in the larger context of removing barriers to care. Patient Navigators differ from Community Health Workers in that they are focused on an individual in the health care system. Patient Navigators may connect an individual with community resources or support services, but in the context of addressing barriers to accessing care and allowing a patient to adhere to treatment. Community Health Workers are firmly embedded in the community and focus broadly on community health, a characteristic that distinguishes them from other professions. Their focus is on community health and it is more generally applied. Patient Navigators, on the other hand, are often embedded in or perform

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work in the health care setting and are focused on individuals with a particular disease, condition or specific group of individuals at high risk for poorer health outcomes. The focus of Patient Navigators is more specific and is on removing barriers to accessing care. In removing these barriers they may provide services similar to those of other professions, but patient navigation is unique in that it tracks a patient across the health care continuum, advocating and empowering that patient to access and receive high-quality, patient-centered care. Patient Navigators work to reduce individual and systemic issues in the context of supporting better patient care. Two emerging roles in the healthcare continuum are that of the care coordinator and the health coach. These two roles are separate and unique from the services provided by a patient navigator. The primary difference between a Patient Navigator and a care coordinator is that Patient Navigators are focused on removing barriers to accessing care. The core function of the Patient Navigator is to ensure patients have timely access to high-quality medical care and support adherence to treatment established by the patient and their physician or healthcare provider. Care coordination, requiring clinical expertise in care planning and clinical assessment, is a duty that may be performed by a Nurse Navigator but is not common to all Patient Navigators. A health coach is different from a Patient Navigator in that the health coach motivates individuals to make healthier choices18. A health coach is focused on the mind, body and spirit of a client and assists them in choosing and maintaining a healthier lifestyle to reduce the risk of disease and improve overall health. A health coach does not address barriers to care and does not assist patients with accessing treatment. Unlike Patient Navigators, who work with at-risk populations to access timely medical care, health coaches focus on general wellness and are not part of the medical care team.

• What changes should be made to existing SOC occupations that have the same or similar work?

We do not propose any changes be made to existing SOC occupations.

3. Job titles.

• What job titles are commonly used by workers in this occupation? Patient Navigator, Nurse Navigator, Non-Licensed Navigator, Lay Navigator, Health Navigator, Resource Navigator

• Are these titles unique to the proposed occupation? Yes

• Are titles listed in the Direct Match File actually in use? N/A

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• Are there other titles that should be included in the file? N/A 4. Indications of the number of jobs or workers in the occupation.

• Employment size and expected growth are helpful in evaluating collectability. Please provide references for the sources of this information.

Patient Navigation programs are particularly strong in oncology, the field in which the concept was coined.19 Although the employment size is currently unavailable, the following sources provide evidence of the numbers of Patient Navigators:

• The Professional Patient Advocate Institute estimates that 1,000 patient navigators are credentialed through various organizations, such as the Professional Patient Advocate Institute, National Association of Healthcare Advocacy Consultants and the Alliance of Professional Health Advocates.20

• As one of the leading professional societies for oncology patient navigators, the Academy of Oncology Nurse and Patient Navigators (AONN+) has over 4,000 members.21

• The American Cancer Society has patient navigators at 125 hospitals, treatment centers, and other health care settings.22

• New accreditation standards for cancer programs from the Commission on Cancer (CoC) of the American College of Surgeons requires a patient navigation process to address health care disparities and barriers to care. Currently, more than 1,400 programs are CoC-accredited. Thus, these standards, which will be in effect beginning January 1, 2015, will significantly increase the patient navigation workforce just in oncology.23

• The Center to Reduce Cancer Health Disparities (CRCHD)24, housed within the National Cancer Institute, created the Patient Navigation Research Program (PNRP)25 to develop and study innovative patient navigation interventions to reduce or eliminate cancer health disparities. The multi-site PNRP tested patient navigation interventions to reduce time to delivery of quality, standard cancer care after identification of an abnormal finding, and measure the efficacy and cost-effectiveness of interventions. The PNRP is one example of a growing body of research in patient navigation.

• The concept of patient navigation is growing beyond the fields of cancer and chronic disease. The Navigator Program in Geriatrics, a University of Massachusetts Medical School program, trains medical students and graduate-level nursing students as Patient Navigators to address the many complex issues facing older adults in the health care setting.26 This innovative use of Patient Navigators working with specific populations as opposed to specific diseases points to a continued expansion of the profession.

