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Cherokee Nation Breast and Cervical Cancer Early Detection Program An Effective Model for Case Management in a Tribal Health System.

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Objectives

Cherokee Nation Breast and Cervical Cancer Early Detection ProgramAn Effective Model for Case Management in a Tribal Health System

Angela Leach, RN, Program ManagerKym Cravatt, MPH, CHES, Director, Cherokee Nation Cancer ProgramsGloria Grim, MD, FAAFP, Medical Director, Cherokee Nation Health Services


Objectives

Objectives

  • To provide an overview of Cherokee Nation and Cherokee Nation Health Services

  • To provide an overview of the Cherokee Nation Breast and Cervical Cancer Case Management system

  • To describe cancer case management outcomes

  • To discover the implication of effective cancer case management for breast and cervical cancer


Cherokee nation

Cherokee Nation

  • 2nd largest tribe in the United States

  • 14 counties in Northeastern Oklahoma

  • Over 274,000 enrolled tribal members

  • Over 111,000 tribal members living in Tribal Jurisdictional Service Area


Cherokee nation health services

Cherokee Nation Health Services

  • Self-governed Health Services (PL-93-638)

  • Operate 6 tribal clinics and 2 satellite clinics

  • Operate some services through Hastings Indian Medical Center an IHS.

  • Provide medical services to a service population of over 115,000


Breast and cervical cancer in the cherokee nation

Breast and Cervical Cancer in the Cherokee Nation

  • Breast Cancer is the 2nd most common cancer in the Cherokee Nation.

  • Cervical Cancer is the 6th most common cancer in the Cherokee Nation

    • mortality is double that of women in OK 6.4 vs. 3.0


Breast and cervical cancer in the cherokee nation1

Breast and Cervical Cancer in the Cherokee Nation


Background

Background

The Breast and Cervical Cancer Mortality Prevention Act of 1990: Public Law 101-354

  • Authorized the National Breast and Cervical Cancer Early Detection Program (NBCCEDP).

  • In 1993, Act amended to allow direct funding to tribes and tribal organizations. Referred to as the NBCCEDP American Indian/Alaska Native Initiative.

  • Initiative designed to address growing concerns about cancer in Native communities and evidence of detection at late stages.


The national breast and cervical cancer early detection program

Basic Implementation

WA

ME

MT

ND

MN

VT

OR

NH

ID

WI

NY

MA

SD

MI

CT

WY

RI

IA

PA

NE

NJ

NV

OH

IN

IL

DC

UT

DE

MD

CO

WV

VA

KS

MO

CA

KY

NC

TN

AZ

NM

OK

AR

SC

AK

MS

AL

GA

LA

PUERTO RICO

TX

REPUBLIC of PALAU

AMERICAN SAMOA

GUAM

FL

HI

HI

American Indian Initiative:

Native American Rehabilitation Assn of the Northwest, Inc

Navajo Nation – Window Rock, AZ

Arctic Slope Native Assn, Ltd – North Slope Borough, Barrow, AK

Poarch Band of Creek Indians – Atmore, AL

Cherokee Nation – Tahlequah, OK

South Puget Intertribal Planning Agency – Shelton, WA

Cheyenne River Sioux Tribe – Eagle Butte, SD

Southcentral Foundation – Anchorage, AK

Hopi Tribe – Kykotsmovi, AZ

Kaw Nation – Kaw City, OK

Southeast Alaska Regional Health Consortium – Sitka, AK

Mississippi Band of Choctaw – Philadelphia, MS

Yukon-Kuskokwim Health Corp – Bethel, AK

The National Breast and Cervical Cancer Early Detection Program

June 30, 2005


Cherokee nation bccedp services

Cherokee Nation BCCEDP Services

  • Pap Test

  • Clinical Breast Exams

  • Screening Mammography

  • Diagnostic Follow-up (pts residing out of OK)

    • Diagnostic Mammography

    • Breast Ultrasound

    • Biopsies

    • Colposcopy

    • LEEP (as diagnostic procedure)

  • Community Outreach

  • Case Management


Cnbccedp eligibility guidelines

CNBCCEDP Eligibility Guidelines

  • Women Ages 40-64

  • Member of a federally recognized tribe

  • Uninsured

  • At or below 250% of the federal poverty guidelines

    • Household of 2- $34,225


What is case management

What is Case Management?

  • Goal: Ensure that women enrolled in the NBCCEDP receive timely and appropriate re-screening, diagnostic and treatment services.

  • Definition: Case management involves establishing, brokering, and sustaining a system of available clinical (screening, diagnostic and treatment) services and essential support services.


