Breast Health Outreach and Counseling Project

State: PA Type: Model Practice Year: 2011

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"The Ambulatory Health Services (AHS) division of the Philadelphia Department of Public Health has implemented a Breast Health Outreach and Counseling Project. The project, piloted in January 2009, focuses on two of AHS’ Health Centers (Health Center #3 and Health Center #6). Uninsured women patients, age 40-69, registered as patients from the two participating AHS’ health centers qualify for inclusion in the project.

The project goal is to get participants to complete a mammogram if they are not up-to-date with their screening. Project objectives are as follows: contact all participants who need a mammogram; provide patients with support they need to address key barriers to screenings; counsel patients taking into account specific barriers/facilitators for obtaining mammograms and key knowledge they should have on breast issues and appropriate breast care practices.

The project strategy was informed by two research-tested interventions. One strategy incorporates direct mail to increase screening mammography. The second approach involves tailored telephone counseling, proven to be more successful than printed communications at promoting mammography screening for women who are non-adherent with breast cancer screening.

Outreach is focused on individuals not up-to-date with a breast cancer screening. On participant’s birth month the patient is sent an initial outreach mailing (a Happy Birthday flyer indicating the individual qualifies for a free mammogram). This is followed 30 days later by a telephone call to nonrespondents.

Respondents are surveyed about barriers and facilitators to obtaining their mammogram; counseled on breast problems and appropriate breast care practices; and given a mammogram appointment. In CY2010, a pre- and post- test was designed and instituted to document patients' increased knowledge of key breast health care topics. In CY2009, 2,500 women were participants; in January 2010 the project tracked 5,500 women. Actual number of participants decreased throughout the year, as individuals became ineligible for the project for numerous reasons including, they obtained insurance, decided to use another provider as their PCP, or moved out of the city. As of November 2010, 3,400 women are being tracked--2,500 received direct mail; 1,700 telephone contacts have been made.

The population served by AHS is challenged with various barriers in accessing health care, including, language and cultural barriers; affording the costs associated with accessing services or related transportation; and lacking understanding how to navigate the health care system. Patients often do not qualify for publicly-funded health insurance and may not have the financial resources to access the health resources available in Philadelphia to those with insurance or the ability to pay.

These characteristics have implications for the community’s health, and impact directly on breast care and to the extent to which AHS’ service area women are compliant in obtaining screening mammograms. According to Boston University Medical Center’s survey findings, “women’s healthcare decisions and adherence to routine health screenings are affected by cultural factors, educational background and access to medical care.” The intent of this project is to address some of these social inequities and barriers to health care, and improve participant’s knowledge of proper breast care. The project was implemented with funding from GlaxoSmithKline (GSK). In the pilot year (CY2009), funding totaled $100,000; in year two funding totaled $135,000. CY2011 funding totals $150,000. GSK funding supports a full-time medical assistant, responsible for outreach activities, surveying patients, obtaining PCP referral for mammogram, appointment scheduling, tracking and monitoring mammogram completion, and data entry. Project funds also support a half-time RN who is responsible for patient counseling and teaching. A small portion of a Project Manager/Continuous Qu"