5. Types of employers.

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Patient Navigators can be found at hospitals, community health centers, primary care practices, insurance companies, state and government agencies, non-profit community-based organizations and in private, for-profit organizations. Any company or organization interacting with patients and the health care system can benefit from having a patient navigator. 6. Education and training. There is no formal training requirement for Patient Navigators. Current programs available range from Community College certificate programs27 and online trainings28 to non-profit organizations29 and trainings offered through colleges and universities.30 Training is also offered through professional associations (see 9 below). 7. Licensing. There is no required licensing for Patient Navigators. Some Patient Navigators can be licensed in other professions, such as nursing or social work. 8. Tools and technologies. Patient Navigators must be able to document encounters and interventions with clients. The most common tool used is the medical record. As more health care systems move toward the electronic medical record (EMR), knowing how to use and document in the EMR will be critical to the profession of Patient Navigation. As the field of Patient Navigation continues to develop, more organizations are interested in tracking Patient Navigation interventions and their impact on patients and patient care. Metrics tracked range from patient demographic information to cost-savings. Patient Navigators may use systems based in Excel, or have more formal databases focused on tracking and analyzing information specific to patient navigation (e.g., OncoNav, NurseNav). 9. Professional or trade associations and unions.

• Are there professional or trade associations or labor unions related to the proposed occupation? Identification of specific associations is helpful.

Yes. There are many professional associations related to patient navigation, at the local and national levels. National:

• Academy of Oncology Nurse and Patient Navigators (AONN+)31 • National Association of Healthcare Advocacy Consultants (NAHAC)32 • National Coalition of Oncology Nurse Navigators (NCONN)33

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Local:

• District of Columbia City-wide Patient Navigator Network (CPNN)34 • Cancer Patient Navigators of Georgia35 • Louisiana Patient Navigation Network36 • Maryland Patient Navigation Network37 • Pennsylvania Patient Navigator Network38 • Virginia Cancer Patient Navigation Network39 • `Imi Hale Native Hawaiian Cancer Network40 • Deep South Cancer Navigation Network41 • Navigator Program Network (New York City)42 • The West Virginia Oncology Patient Navigation Network43 • Colorado Patient Navigation Network (Patient Navigator Training Collaborative)44 • Northeast Ohio Patient Navigation Collaborative45 • Florida Coalition of Oncology Nurse Navigators (FCONN)46

References

1 Patient Navigator Outreach and Chronic Disease Prevention Act of 2005. Pub L. 109-18. 340A (b)(1-6) and (l)(2) http://www.gpo.gov/fdsys/pkg/PLAW-109publ18/html/PLAW-109publ18.htm. 2 Oncology Nursing Society. Oncology Nurse Navigator Competencies. https://www.ons.org/about-ons/competencies. Accessed July 14, 2014. 3 Willis A, Reed, Pratt-Chapman M, Kapp H, Hatcher E, Vaitones V, Collins S, Bires J, Washington E-C. Development of a Framework for Patient Navigation: Delineating Roles Across Navigator Types. Journal of Oncology Navigation and Survivorship. 2013;4(6):20-26. 4 National Cancer Institute. Cancer health disparities fact sheet. Updated March 11, 2008. http://www.cancer.gov/cancertopics/factsheet/dispari ties/cancer-health-disparities. Accessed July 30, 2013. 5 The Office of Minority Health. What is cultural competency? Updated May 9, 2013. http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2& lvlID=11. Accessed July 30, 2013. 6 Agency for Healthcare Research and Quality. Care Coordination Measures Atlas: Chapter 2: What is care coordination? 2011. http://www.ahrq. gov/professionals/systems/long-term-care/resources/coordination/atlas/chapter2.html. Accessed July 30, 2013. 7 Koester, Kimberly A., Morewitz, Mark, Pearson, Charles, Weeks, John, Packard, Rebecca, Estes, Milton, Tulsky, Jacqueline, Kang-Dufour, Mi_Suk, and Myers, Janet J.. AIDS Patient Care and STDs. February 2014, 28(2): 82-90. doi:10.1089/apc.2013.0279. 8Dietz, M., and Farrisi, D. Patient Navigation is a Client Centered Approach that Helps to Engage People in HIV Care. HIV Clinician. Winter 2013, 25 (1) 1-3. http://www.deltaaetc.com/hcarticles/articles%20as%20pdf/winter%202013%20articles%20as%20pdf/patientnavigation.pdf. Accessed July 21, 2014. 9 Kelly, E., Fulginiti, A., Pahwa, R., Tallen, L., Duan, L., and Brekke, J.S. A pilot test of a peer navigator intervention for improving health of individuals with serious mental illness. Community Ment Health J. 2013 Jun 7. 10 TY - JOUR T1 - Development and Implementation of a Navigator-Facilitated Care Coordination Algorithm to Improve Clinical Outcomes of Underserved Latino Patients with Uncontrolled Diabetes A1 - Congdon, Heather Brennan A1 - Eldridge, Barbara Hoffman A1 - Truong, Hoai-An JF - Journal of Health Care for the Poor and Underserved VL - 24 IS - 4 SP - 1604 EP - 1613 PY - 2013 PB - The Johns Hopkins University Press SN - 1548-6869 UR - http://muse.jhu.edu/journals/journal_of_health_care_for_the_poor_and_underserved/v024/24.4.congdon.html N1 - Volume 24, Number 4, November 2013 ER -

