Implementing Cancer Screening & Referrals within Community

Behavioral Health Organizations

Tuesday, April 28th, 2015 Alicia Kirley, MBA

J. Todd Wahrenberger, MD Va’a Tofaeono

Pam Pietruszewski, MA

Shelina D. Foderingham MPH MSW • Director of Practice Improvement • Project Director, National Behavioral Health

Network for Tobacco & Cancer Control • National Council for Behavioral Health • ShelinaF@thenationalcouncil.org

Welcome!

Margaret Jaco MSSW • Policy Associate

• Project Coordinator, National Behavioral Health Network for Tobacco & Cancer Control

• National Council for Behavioral Health • MargaretJ2@thenationalcouncil.org

• Jointly funded by CDC’s Office on Smoking & Health & Division of Cancer Prevention & Control

• Provides resources and tools to help organizations reduce tobacco use and cancer among people with mental illness and addictions

• 1 of 8 CDC National Networks to eliminate cancer and tobacco disparities in priority populations

Free Access to… Toolkits, training opportunities, virtual communities and other resources

Webinars & Presentations

State Strategy Sessions

Community of Practice

#BHtheChange

Visit www.BHtheChange.org and Join Today!

Congratulations to Community of Practice participating organizations!

• American Samoa Community Cancer Coalition

• Arapahoe/Douglas Mental Health Network

• CODAC, Inc. (dba CODAC Behavioral Healthcare)

• Coleman Professional Services

• CommuniCare, Inc.

• Credo Community Center for the Treatment of Addictions, Inc.

• Mirror, Inc.

• Northern Lakes Community Mental Health

• Pittsburgh Mercy Health System

• Way Station, Inc.

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National Behavioral Health Network for Tobacco & Cancer Control

An Integrated Approach to Cancer Screening and Prevention in a Community Primary and Behavioral

Health System

Pittsburgh Mercy Health System

Alicia Kirley, MBA Director of Integrated Services J. Todd Wahrenberger, MD Chief Medical Officer

Pittsburgh Mercy Family Health Center

• A 2010 survey of over 25,000 patients showed that only 50% of Pittsburgh Mercy Health System service consumers were receiving any routine primary care

• PMFHC opened its doors in May 2012, providing a fully integrated Primary and Behavioral Health Practice

• Engaging a highly complex population with complex needs takes a TEAM!

• ACT Model in Primary Care: > Multi-disciplinary Care Team approach, pulling in resources from all

programs > Highly engaging team meets the patient where they are in their lives

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It takes a team!

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Community Teams

Service Coordination

Homeless Services

Housing

Employment

Patient

PCP

Medical Assistant

Care Manager

Tobacco Cessation Specialist

Consulting Psychiatrist

Peer Support

Specialist

Pre-visit, Huddle Planning & Team Meetings

• EHR Clinical Decision Support Systems

• Daily Huddle Checklist:

Care Management

Tobacco Cessation

Mammogram

• Weekly Multidisciplinary Team Meeting

• Sticky Notes

• Accountability

• Follow Up on Referrals

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Embedding Tobacco Cessation and Cancer Screening in Behavioral Health

Cancer Prevention and Screening

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An ounce of prevention is worth a pound of cure

Benjamin Franklin

Tobacco Cessation and Lung Cancer Screening

• Make tobacco cessation a part of your workflow > Know your upcoming schedule: is patient a tobacco user? If so, plan to

have a TTS or other staff counsel on tobacco use Ask at EVERY encounter!

> Create a system for flagging enabling services

• Develop a tobacco cessation protocol that is efficient and effective

• Track referrals to Tobacco Support Specialists and lung cancer screens

• Document patient progression through stages of change to continuously improve your process

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PMFHC Tobacco Cessation Protocol

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Tobacco Screening & Cessation: The Evidence

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“In God we trust; all others bring data”

How can you choose the best screening and prevention guidelines?

U.S. Preventative Services Task Force Recommendations for Grading

There is high certainty that the net benefit is substantial. Offer this service.

There is moderate certainty that the net benefit is moderate to substantial. Offer this service.

“It depends” there may be a benefit depending on individual patient and their S/S.

No benefit and possible harm. Discourage using this service.