Key components of case management

Key Components of Case Management

  • Assessment

  • Planning

  • Coordination

  • Monitoring

  • Resource Development

  • Evaluation


Case management defined

Case Management Defined

  • A “real-time” patient-centered service involving the provision of the key component activities to assure timely diagnostic and treatment services, as well as re-screening. (1998)

  • Case Management services may be needed to ensure that women with abnormal screening results are able to comply with the recommended clinical follow-up. These services are intended to ensure timely and complete clinical follow-up of abnormal screening results for the patient. (4/2007)


Cherokee nation case management background

Cherokee Nation Case Management Background

  • In 1996, CNBCCEDP began screening Native American women for breast & cervical cancer

    • 2 case managers operating centrally or “off site”

  • By 2002, case management decentralized or “on site”

    • 8 case managers total, 7 located in the clinical setting


Background1

Background

  • Today, case management completely decentralized “on site”

    • 7 case managers, all in the clinical setting

  • Tribal Health Clinics

  • IHS Hospital


Oklahoma cares breast cervical cancer treatment act

Oklahoma Cares- Breast & Cervical Cancer Treatment Act

  • Oklahoma Cares- Breast & Cervical Cancer Treatment Act

    • Implemented January 1, 2005

  • Five Agencies

    • Cherokee Nation

    • Kaw Nation

    • Oklahoma State Department of Health

    • Oklahoma Health Care Authority (Medicaid Agency)

    • Oklahoma Department of Human Services

  • Interagency Agreement signed by all five agencies.

  • Continued inter-agency collaboration


Case management flow

Case Management Flow

ENROLL

RE-ENROLL

(Enrollment form

issued at check-in)

ENROLL

RE-ENROLL

(Enrollment form

issued at check-in)

ENROLL

RE-ENROLL

(Enrollment form

issued at check-in)

EXAM and/or SCREEN /

RE-SCREEN

(CN / IHS/ Contract Provider)

EXAM and/or SCREEN /

RE-SCREEN

(CN / IHS/ Contract Provider)

EXAM and/or SCREEN /

RE-SCREEN

(CN / IHS/ Contract Provider)

  • Case Management

  • Initial Assessment

  • * High Risk? Symptoms? Barriers?

  • Written Plan

  • Refer to Patient Benefits Advocate

  • * Assists with OK Cares App. completion

  • Clinical oversight

  • * Initiate Referral for diagnostic test

  • * Provider review/sign

  • Patient Education

  • Support to reduce barriers

  • Schedule Referrals

  • Case Management

  • Initial Assessment

  • * High Risk? Symptoms? Barriers?

  • Written Plan

  • Refer to Patient Benefits Advocate

  • * Assists with OK Cares App. completion

  • Clinical oversight

  • * Initiate Referral for diagnostic test

  • * Provider review/sign

  • Patient Education

  • Support to reduce barriers

  • Schedule Referrals

  • Case Management

  • Initial Assessment

  • * High Risk? Symptoms? Barriers?

  • Written Plan

  • Refer to Patient Benefits Advocate

  • * Assists with OK Cares App. completion

  • Clinical oversight

  • * Initiate Referral for diagnostic test

  • * Provider review/sign

  • Patient Education

  • Support to reduce barriers

  • Schedule Referrals

ABNORMAL

‘OK Cares’

ELIGIBLE

ABNORMAL

‘OK Cares’

ELIGIBLE

ABNORMAL

‘OK Cares’

ELIGIBLE

RESULTS

RESULTS

RESULTS

NORMAL

NORMAL

NORMAL

DIAGNOSTIC

WORK-UP

(CN / IHS/ Contract Provider)

DIAGNOSTIC

WORK-UP

(CN / IHS/ Contract Provider)

DIAGNOSTIC

WORK-UP

(CN / IHS/ Contract Provider)

Case Management

OHCA Care Management Staff

Case Management

OHCA Care Management Staff

Case Management

OHCA Care Management Staff

NOT

CANCER

NOTIFY

DHS

NOT

CANCER

NOTIFY

DHS

NOT

CANCER

NOTIFY

DHS

CANCER

NOTIFY

CARE

MGMNT

CANCER

NOTIFY

CARE

MGMNT

CANCER

NOTIFY

CARE

MGMNT

FINAL

DIAGNOSIS

FINAL

DIAGNOSIS

FINAL

DIAGNOSIS

TX

DONE

CARE

MGMNT

NOTIFIES

CNCMand DHS

TX

DONE

CARE

MGMNT

NOTIFIES

CNCMand DHS

TX

DONE

CARE

MGMNT

NOTIFIES

CNCMand DHS

TREATMENT

TREATMENT

TREATMENT


Tracking follow up

Tracking & Follow-up

  • Mechanism for reviewing and assessing the completeness, accuracy, and timeliness of data collected by the program

    • Quality Assurance Activities

    • Monthly Data reports

    • Monthly Case Management reports


Challenges to effective case management

Challenges to Effective Case Management

  • Limited Colposcopy Services

  • Missed patient appointments

  • Other clinic demands

    • Committees

    • Outreach

    • Clerical


Data quality indicators

Data Quality Indicators


Contact information

Contact Information

  • Gloria Grim, MD, FAAFP, Medical Director, Cherokee Nation Health Services

    • [email protected]

  • Kym Cravatt, MPH, CHES, Director, Cherokee Nation Cancer Programs

    • [email protected]

  • Angela Leach, RN, Program Manager, Cherokee Nation Breast & Cervical Cancer Early Detection Program

    • [email protected]

    • (918) 453-5756 THANK YOU!


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