1. Increasing Breast and Cervical Cancer Screening in Michigan May 18, 2016 Integrated Health Partners

2. Michigan cancer screening rates: Cervical cancer screening (18 and over) = 77.3 Breast cancer screening (40 and over) =74.9 Mammogram in the past 2 years What are your breast and cervical cancer screening rates? How does that compare to the state rate? Cancer Screening Disparities

3. Screening by Educational Attainment : Source: Michigan Behavioral Risk Factor Survey – State level data Calhoun County Education: Source: U.S. Census Bureau, 2010-2014 American Community Survey 5-Year Estimates Cancer Screening Disparities in Michigan Breast Cancer ScreeningCervical Cancer Screening Less than High school65.170.1 College Graduate81.383.3 Education (females only) five year estimates Less than High School11.30% High school graduate30.60% some college50.70% College Graduate7.40%

4. Screening by Income Level: Source: Michigan Behavioral Risk Factor Survey – State level data Calhoun County Household Income: Source: U.S. Census Bureau, 2014 American Community Survey 5-year Estimates Cancer Screening Disparities in Michigan Breast Cancer ScreeningCervical Cancer Screening Less than 10,00044.266.6 $50,000 or more82.180.4 Median Household Income (5 year estimates) Less than $10,0008.20% $10,000 - $14,9995.70% $15,000-$24,99913.60% $25,000 - $34,99913.40% $35,000 - $49,99915.60% $50,000 or more43.40%

5. First started paying for cancer screening services for low income women in 1990. Funded by the Center’s for Disease Control and Prevention (CDC) Reached a maximum of 30,000 women in 2013. Michigan’s Breast and Cervical Program

6. Insurance may not be the only reason for low screening rates. Initial data from Healthy Michigan Plan (13 health plans) indicate screening rates below the state average: Over the 16 month period (4/2014 to 8/2015): Breast Cancer Screening rates averaged < 4%/month Cervical Cancer Screening rates averaged < 3% month Possible reasons for low screening rates in the newly insured: Both provider and patient are focused on urgent health issues first Difficulty accessing health system Lack of understanding of the importance of screening Cancer Screening Rates Healthy Michigan Plan

7. Assure low-income women receive timely access to needed breast and/or cervical cancer services. Program Goal

8. Two Services: Caseload Services –acts as a “insurance company” and pays for breast and cervical cancer screening and diagnostic services for uninsured or underinsured women. Navigation Only Services – provides reimbursement for patient navigation to insured women to address barriers to breast and cervical screening. What is the BCCCNP?

9. Navigation-Only Services: Provide payment to IHP providers for navigating patients who are in need of but are not completing breast and/or cervical cancer screening. NOT for women who simply call and schedule annual screening and complete it without additional assistance. AIMED at women who have never been screened or who need an additional intervention in order to complete cancer screening. Integrated Health Partners

10. Providers have limited time to provide education on preventative health. Intent of this project is to provide funding to offices to enable outreach and education to practice patients to facilitate breast and cervical cancer screening. Integrated Health Partners

11. Be between the ages of 40 and 64 Income < 250% Federal Poverty Level*  Income criteria set by federal law- must document woman’s verbal statement of income; no written proof required  INSURED  Requires breast/cervical cancer-related services ONLY  Pap test, Mammogram, and/or follow-up services for abnormal test result Eligibility Criteria for Navigation- Only Services

12. Why use Navigation?

14. Navigation Works 1964-1986 the 5 year survival rate at the Harlem Hospital center = 39 % (60% for white women) 1995-2000 the 5 year survival rate at Harlem Hospital = 70% Stage O and 1 moved from 6% to 41% Stage 3 and 4 moved from 49% to 21% 1964- 1986 1995- 2000 Stage 0 0%12% Stage I 6%29% Stage II 45%38% Stage III 39%14% Stage IV 10%7%

15. Patient Navigation

16. Is fear the reason she is not being screened? Does she understand how cancer screening helps? Are there family care or transportation issues? Have you looked for appointment times that work with HER schedule? Ask… Understand… Educate… How can Navigation Help?