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Philadelphia Department of Public Health
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Breast Health Outreach and Counseling Project
"The Ambulatory Health Services (AHS) division of the Philadelphia Department of Public Health has implemented a Breast Health Outreach and Counseling Project. The project, piloted in January 2009, focuses on two of AHS’ Health Centers (Health Center #3 and Health Center #6). Uninsured women patients, age 40-69, registered as patients from the two participating AHS’ health centers qualify for inclusion in the project. The project goal is to get participants to complete a mammogram if they are not up-to-date with their screening. Project objectives are as follows: contact all participants who need a mammogram; provide patients with support they need to address key barriers to screenings; counsel patients taking into account specific barriers/facilitators for obtaining mammograms and key knowledge they should have on breast issues and appropriate breast care practices. The project strategy was informed by two research-tested interventions. One strategy incorporates direct mail to increase screening mammography. The second approach involves tailored telephone counseling, proven to be more successful than printed communications at promoting mammography screening for women who are non-adherent with breast cancer screening. Outreach is focused on individuals not up-to-date with a breast cancer screening. On participant’s birth month the patient is sent an initial outreach mailing (a Happy Birthday flyer indicating the individual qualifies for a free mammogram). This is followed 30 days later by a telephone call to nonrespondents. Respondents are surveyed about barriers and facilitators to obtaining their mammogram; counseled on breast problems and appropriate breast care practices; and given a mammogram appointment. In CY2010, a pre- and post- test was designed and instituted to document patients' increased knowledge of key breast health care topics. In CY2009, 2,500 women were participants; in January 2010 the project tracked 5,500 women. Actual number of participants decreased throughout the year, as individuals became ineligible for the project for numerous reasons including, they obtained insurance, decided to use another provider as their PCP, or moved out of the city. As of November 2010, 3,400 women are being tracked--2,500 received direct mail; 1,700 telephone contacts have been made. The population served by AHS is challenged with various barriers in accessing health care, including, language and cultural barriers; affording the costs associated with accessing services or related transportation; and lacking understanding how to navigate the health care system. Patients often do not qualify for publicly-funded health insurance and may not have the financial resources to access the health resources available in Philadelphia to those with insurance or the ability to pay. These characteristics have implications for the community’s health, and impact directly on breast care and to the extent to which AHS’ service area women are compliant in obtaining screening mammograms. According to Boston University Medical Center’s survey findings, “women’s healthcare decisions and adherence to routine health screenings are affected by cultural factors, educational background and access to medical care.” The intent of this project is to address some of these social inequities and barriers to health care, and improve participant’s knowledge of proper breast care. The project was implemented with funding from GlaxoSmithKline (GSK). In the pilot year (CY2009), funding totaled $100,000; in year two funding totaled $135,000. CY2011 funding totals $150,000. GSK funding supports a full-time medical assistant, responsible for outreach activities, surveying patients, obtaining PCP referral for mammogram, appointment scheduling, tracking and monitoring mammogram completion, and data entry. Project funds also support a half-time RN who is responsible for patient counseling and teaching. A small portion of a Project Manager/Continuous Qu"
The population served by AHS is challenged with various barriers to accessing health care, including lacking knowledge of critical health information; language and cultural barriers; costs associated with accessing services or related transportation; and or lacking understanding how to navigate the health care system. Patients may not qualify for publicly-funded health insurance and may not have the financial resources to access the vast health resources available in Philadelphia to those with insurance or the ability to pay. These characteristics have implications for the community’s health, and impact very directly on breast care and the extent to which women in AHS’ service area are compliant in obtaining screening mammograms. According to Boston University Medical Center’s survey findings, “women’s healthcare decisions and adherence to routine health screenings are affected by cultural factors, educational background and access to medical care.” With respect to mammography screening, studies highlight the extent to which women from minority cultural backgrounds are likely to have a current mammography. One national study documents that only 60% of African Americans have had a mammogram; regional studies of Hispanic and African American women indicate rates are half as high. The National Committee for Quality Assurance publishes industry statistics identifying the extent to which women enrolled in health plans received a mammogram in the previous 2 years. For Medicaid patients, the percent of women who are up-to-date with their mammograms ranges from 50% (at the 50th percentile) to 61% (at the 90th percentile). Through this outreach and counseling project, AHS makes available support that facilitates completion of the mammogram. Patients are assured they qualify for the free mammogram; translation service is provided; guidance is provided on obtaining past mammogram films; mammogram referrals are obtained; and mammogram appointments are made. In essence, the intent of this project is to address various social inequities, minimize key barriers to health care, and improve participants’ knowledge of proper breast care.
