Navajo Nation Breast

1
Navajo Nation Breast Cervical Cancer Prevention
Program (NNBCCPP)

• J. Scott Deasy, MD FACOG
• Chief Medical Officer TCRHCC
• With assistance from
• Michael Wilcox, MD
• Diana Hu, MD
• Sally Ann Joe
• Loretta Chino-Welch

2

• Provide screening to women due to the fact that
  the majority of our Navajo women who are
  diagnosed with breast and cervical cancer but the
  life expectancy rate, once a woman is diagnosed,
  is less than the national average, which for
  Navajo is less than 5 years

3
Purpose for Cervical Cancer Screening

• Pap smear screening is recommended annually for
  most women ages 18 over. It is the goal of the
  Navajo Nation Breast Cervical Cancer Prevention
  Program (NNBCCPP) to promote cervical cancer
  screening through increased participation of
  women 18 to 64 in Pap testing, which for most
  Native American women residing in the Navajo area
  would be provided through Indian Health Service
  (IHS) facilities. It is also the goal of the
  NNBCCPP to promote prompt follow-up of any
  abnormal results case management services for
  tracking subsequent testing treatment
  improving patient understanding and follow-up.

4
Historical Background

• 1995 Application/Negotiation/coverage
• 1996 5 Year Grant
• 2002 Awarded another 5 Years
• 2007 Reapplied pending
• Authorization BCCP Mortality Prevention Act of
  1990 P.L. 101-354
• Act Authorized CDC to make grants to
  states/tribes
• Key element of the law low income/60/Matching/1
  0
• Amendments Other Medical Assistances, Cervical
  Cancer and HPV, Medicaid
• CDC Role and Responsibilities CDC (Component,
  eligibility, Policies)
• Grantee (Work plans, Assurances)

5

• Initially began as Breast Cancer screening
  program
• Data collected by Dr. Michael Wilcox at Tuba
  outlines incidence of Breast Cancer seen at that
  time

6
Breast Cancer at TCIMC1990-1999

• 43 Cases of Breast Cancer
• age range 34 - 92 years
• average age 54 years
• median age 50 years
• most common age 76 years
• 95 Navajo

7
Breast cancer at TCIMCnumber of cases per year
8
Breast cancer at TCIMCnumber of cases by age
9
Breast cancer at TCIMCpercentage of cases by age
vs. Navajo Area, 1995
10
Breast cancer at TCIMCpercentage of cases by age
vs. NCDB data
11
Breast cancer at TCIMCaverage incidence per
100,000 women
12
US Breast CA incidenceper 100,000 women
13
Breast cancer

• Incidence rates per 100,000 (SEER Data)
• White 113
• Black 99
• American Indian 34
• (primarily New Mexico and Arizona)
• Incidence rate at TCIMC (1990-1999)
• 34 per 100,000
• (using 1990 US census data)

14
Breast Cancer at TCIMC
15
Breast Cancer US Whites
16
Breast Cancer US Blacks
17
Breast cancer at TCIMCnumber of cases by age and
stage
18
Breast cancer at TCIMC
19
Breast cancer at TCIMC
20
Breast cancer at TCIMCOverall survival,
life-table analysis
21
Program Profile

• Program Manager Leadership Information
• Program Supervisor
• Directs the overall operation of the program
  activities and supervises all staff. Plans,
  implements program goals and objectives, develops
  policies to supplement and improve existing
  policies, prepares budgets, conducts program
  evaluation and staff annual performance
  evaluation, interpret all program policies, rules
  and regulation. Conducts staff and medical
  advisory meetings, training for the staff.
  Prepares all reports to supervisor, government
  offices, IMS and CDC funding sources.
• Case Management Specialist
• Performs case management for patient with
  abnormal and normal screening results by
  developing individual service plans, modifies
  plan through consistent and timely monitoring
  aspects of treatment/services. Implements and
  administers systems for screening, tracking,
  follow-up and case managing. Coordinates and
  conducts mammogram screening clinics, organize
  and update womens health database, follow-up on
  abnormal mammograms, pap smears, CBE, make
  referrals for treatment procedures, provide
  health education at school, clinics, public
  settings, schedules mammogram appointments,
  prints and mail letters to patient. Attend
  meetings, submit monthly program progress and
  data reports.
• Office Assistant
• Establish a patient registry system in the
  RPMS-WHSP. Receive all normal pap reports and
  send out congratulation letters. Abnormal pap
  reports and return to doctor for recommendation.
  Enter all normal mammogram reports and send out
  congratulation letters. Enter and close out case
  after diagnostic/treatment. Enter all abnormal
  mammogram reports and return to doctor for
  recommendation send letter on abnormal results.
  Send out another letter per providers
  recommendation to come in for further diagnostic
  procedure (biopsy, consultation, compression,
  spot view, ultrasound, and additional view).
  Submit monthly MDE, procedural statistics and
  surveillance reports to the Data Manager. Attend
  meetings.

