Mobile Mammography and Lay Navigation:Successes and Challenges

Melanie Slan, MLIS, BSProgram Manager, Outreach and Community RelationsMedical University of South Carolina, Hollings Cancer Center

CA Cancer Journal for Clinicians, 2018

Reduce the cancer burden in South Carolina

• Provide highest quality patient care through innovative research

• Outstanding professional education

• Statewide cancer prevention programs focused on reaching underserved populations.

Hollings Cancer Center Mission

75% of new cancers and deaths are caused by preventable lifestyle factors

Cancer Incidence and Mortality

• Socioeconomic factors

• Cultural factors

• Geographic

ResearchExpertise in Health

Behaviors & Epidemiology

CommunityBuilding Relationships,

Trust & Advocacy

Outreach Services Cancer Screening & Education

Navigation Services

Siegel, R.L., Miller, K.D., et. al. Cancer Statistics, 2018

Cancer Prevention and Control

Community Outreach and Engagement Program

Mobile Health Unit -Lay Navigation Program

Cancer Prevention and Control

ResearchExpertise in Health

Behaviors & Epidemiology

CommunityBuilding Relationships,

Trust & Advocacy

Outreach Services Cancer Screening & Education

Navigation Services

• Community-based programs to deliver cancer education and screening services

• Forum for ongoing discussions about collaborative science

• Set standards for removing barriers and improving cancer care

Mobile Health Unit Service Area Partners with Federally Qualified Health Centers, health care providers, community organizations, churches and worksites

• Breast Health: Clinical breast exams & mammograms

• Cervical Health: Pap test & Pelvic exam

• Skin Cancer: Visual inspection of skin for suspicious moles or lesions

• Launched in 2005

• Funded by The Avon Foundation for Women

• Ensures access to screening and follow-up breast care services

• May enter navigation program or continuum of care at any point

Lay Patient Navigation Program

Normal

No cancer diagnosis

Screening

Diagnostic follow-up

Treatment

Follow-up or Annual Re-screen

Abnormal

Cancer Diagnosis

Lay Navigation on the Hollings Mobile Health Unit

• Helps patients navigate the complex maze that is the health care system

• Ensures clients receive timely, appropriate diagnostic and treatment care

• Helps individuals overcome multiple barriers to care

C-Change. Cancer patient navigation. www.cancerpatientnavigation.org/resources.html. 2005.

Lay Navigation on the Hollings Mobile Health Unit

• Initially funded two full-time lay navigators dedicated to mobile unit patients as well as Hollings Cancer Center patients

• Patients enter the program through referrals (internal and external), community outreach activities, word of mouth

• Works with nurse navigators, doctors, clinical staff, social workers, financial counselors, primary care provider

1. Outreach: Primary prevention – Healthy lifestyle – Disease prevention – Navigation Program information and sign-up

2. Screening / Diagnostic Navigation: Receives screening /early detection/diagnostic services – Identify and remove barriers

3. Treatment Navigation: Surgery, Chemotherapy, Radiation – Coordination of care – Educational support/resources

4. Follow-up: Calls, letters, home visits, documentation1. Ensures entire care team is aware of navigation efforts 2. EMR generates annual re-screen letters3. Renew eligibility for screening programs

FY 2012-2016

3,224 patients navigated

2,171 barriers removed

Lay Patient Navigation Program

• Funding ended FY 2016

• All patients screened on the mobile unit receive navigation assistance

• Continues to coordinate with cancer center clinical staff as local patients are referred back to Hollings for diagnostic treatment/follow-up

• All patients tracked and navigated to annual mammography and cervical re-screening

MOBILE SCREENING SERVICES FY 2014-2018

0

500

1000

1500

2000

Skin Screening 253 270 168 136 46

Mammography Screening 1515 1281 1318 1203 1254

Cervical Screening 77 56 40 51 31

FY14 FY15 FY16 FY17 FY18

1,845

1,607 1,526 1,390 1,331

• Mobile mammography with lay navigation has a positive impact on increasing the number of women who enter, stay in, or progress through the continuum of care.

• 80% of women screened on the mobile unit report that they would not have sought breast or cervical cancer screening if not for the mobile unit coming to their community.

• Percentage of patients lost to follow-up after abnormal finding decreased from 12% in FY 2009 to less than 5% in FY 2012, to 3% in FY 2015.

Lay Patient Navigation Program Success

Effectiveness of a Mobile Mammography ProgramStanley, E., Lewis, M., Irshad et. Al. AJR:209, December 2017

Lay Navigation Program Success

Pamala Reese let too many years go between mammograms.

• Screened on the mobile unit, diagnosed with breast cancer.

• Successfully treated (including participation in a clinical trial)

“I feel truly blessed to be here. If I had not gotten that mammogram when I did, I don’t know what would have happened. Now I urge other women to get their mammograms.”

Lay Navigation Program Success

School Librarian Rhonda Kierpiec put off getting her mammogram for 10 years. “It wasn’t a priority- It wasn’t something I feared.”

She decided to get a mammogram when the mobile health unit visited her school. Rhonda was diagnosed with breast cancer, had surgery, radiation and chemotherapy.

“If I had not had that mammogram in that bus,” she said, “we wouldn’t be having this conversation today.”

Lay Navigation Program Success

• Administrators developed system to address financial and insurance barriers previously handled by lay navigators.

• Uninsured patients referred to a financial counselor prior to scheduling of screening and/or diagnostic testing.

• The Comprehensive Breast Care Program incorporated lay navigation training for administrative coordinators to supplement the care provided by the breast cancer nurse navigators.

• Medicaid workers now located in the cancer center to assist with completion and processing of applications.

Lay Navigation Program Challenges

Screening and Diagnosis

• No primary provider/medical home

• High no-show rates costly for mobile unit

• Self referral

• Limited access to care in rural communities

• Distance from diagnostic facility

Funding

• Cost of overnight travel to meet needs of rural population outside of Charleston

• Funding sources and amounts fluctuate, affecting service levels

• Must continually seek ongoing support to sustain mobile staff and operational expenses

Lay Navigation Program SolutionsScreening and Diagnostics

• Link patients to medical home ( FQHCs, Free clinics, MUSC, area providers)

• Combine screening site visits

• Reduce frequency of visits (monthly to bi-monthly or bi-monthly to quarterly), adjust scheduling

• Expand mobile services to other (particularly rural) counties; Went from 12 to 27 counties

• Link to community resources for transportation assistance; proposal to include diagnostic mammography services on the mobile; utilize telemedicine to consult with radiologist to read images

Lay Navigation Program SolutionsFunding

• Office of development charged with seeking funds – philanthropic, local, state & federal sources

• Ongoing support from Citizens Advisory Council which advocates statewide on behalf of the Hollings Cancer Center in the areas of cancer prevention, patient care and research, and raises financial support.

• Inclusion of mobile services in research grant submissions

• Continue to seek out appropriate grant opportunities

• Recovered unpaid revenue from BCN contract payments

• Secured WiseWoman contract (cardiovascular, stroke risk factor screening funded by DHEC)

Partnerships

2016 - Hollings Cancer Center and Clemson University Mobile Health Units collaboration with South Carolina Department of Health and Environmental Control (SC DHEC)

2017- Both mobile clinics awarded state funding to support the collaboration

Contract provider Partnership with the Best Chance Network (BCN), South Carolina’s Breast and Cervical Cancer Early Detection Program since 1998.

Well Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN)

Melanie Slan, Program ManagerOutreach and Community RelationsHollings Cancer Centerslan@musc.edu843-792-6184

Thank You!