I Statement: “I/We don’t know”

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A

B

C

D

I

Breast Cancer Screening

• Referral To: > Mammogram (Film and Digital)

Women age 40-49: Grade C recommendation

Women age 50-74, every 2 years: Grade B recommendation

Women age >74: Grade I

> MRI: Grade I

> Self Breast Exam: Grade D

> CBE: Grade I

> BRCA Mutation testing only if family history: Grade B

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Cervical Cancer Screening

• PAP Cytology > Women under 21: Grade D

> Women 21 to 65 every 3 years: Grade A

> Women 30 to 65 every 5 years with HPV Co-testing: Grade A

> Women over 65 (low risk): Grade D

> HPV Testing under age 30: Grade D

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Colorectal Cancer Screening

• FOBT, Flex Sig, Colonoscopy: Grade A > Age 50 to 75: Grade A

> Age 76 to 85: Grade C

> Age over 85: Grade D

> CT and Fecal DNA: Grade I

> Gloved Rectal and Prophylactic Aspirin: Grade D

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Tobacco Use & Lung Cancer Screening

• Low Dose Computed Tomography (CT Scan): Grade B > Asymptomatic adults aged 55 to 80 years who have a 1 pack per day for

30 years smoking history

> Screen annually

> Discontinue screening when the patient has not smoked for 15 years

• Tobacco Use: Grade A > Questionnaire:

Are you a tobacco user?

Frequency and duration

Motivation to quit?

Counseling and education

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Cancer Screening (what not to do…)

• Oral Cancer: Grade I

• Ovarian Cancer: Grade D (unless BRCA gene, etc.)

• Pancreatic Cancer: Grade D

• Prostate Cancer PSA Testing: Grade D

• Skin Cancer: Grade I

• Testicular Cancer: Grade D

• Bladder Cancer: Grade I

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Putting Prevention into Practice

• Embed Tobacco Support Specialists in a variety of settings

• Trainings to all staff to understand screening criteria

• Involve your ENTIRE team

• Use handouts and keep it simple!

• Use charts and graphs to remind yourself

• Utilize EHR alerts and CDSS

• Know the evidence, don’t waste time on practices that have no evidence, even if they are easy to perform

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Va’a Tofaeono

•Special Projects Coordinator ,

American Samoa Community Cancer Coalition

•vtofaeono@gmail.com

Guest Speaker #2

American Samoa Community Cancer Coalition

• Began in 2004

• 2nd Leading Cause of Death

• Non-Profit Community Based Organization

• Mission “Helping the people of American Samoa Fight Cancer”

• Develops and Maintains a Comprehensive Cancer Control Map

• Prevention to End of Life

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Cancer Data

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Cancer Data

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Cancer Data

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Cancer Data

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Available Services

• ASCCC Does Not Provide Direct Clinical Services

• LBJ Tropical Medical Center

• DOH Breast and Cervical Cancer Early Detection Program

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Screening Guidelines

• Gathered current information

• Comprised Ad-Hoc Committee

• Established Draft Guidelines

• Reviewed and Approved by LBJ and DOH Medical Executive Committee

• Developed Physician Educational Materials

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Outcomes

• Provider Compliance

• Chart Audit > Provider Performance

> Increase in Quality Care

• New Electronic Health Record System

• What’s Next?

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Fa’afetai Tele Lava

Va’a Tofaeono Special Project Coordinator

American Samoa Community Cancer Coalition vtofaeono@gmail.com or 684-258-8745

Pam Pietruszewski, MA

•Integrated Health Consultant,

National Council for Behavioral Health

•PamP@thenationalcouncil.org

Guest Speaker #3

Why Screening?

People with serious mental illnesses die 25 years earlier on average than the general population

• Medications, especially atypical antipsychotic drugs, effect on weight gain, dyslipidemia and glucose metabolism

• Modifiable risk factors: High rates of smoking, lack of weight management/nutrition, and physical inactivity

Morbidity and Mortality in People with Serious Mental Illness, 2006. National Assoc of State Mental Health Program Directors, Medical Directors Council

Bladder

Colorectal

Ovarian

Oral Heart Disease

Hepatitis C

Preventive Care

HPV

Tdap

Abdominal Aortic Aneurysm

Cholesterol

Diabetes

Depression

U.S. Preventive Services Task Force Rankings

Cervical A

The USPSTF recommends the service. There is high certainty that the net benefit is substantial. Colorectal

Breast B

The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

Lung

Cervical Cancer Screening

• 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

Colon Cancer Screening

• Adults age 50 to 75 years

> High-Sensitivity FOBT (Stool Test): Once a year

> Flexible Sigmoidoscopy: Every 5 years, with FOBT every 3

years

> Colonoscopy: Every 10 years

Breast Cancer Screening

• Women 50-74 years, mammography every 2 years

– Women aged 40-49 years, individualize decision to begin biennial screening according to patient’s circumstances and values. (Grade C)

Lung Cancer Screening

• Adults ages 55 to 80 years who have a 30 pack-year

smoking history and currently smoke or have quit within

the past 15 years, annual screening with low-dose

computed tomography.