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11 Scott, L. Benz; Gravely, S.; Sexton, T.R.; Brozostek, S. & Brown, D. L. (2013). Effect of a Patient Navigation Intervention on Outpatient Cardiac Rehabilitation Awareness and Enrollment. Journal of Cardiopulmonary Rehabilitation & Prevention: September/October 33(5) 281-291. doi: 10.1097/HCR.0b013e3182972dd6. 12 A Patient Navigation Intervention for Drug Involved Former Prison Inmates Ingrid A. Binswanger, Elizabeth Whitley, Paul-Ryan Haffey, Shane R. Mueller, Sung-Joon Min Substance Abuse. http://www.tandfonline.com/doi/full/10.1080/08897077.2014.932320#tabModule. Accessed July 21, 2014. 13 When Patients Are Impatient: The Communication Strategies Utilized by Emergency Department Employees to Manage Patients Frustrated by Wait TimesElizabeth L. Cohen, Holley A. Wilkin, Michael Tannebaum, Melissa S. Plew, Leon L. Haley Health Communication Vol. 28, Iss. 3, 2013. 14Manderson, B., Mcmurray, J., Piraino, E. and Stolee, P. (2012), Navigation roles support chronically ill older adults through healthcare transitions: a systematic review of the literature. Health & Social Care in the Community, 20: 113–127. doi: 10.1111/j.1365-2524.2011.01032.x 15 University of Massachusetts Medical School. The Navigator Program in Geriatrics. http://www.umassmed.edu/age/geriatrics-interest-group/navigator/. Accessed July 14, 2014. 16 Johns Hopkins School of Nursing. Community outreach program. http://nursing.jhu.edu/excellence/community/outreach.html. Accessed July 30, 2013. 17 Community Tool Box. Section 6: Using Outreach to Increase Access. http://ctb.ku.edu/en/tablecontents/sub_section_main_1876.aspx. Accessed July 30, 2013. 18 Health Coach Certification. Institute for Integrative Nutrition website. http://www.integrativenutrition.com/career/healthcoaching. Accessed July 21, 2014. 19 1. Freeman HP, Rodriguez RL. History and principles of patient navigation. Cancer. 2011;117(S15):3537-3540. doi:10.1002/cncr.26262. 20 Next Avenue. Patient Navigators: New Help for Caregivers. http://www.nextavenue.org/article/2013-01/patient-navigators-new-help-caregivers. Accessed July 14, 2014. 21 Academy of Oncology Nurse and Patient Navigators. About. https://aonnonline.org/about. Accessed July 14, 2014. 22 American Cancer Society. Navigators Can Help Pateints Manage Their Care. http://www.cancer.org/cancer/news/news/navigators-help-cancer-patients-manage-their-care. Accessed July 14, 2014. 23 American College of Surgeons. New Commission on Cancer Accreditation Standards Gain Strong Support from Four National Cancer Advocacy Organizations. http://www.facs.org/news/2011/coc-standards0811.html. Accessed July 14, 2014. 24 Center to Reduce Cancer Health Disparities. Center to Reduce Cancer Health Disparities website. http://crchd.cancer.gov/index.html. Accessed July 16, 2014. 25 Patient Navigation Research Program. Center to Reduce Cancer Health Disparities Website. http://crchd.cancer.gov/pnp/pnrp-index.html. Accessed July 16, 2014. 26 University of Massachusetts Medical School. The Navigator Program in Geriatrics. http://www.umassmed.edu/age/geriatrics-interest-group/navigator/. Accessed July 14, 2014. 27 Sonoma State University. Health Navigator Certificate Program. http://www.sonoma.edu/exed/patient-navigator/. Accessed July 14, 2014. 28 Patient Navigator Training Collaborative. Patient Navigator Training Collaborative Website. http://patientnavigatortraining.org/. Accessed July 14, 2014. 29 Harold P. Freeman Patient Navigation Institute. Harold P Freeman Patient Navigation Institute Website. http://www.hpfreemanpni.org/. Accessed July 14, 2014. 30 George Washington University Cancer Institute. Education and Training. http://smhs.gwu.edu/gwci/education. Accessed July 14, 2014. 31 Academy of Oncology Nurse and Patient Navigators. Academy of Oncology Nurse and Patient Navigators Website. https://aonnonline.org/. Accessed July 14, 2014.