Agency Community RolesAmbulatory Health Services falls within the purview of Philadelphia Department of Public Health (PDPH). As such the scope of health services AHS offers (including primary care and public health services) are easily available to project participants. PDPH resources are offered via in-kind services, including partial support for administrative and clinical staff time, costs of mammograms over and above the grant resource allotment; and miscellaneous costs associated with project activities. Costs and ExpendituresThe Ambulatory Health Services (AHS) division of the Philadelphia Department of Public Health has implemented a Breast Health Outreach and Counseling Project. The project, piloted in January 2009, focuses on two of AHS’ Health Centers (Health Center #3 and Health Center #6). Uninsured women patients, age 40-69, registered as patients from the two participating AHS’ health centers qualify for inclusion in the project. The project goal is to get participants to complete a mammogram if they are not up-to-date with their screening. Project objectives are as follows: contact all participants who need a mammogram; provide patients with support they need to address key barriers to screenings; counsel patients taking into account specific barriers/facilitators for obtaining mammograms and key knowledge they should have on breast issues and appropriate breast care practices. The project strategy was informed by two research-tested interventions. One strategy incorporates direct mail to increase screening mammography. The second approach involves tailored telephone counseling, proven to be more successful than printed communications at promoting mammography screening for women who are non-adherent with breast cancer screening. Outreach is focused on individuals not up-to-date with a breast cancer screening. On participant’s birth month the patient is sent an initial outreach mailing (a Happy Birthday flyer indicating the individual qualifies for a free mammogram). This is followed 30 days later by a telephone call to nonrespondents. Respondents are surveyed about barriers and facilitators to obtaining their mammogram; counseled on breast problems and appropriate breast care practices; and given a mammogram appointment. In CY2010, a pre- and post- test was designed and instituted to document patients' increased knowledge of key breast health care topics. In CY2009, 2,500 women were participants; in January 2010 the project tracked 5,500 women. Actual number of participants decreased throughout the year, as individuals became ineligible for the project for numerous reasons including, they obtained insurance, decided to use another provider as their PCP, or moved out of the city. As of November 2010, 3,400 women are being tracked--2,500 received direct mail; 1,700 telephone contacts have been made. The population served by AHS is challenged with various barriers in accessing health care, including, language and cultural barriers; affording the costs associated with accessing services or related transportation; and lacking understanding how to navigate the health care system. Patients often do not qualify for publicly-funded health insurance and may not have the financial resources to access the health resources available in Philadelphia to those with insurance or the ability to pay. These characteristics have implications for the community’s health, and impact directly on breast care and to the extent to which AHS’ service area women are compliant in obtaining screening mammograms. According to Boston University Medical Center’s survey findings, “women’s healthcare decisions and adherence to routine health screenings are affected by cultural factors, educational background and access to medical care.” The intent of this project is to address some of these social inequities and barriers to health care, and improve participant’s knowledge of proper breast care. All project objectives were met. Improved mammogram completion rates were achieved for active patients; noncompliant participants were reached via outreach efforts; and patients were taught about breast problems and health practices The following specific factors led to success of this practice •Closely tracking patients'date of last mammogram and completion of appointment •Dedicated staff to focus on outreach efforts and counseling activities •An effective team, representing the various relevant disciplines, working together. Implementation1. Establish/ Maintain Database Establish database/registry Designed and establish Microsoft Access database system. 2 to 4 mths in year 1 Identify un/underinsured women, age 40-69 at two HC; add patients to database 2 weeks Assess mammography status to identify project participants—review paper charts Monthly Enter in database--data abstracted from paper medical record, data of completed mammograms from radiology consults, and data documented in patient calls Monthly Create monitoring/ reporting system Design reports to support project activities, and meet project reporting requirements Ongoing 2. Contact all project participants Designed postcard/mailer Design and print mailer. 2 weeks in year 1 Mail initial postcards to women on their birth month. Monthly Identify non-respondents Monthly Call non-respondents Complete telephone calls to non-respondent patient, 1 month after mail-out of postcard. Monthly 3. Health Education Conduct education sessions Conduct education sessions (group session, waiting room roll-about; or individually via daily telephone calls) Periodically/daily Evaluate knowledge gained Administer 200 pre/post tests to respondents contacted/counseled by phone; prepare report documenting improved knowledge. Ongoing, 4. Project participants complete breast screenings Patients make mammogram appointments and complete mammograms Schedule appointments for mammograms; obtain provider referral for mammogram; track scheduled and completed mammogram appointments; enter information in database; provide patient with support, as needed Ongoing Minimize broken appts Track appointments for mammography; call to remind patients of appts; reschedule, as necessary Ongoing Make follow-up calls to pts with broken appts. Make at least 2 attempts to track/contact participants who break mammography appt; reschedule appointment if contact is made; assess why appointment broken; provide support, as needed Monthly 5. Provide specialty diagnostic care/trtmt Schedule/track treatment, as needed Track mammogram outcome. Provide specialty services for abnormal screening results/cancer diagnosis Ongoing
