Thursday, January 24, 2013 2:00-3:30pm ET

1. BPHC Enrichment Series for Grantees:Improving Cervical Cancer Screening in Health Centers through PCMH Thursday, January 24, 20132:00-3:30pm ET

2. Cervical Cancer Screening & PCMHLearning Objectives • Understand the epidemiological basis of cervical cancer and cervical cancer screening • Identify barriers to improving cervical cancer screening rates • Analyze how to overcome screening barriers using PCMH • Describe successful grantee screening programs • Identify additional TA and resources on PCMH and cervical cancer screening Widening Perspectives to Improve Outcomes

3. Agenda in Brief Welcome Seiji Hayashi, HRSA Profile of Cervical Cancer & Cervical Cancer Screening Jacqueline W. Miller, CDC Challenges to Improving Cervical Cancer Screening Rates Nina Brown, HRSA Using PCMH to Improve Cervical Cancer Screening Rates Preeta Chidambaran, HRSA Successful Health Center Cervical Cancer Screening Programs Rise Phillips, T.H.E. Clinic, Inc. Chad Hess, Pueblo Community Health Center

4. Cervical Cancer Overview CAPT Jacqueline Miller, MD, FACS US Public Health Service Medical Director, National Breast and Cervical Cancer Early Detection Program Program Services Branch National Center for Chronic Disease Prevention and Health Promotion Division of Cancer Prevention and Control

5. Cervical Cancer Burden In 2009, • 12,357 new cervical cancer cases (7.9/100,000)* • 3,909 cervical cancer deaths (2.3/100,000)* • Over $2 billion per year is spent in the United States on the treatment of cervical cancer • Number of new cases and deaths decreasing U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2008 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2012. Available at: www.cdc.gov/uscs.

6. 16 14 Rate/100,000 12 10 Incidence 8 6 4 Death 2 0 '98 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '00 '02 '04 '06 Year Trend in Cervical Cancer Incidence and Mortality Rates*, 1975-2006 *Incidence source: Surveillance Epidemiology, and End Results Program ( 9 areas) Mortality source: US Mortality Files, National Center for Health Statistics, CDC Rates are per 100,000 and are age-adjusted to the 2000 US Std Population (19 age groups - Census P25-1130).

7. Cervical Cancer Incidence Rate by Race, 2009 Per 100,000 Source: U.S. Cancer Statistics Available at: http://www.cdc.gov/uscs.

8. Cervical Cancer Incidence Rate by State, 2009 Source: U.S. Cancer Statistics Available at: http://www.cdc.gov/uscs.

9. Cervical Cancer Mortality Rate by State, 2009 Source: US Cancer Statistics Available at http://www.cdc.gov/uscs

10. Cervical Cancer Screening • Two goals • Prevention • Early detection • Precancerous lesions can be treated before developing into invasive disease. • Main reason for decline in cervical cancer incidence and mortality.

11. Cervical Cancer Survival by Stage Source: National Cancer Database

12. USPSTF Screening Guidelines • Recommends screening in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. • Grade: A Recommendation.

13. USPSTF Screening Guidelines • Recommends against screening in women younger than age 21 years. • Grade: D Recommendation • Recommends against screening in women older than age 65 years who have had adequate prior screening and are not at high risk . • Grade: D Recommendation

14. USPSTF Screening Guidelines • Recommends against screening in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion or cervical cancer. • Grade: D Recommendation • Recommends against screening with HPV testing alone or in combination with cytology in women younger than age 30 years. • Grade: D Recommendation

15. Screening Guidelines • Consistent recommendations from USPSTF, ACS, and ACOG • Only for average risk women

16. U.S. Cervical Cancer Screening Rates, 2010 Data source: Behavioral Risk Factor Surveillance System Data source: Behavioral Risk Factor Surveillance System

17. Cervical Cancer Screening Trend HP2020 goal Data source: National Health Interview Survey Healthy People 2020 goal is 93%.