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32 National Association of Healthcare Advocacy Consultants. National Association of Healthcare Advocacy Consultants Website. http://nahac.memberlodge.com/. Accessed July 14, 2014. 33 National Coalition of Oncology Nurse Navigators. National Coalition of Oncology Nurse Navigators Website. http://www.nconn.org/. Accessed July 14, 2014. 34 George Washington University Cancer Institute. City-wide Patient Navigator Network (CPNN). http://smhs.gwu.edu/gwci/patient-care/patient-navigation/cpnn. Accessed July 14, 2014. 35 Cancer Patient Navigators of Georgia. Cancer Patient Navigators of Georiga Website. http://www.gacancerpatientnavigators.org/. Accessed July 14, 2014. 36 Louisiana Patient Navigation Network. Louisiana Patient Navigation Network Website. http://louisianacancer.org/patient-navigation/. Accessed July 14, 2014. 37 Maryland Patient Navigation Network. Maryland Patient Navigation Network Website. http://mdpnn.wordpress.com/. Accessed July 14, 2014. 38 Pennsylvania Patient Navigation Network. Pennsylvania Patient Navigation Network Website. http://pubweb.fccc.edu/panavnet/. Accessed July 14, 2014. 39 Virginia Patient Navigation Network. Virginia Patient Navigation Network Website. http://cancercoalitionofvirginia.org/pages/Resources/patientNavigation.html. Accessed July 14, 2014. 40 `Imi Hale Native Hawaiian Patient Navigation Network. Imi Hale Native Hawaiian Patient Navigation Network Website. http://www.imihale.org/whatisCPN.html. Accessed July 15, 2014. 41 Deep South Cancer Navigation Network. PatientCareConnect Website. http://www.patientcareconnect.org/. Accessed July 15, 2014. 42 Navigator Program Network. New York City Department of Health and Hygiene Website. http://www.nyc.gov/html/doh/html/living/cancer-colon-provider-npn.shtml. Accessed July 15, 2014. 43 West Virginia Oncology Patient Navigation Network. West Virginia Oncology Patient Navigation Network Website. http://www.wvopnn.com/index.php. Accessed July 15, 2014. 44 Colorado Patient Navigation Network. Patient Navigation Training Collaborative Website. http://patientnavigatortraining.org/. Accessed July 14, 2014. 45 Northeast Ohio Patient Navigation Collaborative. The Center for Health Affairs Website. http://www.chanet.org/TheCenterForHealthAffairs/MediaCenter/NewsReleases/2012/March/03-12_PatientNavigationLaunch.aspx. Accessed July 15, 2014. 46 Florida Coalition of Oncology Nurse Navigators. Florida Coalition of Oncology Nurse Navigators Website. http://www.fconn.org/. Accessed July 21, 2014.

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July 18, 2014

The GW Cancer Institute

2030 M Street N.W.,

Washington, D.C. 20036

Via email to: soc@BLS.gov

To Whom It May Concern:

The Commission on Cancer developed an accreditation Standard 3.1: Patient Navigation Process

defining a process driven by a community needs assessment and established to address health care disparities and barriers to care for patients. The standard is for programs to provide

resources to address identified barriers and to work to eliminate resource gaps. The standard

does not specify a service provider nor does it specify the level of complexity of the care that

individual would provide. The Commission on Cancer supports programs making decisions,

based on their assessment, about the scope of practice needed to address identified barriers and

if that practice is to be provided by an individual designated as a Patient Navigator. Because

programs have identified a need for nurses, social workers, and other licensed professionals to

be designated as Navigators we would support the recommendation to establish a recognized

job code for Patient Navigator as long as that code was specific to an unlicensed provider and/or

would recognize that the training and licensing of a nurse, social worker or other licensed

professional can also be an appropriate provider of navigation services.

CoC Standard does not suggest having a Patient Navigator on staff, but recognizes the need to

define the role of the Patient Navigator when one is present on the cancer care team.

The American College of Surgeons Commission on Cancer supports the GW Cancer Institute’s

proposed definition of a Patient Navigator as included in their submission to the Office of

Management and Budget (OMB) for consideration for inclusion in the 2018 Standard

Occupational Classification (SOC) system, a system is used to classify workers into occupational

categories.

Respectfully submitted,

Daniel P. McKellar, MD, FACS

Chair

Commission on Cancer