> Screening should be discontinued once a person has not

smoked for 15 years.

Why Don’t People Get Needed Screenings?

• Fear of results

• Misconceptions

• Embarrassment

• Don’t know they need one

• Access, wait times, prep

• No symptoms

• Costs

What Can We Do About It?

Ability Response

Workflows & System Design

1. Tracking system

- Reports, alerts, prompts

2. Logistics

- Onsite screening, referral relationships

- Access, scheduling

3. Communication

- Multiple touch points

- Roles & responsibilities

“At every opportunity”

Questions to Ask When

Developing your Process 1. What is our clinic’s approach to whole health & wellness?

2. Which screenings will have the greatest impact on our

population, partners and stakeholders?

3. How will I know what screenings are due?

4. Who does what?

5. Who supports & reiterates what?

6. What if the patient refuses?

7. How can my skills and relationships influence behavior?

Motivational interviewing is

a patient-centered, directional method

for enhancing intrinsic motivation to change

by exploring and resolving ambivalence.

Miller & Rollnick, 2002

Engagement & Messaging

Instead of… Try…

1. Can you cut back on your smoking?

1. What are the good things, and the not so good things about smoking for you?

2. Do you know you’re due for a colonoscopy?

2. What do you know about screening options for colon cancer?

3. Why haven’t you had a mammogram?

3. Tell me about your health goals in relation to prevention & screenings.

Enhancing “Change Talk”

• What would be good about…?

• What else have you been thinking about?

• How might you make the best of it?

• So where does this leave you now?

• What is your next step?

Messaging

• Social Proof

• Authority

• Liking

• Commitment

Social Proof

“We discuss colon cancer screening with all our patients age 50 and older.”

We tend to accept a concept or approach if we know others are doing it

Authority

We respond to those with perceived influence

“The U.S. Preventive Services Task Force recommends

yearly screening for people ages 55 to 80 years who have

a 30 pack-year smoking history and currently smoke – and

even for those who have quit within the past 15 years.”

Liking

We are persuaded by people & things we like

“We’ve partnered with mobile mammogram

services and they are going to be in our

parking lot every Tuesday!”

Commitment

We want to show we honor commitments

“Will you stop at the front desk and make an appointment?”

Screening Strategies

Setting screening goals, posting data, promoting data

Pre-visit planning

Staff training in MI

Staff-developed messaging

Group events (Ladies Spa Night, Men’s Monday)

Awareness promos & blitz campaigns: Buttons, posters, freebees

Birthday postcards

Convenient screening – same day, workplace/onsite

Resources CDC: Cancer Prevention and Control

http://www.cdc.gov/cancer/dcpc/prevention/screening.htm

U.S. Preventive Services Task Force: Published Recommendations

http://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

Colon Cancer Alliance

http://www.ccalliance.org/

American Cancer Society: Cervical Cancer Prevention and Early Detection

http://www.cancer.org/cancer/cervicalcancer/moreinformation/cervicalcancerpreventionandearlydetec

tion/index

Affordable Care Act: Preventive Health Services for Adults

https://www.healthcare.gov/preventive-care-benefits/

Motivational Interviewing

http://www.thenationalcouncil.org/areas-of-expertise/motivational-interviewing/

Comments & Questions?

• Jointly funded by CDC’s Office on Smoking & Health & Division of Cancer Prevention & Control

• Provides resources and tools to help organizations reduce tobacco use and cancer among people with mental illness and addictions

• 1 of 8 CDC National Networks to eliminate cancer and tobacco disparities in priority populations

Free Access to… Toolkits, training opportunities, virtual communities and other resources

Webinars & Presentations

State Strategy Sessions

Community of Practice

#BHtheChange

Visit www.BHtheChange.org and Join Today!

Thank you for joining us for the Implementing Cancer Screening &

Referral Within Community Behavioral Health Organizations Webinar!