Objectives

1. 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

2. 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

3. 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

4. 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

5. 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

6. Breast and Cervical Cancer in the Cherokee Nation

7. 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.

8. 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

9. 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

10. 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

11. 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.

12. Key Components of Case Management • Assessment • Planning • Coordination • Monitoring • Resource Development • Evaluation

13. 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)

14. 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

15. Background • Today, case management completely decentralized “on site” • 7 case managers, all in the clinical setting • Tribal Health Clinics • IHS Hospital

16. 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

17. 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

18. 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

19. Challenges to Effective Case Management • Limited Colposcopy Services • Missed patient appointments • Other clinic demands • Committees • Outreach • Clerical

20. Data Quality Indicators

21. Contact Information • Gloria Grim, MD, FAAFP, Medical Director, Cherokee Nation Health Services • gloria-grim@cherokee.org • Kym Cravatt, MPH, CHES, Director, Cherokee Nation Cancer Programs • kym-cravatt@cherokee.org • Angela Leach, RN, Program Manager, Cherokee Nation Breast & Cervical Cancer Early Detection Program • angela-leach@cherokee.org • (918) 453-5756 THANK YOU!