Brevard County Health Department: Heidar Heshmati M.D., M.P.H., PhD, Director

1. Brevard County HealthDepartment:Heidar Heshmati M.D., M.P.H., PhD, Director

2. Cervical Cancer: Screening and Follow-upPresented By R. Bruce Pierce, MN, ARNP Director of Community Health Brevard County Health Department, Florida

3. Demographics • Suburban HD: County population 500k • County is 72 miles long and 15 miles wide • Three clinic sites: Multiple services including FP, OB, STD, Peds • Cervical cancer screening primarily in FP and Maternity clinics, some STD • High Risk population: Multiple partners, STD’s, low socioeconomic

4. Background/Problem • Pap screening long standing service in HD • Cervical Ca100% curable if early ID and Tx • BCHD 6 - 7,000 screenings per year • Abnormality rates fluctuate but >10% (700/yr) • Problem: Frustration in inability to get Dx and Tx services for our clients; we found it, therefore we feel a responsibility

5. Question • How provide expensive services for population with limited resources? • Is it worth pursuing?....YES • What we already had: • Screening program • Desire • Qualified Staff • What we needed: • Additional training • Funding/equipment

6. Problem: Scope • 10-30% paps abnormal (600-2300/yr) • Needed Dx and Tx services (200-700/yr) • Private sector cost precludes service • ~$ 300 for in-office colposcopy • ~$ 300 for in-office cryocautery • ~$ 600 for in-office Looped Electro Excision Procedure (Paradigm shift to Out Pt surgery $$$$$)

7. A Solution: Training • Partnership with Regional Training Center (RTC) for Family Planning • Sent ARNP for training in 1996 • Sent two more ARNP’s in 2001 • All training expenses paid for through Title 10 funding. Cost to the HD was time • Through a grant opportunity RTC able to provide an additional colposcopy and bx instruments

8. A Solution: Funding • Partnership with Holmes Regional Medical Center (local hospital) • Key Players: • Women’s advisory board • CEO of the hospital • Oncology Department Chair • OB/GYN’s • HOPE: Health Outreach Prevention Education

9. A Solution: Funding • Original request was for $50K to include new equipment and staff cost. (one year) • Second year was for $20K to sustain program • Subsequent years have been funded from general revenue due to commitment of Senior leadership and success of program. • Minimal Medicaid, EMBRACED billings

10. Service/Cost • Services are provided County-wide • Colposcopy – Cryocautery – LEEP • LEEP: Pay $75/hr or $300/session for PMD consultant once per month = $3600/yr, 40 LEEP/yr = $90/LEEP (MD) • Cryocautery done by ARNP’s (existing staff) • Residents help with colpo – OB program

11. Service/Cost • ARNP’s screen at the busiest site • Income eligible for hospital outreach referrals (HOPE etc): no pay and hospital pays pathology at their institution • Sliding fee for HD patients or Medicaid/Embrace • Local pathologists essential - $25/container

12. Program Highlights • Began in 1993 – bare bones, colpo/bx • 1996 - First ARNP trained • 1997 - Need became greater and funding sought for equipment and service – enabled expansion of service to other sites • 1999 - OB/GYN left our practice, but retained as contract provider for LEEP • 1999 – OB residents added to practice to continue with colpo/cryo services

13. Program Highlights • 2000 new lab for paps – abn dropped from 30% to 10% (missing dz or closer to Nat'l standard?) • Average about 50 high grade lesions – carcinoma in-situ per year (need tx) • Average about 500 colposcopies/yr • 1993- 2004 and still going strong

14. Results???

15. Lessons Learned • Have a vision – be clear and well defined • Sell it to your organization first – must believe not only in idea, but people • Be flexible – a must in public health • Do not lose sight of taking care of people – it truly is all about service