22
Program Profile (Cont.)

• Health Educator
• Responsible for coordination and delivery of
  health education in the communities. Includes
  planning the events/presentations, developing all
  the presentation materials, and implementing and
  carrying out the planned activities. Attend and
  participate in all staff meeting, providers staff
  meeting, community meetings and other resource
  meetings. Maintain all data, all evaluations for
  reporting purpose, and submit all required
  reports.
• Data Manager
• Identifies, analyzes, determines implementation
  measures, studies and determines data reporting
  procedures and system requirement creating and
  implementing the most efficient and economical
  data information environment, researches and
  design data integration and data migration
  methods of both internal and external data
  systems, design and implement improved efficient
  environments for data processing, data reporting
  and electronic data transmission, examines and
  analyzes developed computer programs to ensure
  proper methods of data computing, data migration,
  and data control.
• Administrative Assistant
• Assists in varied administrative, management
  problems, directs, participates in work which may
  include some of the following budget preparation
  and control, program funding and modification,
  program compliance, accounting lease and contract
  negotiations, collections, supply, personnel,
  payroll, office services, and general business
  activities of an organization unit, reviews
  expenditures for compliance with approved budget
  plan, supervises program activities to ascertain
  conformance to plan, interviews and recommends
  employment of job applicants, develops and
  approves programs for the effective utilization
  of office space, forms, supplies, equipment, and
  other property, makes cost of procedures studies,
  revises rules and manuals of procedures and
  directs the instruction in their use, prepares
  correspondence, administrative, fiscal and
  budgetary reports.

23
Historical Background (Cont.)

• Agreements
• Indian Health Services (Chinle, Fort Defiance,
  Kayenta)
• 638 Facilities (Tuba City and Winslow)
• Hopi Womens Health Program
• U of A Data Analysis, surveys, Internship
  Technical Assistance
• National Indian Women Health Resource Oklahoma
• New Mexico Cancer Registry
• Future
• Community Health Representative Program
• Health Education Program
• Navajo Agency on Aging Program
• Transportation Native Resources
• New Mexico Sites (Crownpoint, Gallup Shiprock)
• Contracts
• Mobile on-Site Mammography
• Plan of Operation
• Establishment
• Purpose
• Staffing and Organization

24
Comprehensive Program Status Report

• FY 2003 2006.
• Budget Information
• 2003 CDC - 785,000 Avon - 45,000
• 2004 CDC - 785,000 Avon - 45,000
• 2005 CDC - 785,000 Avon - 50,000
• 2006 CDC - 785,000 Avon - 60,000
• 2007 CDC - 785,000 Avon - 60,000

25
Budget Information
26
Budget Information (Cont.)
27
Program Goals for FY 2007 - 2012

• To ensure that older, low-income woman have
  access to regular breast and cervical cancer
  screenings.
• To reduce the incidence of invasive cervical
  cancer by increasing the detection and treatment
  of precancerous cervical cancer screening.
• To provide prompt follow-up for patients with an
  abnormal pap test or mammogram screening results.

28
Program Goals (Cont.)

• FY 2007 2012 Work Plans covering eight
  Components
• Program Management
• Responsible for Developing Implementing program
• Program is in Compliance with laws, guidelines
  and policies
• Fiscal Management
• Data Management
• Improve data system collection
• Analysis techniques of health data to facilitate
  planning and patient care management
• Evaluation
• Assessment (Achievement)
• Deliverance
• Outcome Achieve
• Defining and Designing Program Plan
• Recruitment
• Increase rate of screening
• Increase womens knowledge
• Development of strategies (assessment, etc.)
• Three tiered Awareness-raising, community
  based/education, outreach interpersonal

29
Program Goals (Cont.)

• Screening Diagnostic Services
• Ongoing collection of data (planning,
  implementation and evaluation)
• Minimum Data Element (MDE)
• CM-Assessment, planning, coordination, monitor,
  evaluation resource development
• Partnership
• Recruitment/Selection of criteria
• Identification of roles and outcomes are clear
• Building community infrastructure
• Enhancement
• Professional Development
• Affect HCPs knowledge, Attitudes and Behaviors
• Education of staff (pre-professional,
  postgraduate and continuing education)
• Development of Education Plan
• Quality Assurance Improvement
• Monitoring
• Development of Guidelines/Protocol based on
  National Standards
• Development of Guidelines that are accessible

30
Personnel Information

• Personnel Central Chinle Ft. Def. Kayenta
  Winslow Tuba City Total
• Full Time 3 3 2 3 1
  2 14

31
Program Fact Sheet (Cont.)Organizational Chart
32
Budget Information (Cont.)
Increase No Decrease No Client Success and
Supporting Data
33
Program Fact Sheet

• Program Description
• The Navajo Nation Breast Cervical Cancer
  Prevention Program (NNBCCPP) was established in
  1996. It is funded through a cooperative
  agreement with the Centers for Disease Control
  and Prevention (CDC) Atlanta, Georgia.
• Organization
• The NNBCCPP operates under the Navajo Division of
  Health and covers the Arizona portion of The
  Navajo Nation. Within the NNBCCPP, one Case
  Manager and one Office Assistant are located at
  each of the following Chinle Comprehensive
  Health Care Facility, Fort Defiance Indian
  Hospital, Kayenta Health Center, Tuba City
  Regional Health Care Corporation, and Winslow
  Indian Health Care Center. The Kayenta Case
  Manager and Office Assistant provide services to
  Inscription House Health Clinic.