17. What is a Root Cause? The word “root” refers to underlying causes, rarely one cause. 17 Symptom = Above the surface, obvious Root cause= Below the surface, not obvious

18. When using “5 Whys?” ask the following... Do you think this is the root cause? Should we ask “Why” again? If you address the root cause will the problem be permanently fixed? Root Causes

19. Navigation Examples Education Providing information on the importance of screening, types of screening tests, and/or addresses fear of cancer or cancer screening. Brainstorming around or assistance with: Transportation, child care, elder care Follow-up on “no-shows” or lack of follow-through on mammogram or diagnostics Asking about work schedules and how flexibility in scheduling will promote screening completion Interpreter services Assistance with completing forms or understanding written materials

20. Patient Navigation Team Navigation is a process not an individual: Navigation services can be provided by one person or shared by several individuals. Patient Navigator does not need to be a health care professional to provide non-clinical services. Unmet needs are identified and then split based on the skills of each team member.

21. Improves provider screening rates Promotes earlier screening and successful diagnostic resolution Decreases no-shows Navigation payment ($60) per woman navigated for breast and cervical cancer screening / diagnostics. Navigation in Provider Offices

22.  Identify individual barriers/problems that impede access to obtaining breast/cervical cancer screening, diagnosis and/or treatment services  Provide individualized support and assistance to overcome barriers/problems  Document your work Navigation in Provider Offices

23.  Meets age, income, insurance eligibility criteria AND  Is in need of breast / cervical cancer screening or diagnostic assistance AND  Requires education/assistance/resources to obtain needed breast/cervical cancer services  Is willing to complete breast /cervical cancer screening Who Do We Navigate?

24. This is a federal requirement so to receive payment you will have to ask. Potential language: “We are participating in a program that is aimed at helping our patients to get screened for breast and cervical cancer. We would like to talk to you about what has been standing in the way of getting you cancer screening and potential resources available to ” “This program assists lower income patients, therefore I need to ask your household income and the number of people in your home. We will use this information only for the purposes of this program.” “In return we will help you problem solve completing your cancer screening and if necessary may be assist you with resources to get this screening done.” But we don’t have income information!

25. 1.Age/Income 2.Breast/Cervical screening services needed 3.Barriers/problems the woman may have to receiving services 4.Assistance provided by navigator to overcome barriers/problems 5.Types and dates of services received Information Needed to Document Navigation Services

26. IHP Patient Navigation Forms

27. Form #1 – Intake Form

28. Documents: Eligibility Breast and/or cervical services required by the client Barriers that may interfere with obtaining these services IHP Patient Navigation Intake Form

29. Encounter # 1 Date - When did you first talk to this client about cancer screening and assess the reasons they are not completing screening Write date Type of Encounter – How did you have this conversation? Face-to-Face? By phone? Check the appropriate box Intake Form

30. Size of Family UnitPoverty Guideline250% of Poverty138% of Poverty 1 $11,880.00$29,700.00$16,394.40 2 $16,020.00$40,050.00$22,107.60 3 $20,160.00$50,400.00$27,820.80 4 $24,300.00$60,750.00$33,534.00 5 $28,440.00$71,100.00$39,247.20 6 $32,580.00$81,450.00$44,960.40 7 $36,730.00$91,825.00$50,687.40 8 $40,890.00$102,225.00$56,428.20 Each Additional Member (Beyond 8) $4,160.00$10,400.00$5,740.80 2016 Federal Poverty Level (FPL) Guidelines 2016 FPL Guidelines

31. Record reported income and # people in household Verbal declaration by client is accepted (no proof of income required) If the household income is above 250% of the Federal Poverty Level for the family/unit the BCCCNP program will not be able to provide payment for navigation. Note: Numbers indicate 2016 FPL guidelines Intake Form: Client Eligibility

32. Starred (*) items must be completed on form Address, phone number & email address is optional We are required to collect race/ethnicity data. However the client has the right to refuse to provide that information. Intake Form: Client Information

