Navajo Nation Breast & Cervical Cancer Prevention Program (NNBCCPP)

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/10% • 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 women’s 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 provider’s 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 Women’s 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 • Responsibility and Authority

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 women’s 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 HCP’s 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 • DIAGNOSIS: • Mammography • Ultrasound • Fine Needle Aspiration • Breast Biopsy • Colposcopy • Colposcopy with biopsy • Consultation SCREENING: • Clinical Breast Exam (CBE) • Mammography • Pelvic Exam • Pap Test • 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, 2007—March 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

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 Women’s Health Check – Arizona Dept. of Health Services • Farmington Cancer Treatment Center • Utah Navajo Health System • NCI Project Dine College, Shiprock, NM • National Indian Woman’s 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