Performance measures: % of participants up-to-date with annual mammogram; % of participants up-to-date with bi-annual mammogram; A key task throughout the project period involves identifying the last mammogram date for each woman to determine whether she is up-to-date with her mammogram. The following data sources were reviewed by the medical assistant; she enters new data into the database: 1) AHS’ claims information system; 2) patient logs used in mammography clinics at HC #4 and #10; and 3) patient listing from Radiology provider listing mammogram data for all patients for whom they prepared a report. Effort then focuses on confirming that the women had not actually had a recent mammogram, so mailings would not be sent in error to women up-to-date with their screening. The most viable strategy for this activity is to review charts month by month, prior to sending the mailing. All mammogram dates obtained via this step are also entered into the database. A report is then generated--listing by Health Center, the number of participants, the number of participants with a mammogram date noted in the database, the number of participants with a current mammogram (annual/bi-annual); and the percent of participants current with their mammogram (annual/bi-annual). The lesson learned relates to assessing the total visits the patients makes to the health center in the analysis period, and analyzing data at the appropriate specification so accurate conclusions are drawn from the findings. Data analysis should group patients into active patients; patients with one visit; patients with no visits. In Year 3, findings as of November 30, 2010 are as follows: Active women (who made 2 visits during the year) had the highest rates of compliance (at both annual and biannual level). At the biannual level, active women demonstrated mammogram completion rates of 75% (for individuals making 2 visits in 2009 or 2010) and 87% (for individuals making 2 visits in 2009 and 2010). Both bi-annual rates surpass biannual completion rates associated with Medicaid managed care patients at 55% (50th percentile) and 60% (90th percentile) as reported by NCQA HEDIS reports in 2008. In terms of the completion rate for an annual mammogram, the project reveals 46% compliant (for individuals making 2 visits in 2009 or 2010) and 60% compliant (for individuals making 2 visits in 2009 and 2010)—rates that very closely approach the biannual rate quoted above for medicaid managed care patients. These findings are quite notable given that participants are uninsured minority women, who generally have the lowest rate of mammogram completion. The key finding is that AHS providers are referring women for their annual mammogram. Tracking kept appointments and reaching out to women who break appointments is critical to maintaining such high completion rates. This objective was reached. The key lesson learned is that analysis must be specific enough to indicate actual project success. Analyzing the overall mammogram completion rate across all respondents is inappropriate, particularly in a population that is transient. Patients new to the practice have not had sufficient encounters to generate the referral; a second visit is generally sufficient to increase compliance. Results were shared with clinical directors and AHS leadership. In this case, mammogram completion rates must account for whether patient is an active user, new patient, or individual who has made few or no visits in the last year. Performance Measures. % of patients surveyed with correct answers to three questions (signs of breast problem); how often should have a mammogram; how often should do a BSE (Breast Self Exam); time of month to do BSE Throughout the year, the project’s medical assistant directly spoke with a small sample of project participants. During this discussion she utilized a pre- and post-test designed early in April 2010 to assess patient’s knowledge on four topics th
This project has been sustained for three years with GSK funding and in-kind services offered by PDPH/AHS. At this point, fourth year funding is unlikely. Despite such a threat, there is sufficient stakeholder commitment to the principles of the project—tracking individuals; counseling and teaching women about breast health care and importance of early screening and treatment; assuring timely mammogram referrals are written; tracking completion of mammogram, and using relevant performance indicators and reports to monitor and maintain highest level of mammogram compliance. In year 2 of the project over 100 AHS nursing staff attended a continuing education session that outlined project activities and goals, stressing the role of the nurse in assuring AHS’ patients were assessed for mammogram compliance and flagged where a referral was required. The scope of the project’s breast health education program was reviewed in detail, and the nurses were made aware of the breast models procured with GSK funding. These models are available at two health centers included in the project, and since the training session nurses have expressed interest in accessing and using the models in their post visit patient conference. With respect to providers, AHS’s practice guidelines stipulates the requirement for mammogram for women age 40 to69, and includes the indicator “mammogram referral completed” in the chart review component of the annual provider evaluation. Performance data is shared annually with clinical directors and providers, thus assuring attention is given to mammogram compliance in the course of providing clinical care. • Describe plans to sustain the practice over time and leverage resources. (350 word limit) Third year funding from GSK provided resources to procure health education materials (DVDs, display equipment, literature, and messaged giveaways). The automated materials address as closely as possible the counseling topics and information provided by the project’s counselor and medical assistant; additional health topics will be procured to address key health conditions in our patient population. These resources will be adopted starting at the two project sites and the health centers where mammogram units are located (in essence covering 5 of AHS’ 8 health centers). Assuming sufficient funds are available the health education materials will be also provided to the remaining 3 sites. The initial plan is to locate the health education display in the waiting areas for mammogram and family planning service. Our goal is to ensure women and the wider audience of patients receive the health education they need to address breast and general health issues. Another opportunity to sustain the objectives of the practice and leverage resources will be presented as AHS goes live with its EHR initiative. A vendor was engaged in Spring 2011. The EMR functionality includes the clinical reminders to support real-time patient tracking and prompting for a mammogram referral, and a health education module that provides literature (in key patient languages) relevant to health issues and care requirements. For example, clinical reminders alert the provider a woman needs a mammogram; the alert appears on the provider’s dashboard until the referral is written and procedure is complete. Sending appointment reminders and tracking broken appointments also will be facilitated by automation. In essence, with the EHR in place in 2012, there is no real need for current project resources to be dedicated to 1) manually reviewing a paper chart to identify date of last mammogram, or 2) manually tracking whether a patient is compliant with their mammogram or kept their appointment. Of particular significance for AHS is that with the EHR the patient tracking and monitoring is deployed across AHS’ eight health centers. We expect that resources are still needed for outreach and patient counseling, but trust that more efficient operations created
 
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