33. Client Verbal Acknowledgement Informed Consent Not Required “Based on the information that you are telling me, here is what I can do for you.” Explain navigation services that can be provided to the client based on your assessment and confidentiality will be maintained. “I am/will make suggestions for you based on the information you give me. If, for some reason, that information is not correct or if your situation changes, that may affect what I told you. In that case, please call me and we will talk about this further.” Document “Yes” in the Client Verbal Acknowledgement for Services on the Michigan Breast and Cervical Navigation Services Outreach Navigation Intake Form. Prior to ending the contact/call with the client obtain the next date that you will contact her and document it on the enrollment form.

34. Client Verbal Acknowledgement Check “Yes” that client has agreed for assistance in obtaining breast/cervical services If they client does not give verbal acknowledgment, the BCCCNP program will not be able to provide payment for navigation. Intake Form: Client Information

35. Screening Services Received in Past Year Mark services received in the past year For unknown dates - approximate closest date If no services provide – check “none” Screening/Diagnostic Services Needed Check appropriate services needed Client Assessment: Services Required

36. Check identified barriers For each barrier checked, record briefly in comments how you will address the barrier Enter date and type of next planned encounter. Sign and date the form. (List of navigator names needed) Intake Form: Barrier Assessment

37. Form #2 – Encounter From

38. Documents: Breast and/or cervical cancer services received by the client Referrals/Resources provided to the client ______________________ You can complete a separate form for each encounter -or- You may summarize client contacts on one form as long as the navigation process can be clearly understood. IHP Patient Navigation Encounter Form

39. Follow-up Encounter Date – Date of follow-up contact with the patient Type of encounter – how did you have this conversation Basic Client information to allow matching intake and encounter forms Encounter Form

40. Document the following: Dates of screening/diagnostic services received Referrals/Resources provided to client Encounter Form: Navigation Services Completed

41. Navigation status (ongoing): Do you need to contact the client again? – Yes, identify when you will contact the patient. Provide brief comments on current encounter Encounter Form: Navigation Status

42. Navigation status (complete): Do you need to contact the client again? – No, all breast/cervical screening/diagnostic services are complete. Provide brief comments on current encounter. Sign and date encounter form Fax complete forms to IHP. Encounter Form: Navigation Status

43. 1.Client is eligible (age and income) 2.At least ONE Barrier/Problem is identified 3.A solution is put in place for each identified barrier/problem. 4.Client receives needed breast or cervical screening and/or diagnostic services. Key Components

44. Has at least 2 (TWO) encounters with designated office staff via phone, email, or in-person Completes breast and/or cervical cancer screening and any required diagnostics. When is Navigation Complete?

45. Any of the following will count as a second encounter: 1.In-person visit 2.Telephone contact 3.Email or other written contact from the patient 4.Voicemail message left for the navigator by the woman in response to a navigator voicemail message Navigation-Only Clients What counts as a SECOND ENCOUNTER?

46. Did you provide a specific intervention to address an identified need? i.e. problem solve appoint times, provide gas card Did you provide education to a woman on cancer, cancer screening, the use of insurance…? Did you spend time helping her brainstorm family care, work barriers….? Did you spend time helping her address specific health system barriers? How do I know if I resolved a barrier?

47. When you document your navigation you need to tell us what you did: Keep it brief, we don’t need to know specific deals of the woman’s life Do provide us enough information that we know what the barrier was AND how YOU resolved it. Completed service – the woman MUST need and complete cancer screening and/or diagnostic services Documentation

48. Options for the Uninsured and Underinsured

49. Caseload Services BCCCNP acts as a “insurance company” and pays for breast and cervical cancer screening and diagnostic services with contracted providers for uninsured or underinsured women Navigation-Only Services BCCCNP navigator ASSISTS insured women with overcoming barriers/resolving problems that may prevent them from receiving breast and cervical services. BCCCNP Services