18. Cervical Cancer Screening by Demographics, 2010 CDC. Cancer Screening. MMWR 2012;61:41-45. Data source: National Health Interview Survey

19. Cervical Cancer Screening by Demographics, 2010 CDC. Cancer Screening. MMWR 2012;61:41-45. Data source: National Health Interview Survey

20. Human Papilloma Virus (HPV) • Majority of cervical cancer associated with HPV • High-risk HPV DNA testing added to screening regimen • No role for low-risk HPV DNA testing • HPV vaccine may decrease disease burden further, but results too early • Continue screening despite vaccination status • Hopefully begin to monitor national testing rates

21. Benefits of Screening • Usually no early signs • May have vaginal bleeding/discharge, pelvic pain, or painful intercourse • Cervical cancer is easily detectable and highly treatable • Prognosis depends of stage of tumor and patient’s overall health • Screening to look for abnormal cells early leads to better prognosis

22. BPHC Grantee TA call Improving Cervical Cancer Screening in Health Centers through PCMH Thursday, January 24, 20132:00-3:30pm ET

23. Case Study – Undiagnosed Vaginal Bleeding The patient is a 34-year-old gravida 3, para 3 woman with a 2-year history of increasingly profuse vaginal bleeding. Over the past two years, the patient had been placed on oral contraceptives, but these had not stanched the bleeding. The patient reported having a Pap smear approximately 18 months earlier, read as "unsatisfactory, obscured by blood." However, she had not had a follow-up study. Source: http://www.webmm.ahrq.gov/

24. Case Study – Undiagnosed Vaginal Bleeding A gynecologist had seen her about 6 months earlier, and told her she needed a hysteroscopy and a dilation and curettage (D&C). However, he explained that he did not accept Medicaid, which was her source of health insurance. Her follow-up remained sporadic, and her bleeding continued—profuse enough that she required hospitalization for transfusions twice in the preceding 2 months. Source: http://www.webmm.ahrq.gov/

25. Case Study – Undiagnosed Vaginal Bleeding Her bleeding increased again, and she presented to the emergency department (ED). Physical exam revealed that the patient had an extremely friable exophytic cervical lesion, which was biopsied and confirmed to be invasive cervical cancer. Upon evaluation by a gynecologic-oncologist, she was found to be Stage IIB cancer. After undergoing radiation therapy and chemotherapy, she still has persistent disease. Her prognosis is currently guarded. Her oncologist believes that her delayed diagnosis profoundly affected her prognosis. Source: http://www.webmm.ahrq.gov/

26. Cervical Cancer Related Malpractice Concerns/Issues in Health Centers • Over the past 10 years, the majority (58%) of incidents involving cervical cancer have involved the following: • a failure to diagnose • or delay in diagnosis • Significant payout per closed event Source: FTCA Claims Data

27. Cervical Cancer Screening Trends and Goals in Health Centers

28. Cancer Screening Outcomes among Health Center Patients Source: 2009 Patient Survey and 2010 NHIS

29. BPHC’s Efforts to Support Cervical Cancer Screening • 811 health centers funded • $44 million dollars: $55,000 per health center • Focus on PCMH transformation as a tool to improve clinical quality • Cervical Cancer Screening Improvement

30. Cervical Cancer Clinical Measure • Current Measure • Numerator: Number of female patients 24-64 years of age receiving one or more Pap tests during the measurement year or during the two years prior to the measurement year, among those women included in the denominator • Denominator (Universe): Number of female patients 24-64 years of age as of December 31 of the measurement year who were seen for a medical encounter at least once during the measurement year and were first seen by the grantee before their 65th birthday

31. Cervical Cancer Clinical Measure • Cervical Cancer Clinical Measure • Modified for 2013 • Whereas the current measure counts as compliant women age 24 to 64 years with 3 year intervals between screenings, the revision allows 5 year intervals for women age 30 to 64 years with a Pap test accompanied by an HPV test.  This change aligns with the 2012 recommendation of the U.S Preventive Services Task Force.

32. Qualitative Study of PCMH Supplemental 2012Key Barriers to PCMH Transformation to Improve Cervical Cancer Screening 32

33. Patient Level Barriers • Access to care • Patient Demographics (SES factors) • Geographic Issues • Patient Engagement • Cultural Competency * • Workflow Issues • Type of providers • Care coordination between multiple providers • Financial Barriers 33

34. Provider Level Barriers • Workflow Issues • Disconnect between QI staff and clinicians • Significant gaps between patients identified by registry and scheduling appointments • Training and Technical Assistance • Turnover of staff or high growth rate in staff • Software training • Best Practice Guidelines including recent changes to screening recommendations 34

35. System Level Barriers • Clinical Process and workflow issues • EHR • Decision Support systems • Technical and data integrity issues • Resources for outreach and education programs 35

36. Demographics of Health Center Female Patients Source: 2009 Patient Survey 36

37. Barriers Related to Cultural Competency • Need for interpretive services • Need for special outreach programs • Need for multilingual patient education materials 37