34
Program Sites

• Only serve women on the Arizona side of the
  reservation
• New Mexico State Health Department and Navajo
  Area IHS serve Navajo women on New Mexico side of
  the reservation
• Six NNBCCP Program sites
• Chinle (Pinon/Tsaile) - Fort Defiance (Sanders)
• Kayenta - Tuba City (Dennebito)
• Inscription House - Winslow (Dilcon, Luepp)
• Central Office in Window Rock, Az

35
Mammogram Clinics

• Two digital units in (Tuba City Chinle)
• One fixed unit in Fort Defiance
• Three Mobile Unit in Winslow, Inscription House
  and Kayenta
• Screenings are done according to the number of
  patients scheduled throughout the year

36
Target Population

• Mammogram 50 64
• Paps 40 64

37
Program Services

• SCREENING
• Clinical Breast Exam (CBE)
• Mammography
• Pelvic Exam
• Pap Test

• DIAGNOSIS
• Mammography
• Ultrasound
• Fine Needle Aspiration
• Breast Biopsy
• Colposcopy
• Colposcopy with biopsy
• Consultation

• One-on-one Patient Education
• Referrals for Mammogram Screening
• Case Management
• Contract Health Safe Ride Services
• Community Outreach Education
• Community Health Fairs

38
Program Client Eligibility

• Eligibility Women who are age 50-64, low
  income, underinsured, uninsured, and reside in a
  rural area are eligible for mammogram.
• Women who are age 40-64, low income,
  underinsured, uninsured, and reside in a rural
  area are eligible for pap testing. High risk
  women all ages are eligible per approval.

Income Eligibility Guidelines Effective April 1,
2007March 31, 2008 250 Poverty
Household Annual Monthly
Weekly 1. 25,525 2,127 491 2. 34,225
2,852 658 3. 42,925 3,577
825 4. 51,625 4,302 993 5. 60,325
5,027 1,160 6. 69,025 5,752
1,327 7. 77,725 6,477 1,495 8.
86,425 7,202 1,662
39
Case Management Program

• 1. Upon receipt of an abnormal pap smear result,
  the Case Manager will
• Enter the date of testing result with other
  relevant information into the appropriate
  database
• Initiate the Cervical Diagnostic Treatment
  Procedures Report
• An evaluation/management plan for the participant
  should be established within 30 days

40
Case Management Program

• The Case Manager will track and record results of
  additional diagnostic procedures
• Enter the date of additional testing, results,
  other relevant information into the database
• Update the Cervical Diagnostic Treatment
  Procedures Report
• Facilitate scheduling of any recommended treatment

41
Case Management Program

• The Case Manager will track record any
  treatment provided
• Enter the data, specific treatment employed,
  other relevant information into the database
• Update the Cervical Diagnostic Treatment
  Procedures Report.
• Maintain copies of completed Reports and send
  originals to central office for data management

42
Case Management Program

• The Case Manager will provide intensive patient
  education when indicated
• The Case Manager will employ all available means
  (written telephone contact, home visitation) to
  encourage participation in completion of all
  indicated diagnostic and treatment procedures,
  with an emphasis on prompt follow-up for those
  most at risk
• The Case Manager will provide culturally
  appropriate educational materials information
  support for participants who are reluctant to
  pursue indicated follow-up
• The Case Manager will help participants identify
  transportation resources otherwise assist with
  overcoming logistic barriers to care

43
Case Management Program

• Targeting the never/rarely (last Pap 5 years
  ago) population for outreach services

44
(No Transcript)
45
Other Relevant Program Information (Cont.)

• Program Partners/Collaborators
• Indian Health Services (HIS, 638)
• Mobile on-Site Mammography (MOM) Hopi Tribal
  Breast Cervical Cancer Program
• Well Womens Health Check Arizona Dept. of
  Health Services
• Farmington Cancer Treatment Center
• Utah Navajo Health System
• NCI Project Dine College, Shiprock, NM
• National Indian Womans Health Resource Center
• American Cancer Society
• Native American Cancer Research Partnership
  (NACRP) Tucson, Arizona
• Centers for Disease Control (CDC)
• Northern Arizona Radiology Dept., Flagstaff, AZ
• Flagstaff Cancer Center, Flagstaff, AZ
• Albuquerque Cancer Center, Albuquerque, NM
• Hopi Breast and Cervical Cancer Program
• Navajo Health Education Program
• Community Health Representative Program
• Navajo Area Agency on Aging
• New Mexico Breast and Cervical Cancer Program

46
Tuba City Data
47
Tuba City Data