50. BCCCNP will pay for breast/cervical cancer screening and diagnostic services for those who are do not have insurance or who need diagnostics but face a high deductible Defined as: “I cannot afford that amount” Will count as navigation (you resolved an insurance/financial barrier) IMPORTANT: You must refer these women to the Kalamazoo Health Department for these services to be covered by BCCCNP BCCCNP Caseload Services

51. Age - 40-64 and requiring breast/cervical screening/diagnostic services 21–39 and referred to the program with an abnormal screening Pap test OR clinical breast exam which requires breast/cervical diagnostic services Residency and Citizenship Status - Current Michigan Resident Can include non-citizens or migrant workers Insurance Status Uninsured women / Underinsured women (women with high deductibles) Insured women – Navigation Service line only Income - < 250% Federal Poverty Level Caseload Services Program Eligibility

52. EligibleNot- EligibleContact MDHHS Age 40 to 64X Under 40 in need of diagnosticsX 65 and overX Income < 250% of povertyX Income over 250% of povertyX Undocumented / non-citizenX Eligibility

53. No insurance refer to BCCCNP – her breast or cervical cancer screening and any necessary diagnostic services will be covered Underinsured refer to BCCCNP as needed for diagnostics– some women face high deductibles or co-pays You may additionally qualify for navigation payments if you assisted in resolving barrier NavigationRefer to BCCCNP InsuredX UninsuredX UnderinsuredX Which Service Line

54. Mary has Marketplace Insurance. When you talk to her about cancer screening she states she is not sure what her insurance company will cover. She states she cannot afford to pay extra money right now. She also states that she does not have sick time and may be fired if she takes time off of work. 1.Barriers identified? 2.What can be done? Case Scenario # 1

55. Phone call from Angela, who is very upset stating she found a lump on her breast and is afraid that it might be cancer. Her older sister was diagnosed with breast cancer 2 years ago. She has not had a mammogram. Has enrolled for insurance through the Marketplace but not sure what is covered and has no money to pay for testing. 1.What interventions do you see? Case Scenario # 2

56. Gwen, age 50, is in the office for a routine follow-up related to her high blood pressure. You note on her chart that there is no record of breast of cervical cancer screening in the past 5 years. You ask her if she has completed either and she replies she has not. You assess her knowledge of cancer screening and provide education on why and how this screening is done. You ask Gwen if she is willing to set an appointment to start the screening process. What was the barrier? Case Scenario #3

57. Vicki, age 45, is a new patient to you with a Healthy Michigan Plan. You have not seen Vicki since her initial visit. At that time you identified that Vicki had a positive mammogram through a free screening program but she did not follow-up on diagnostics. Vicki no-showed for the diagnostic mammogram you scheduled for her. What is your next steps? Case Scenario #4

58. 1. Who do I call with questions about completing the form or if a woman qualifies for BCCC navigation services? Tory Doney - doneyt@michigan.gov or 517-335-8854.doneyt@michigan.gov 2.Who do I call if I identify a woman who needs help paying for breast of cervical screening or diagnostic services: Kalamazoo County Health and Community Services Department Southwest Michigan BCCCNP a.k.a. Southwest Michigan BCCCNP 888-243-4087 2.Who do I call to learn more about navigation in my practice? Your IHP Coach or Debbie Webster – websterd1@michigan.govwebsterd1@michigan.gov Frequently Asked Questions

59. 4. Does the program provide support for women diagnosed with breast or cervical cancer? YES!! Income eligible women, (insured, uninsured, and underinsured) may be eligible to enroll in a special Medicaid program through the BCCCNP. Women currently enrolled in HMP can transfer into the BCCCNP Medicaid program where they will incur NO co-pays! She MUST be newly diagnosed in order to qualify Frequently Asked Questions

60. 5.Who do I contact about assistance for breast or cervical cancer treatment for my patient? E.J. Siegl - siegle@michigan.gov or 517-335-8814siegle@michigan.gov 6. Where do I find forms and important contact information for this program? The IHP Patient Navigation page found at: http://www.michigancancer.org/bcccp/ptnav/ihp.html Frequently Asked Questions

61. Questions?