38. Qualitative Study of PCMH Supplemental 2012 Solutions to PCMH Transformation to Improve Cervical Cancer Screening 38

39. Solutions Targeting Patients • Workflow • Appropriate matching of patients to providers for first visit • EHR: Patient registries, automatic prompts, Follow up Reminders, Patient Portal • Patient Education Materials 39 Source: FY2012 PCMH Supplemental Application Qualitative Review

40. Solutions Targeting Patients • Outreach • Follow up on referrals, Batch mailings, Appointment Reminders • Advertisement Media, Women’s health fair • Finance • Discounted fee for screening (PAP tests, lab fees) • Incentive gift cards, One time cash rewards • Use funds for out of state patients who don’t qualify for in state programs

41. Solutions Targeting Patients Source: FY2012 PCMH Supplemental Application Qualitative Review

42. Solutions Targeting Providers • Workflow • Pre visit planning • Standing orders • Peer review, quarterly data reports • Access to care • Increase clinic hours, walk ins, bundling approach • Hiring dedicated staff for care coordination, referral follow up • Additional staff resources • Training • Evidence based guidelines, PCMH, Software, Lab protocols • Outreach Efforts 42 Source: FY2012 PCMH Supplemental Application Qualitative Review

43. Solutions Targeting Providers Source: FY2012 PCMH Supplemental Application Qualitative Review

44. System Based Solutions • Organizational Policy and Procedures • Identifying cervical cancer screening measure as a Health Center goal • Leadership commitment to internal policy changes • Quality Improvement QI • Identifying quality gaps • Pursuing PCMH/ Accreditation • Participating in BPHC quality initiatives • HIT • EHR system (registries, educational resources, decision support system) • Training 44 Source: FY2012 PCMH Supplemental Application Qualitative Review

45. Systems Based Solutions Source: FY2012 PCMH Supplemental Application Qualitative Review

46. Solutions Related to Cultural Competency* • Multi lingual patient education materials • Interpretive services for appointments and front desk • Multi lingual patient education classes • Culturally competent events ex: Hmong Tea Ceremony • Training staff on cultural competency * Corresponding NCQA PCMH Domain PCMH 1: Enhance Access and Continuity- Element 1f: Culturally and Linguistically Appropriate Services PCMH 2: Identify and Manage patient Populations - Element 2a: Patient Information 46 Source: FY2012 PCMH Supplemental Application Qualitative Review

47. Case Study – Undiagnosed Vaginal Bleeding The patient is a 34-year-old (Automatic prompt for preventive care service- PAP)gravida 3, para 3 woman with a 2-year history of increasingly profuse vaginal bleeding. Over the past two years, the patient had been placed on oral contraceptives, but these had not stanched the bleeding. The patient reported having a Pap smear approximately 18 months earlier, read as "unsatisfactory, obscured by blood." However, she had not had a follow-up study.(Protocol for appropriate follow up on lab result) Source: http://www.webmm.ahrq.gov/ 47

48. Case Study – Undiagnosed Vaginal Bleeding A gynecologist had seen her about 6 months earlier,(Missed opportunity to repeat PAP, better care coordination and documentation between providers)and told her she needed a hysteroscopy and a dilation and curettage (D&C). However, he explained that he did not accept Medicaid, which was her source of health insurance. Her follow-up remained sporadic, (Adequate follow up on referral) and her bleeding continued—profuse enough that she required hospitalization for transfusions twice in the preceding 2 months. (Consolidated records from multiple providers) Source: http://www.webmm.ahrq.gov/ 48

49. Case Study – Undiagnosed Vaginal Bleeding Her bleeding increased again, and she presented to the emergency department (ED). Physical exam revealed that the patient had an extremely friable exophytic cervical lesion, which was biopsied and confirmed to be invasive cervical cancer. Upon evaluation by a gynecologic-oncologist, she was found to be Stage IIB cancer. After undergoing radiation therapy and chemotherapy, she still has persistent disease. Her prognosis is currently guarded. Her oncologist believes that her delayed diagnosis profoundly affected her prognosis. Source: http://www.webmm.ahrq.gov/ 49

50. FY12 Supplemental Important Dates and Reminders • Survey Submission for at least 1 site or Site Visit Scheduling • June 1, 2013 • Interim Report Due: Including proof of submission or schedules site visit • June 3, 2013 • Achieve PCMH Recognition • September 30, 2013 • Final Reports Due: Including Proof of PCMH Recognition • November 1, 2013 50