NCCCPReducing Disparities at the

Community Level

Kenneth Chu, Ph.D. Center to Reduce Cancer Health DisparitiesDate: 6/25/2007

Source of disparities

• Cancer Health Disparities occur at the community level when beneficial cancer interventions are not accessible and not utilized by all

NCCCP and DisparitiesUnique Characteristics

NCCCP can address the ACCESSIBILITY issue:

• “Those screened for cancer will receive treatment,” regardless of financial status

• The NCCCP hospitals allocate 40% of the NCI funding to disparities

• NCCCP hospitals provide health care for the uninsured and the underinsured

Beneficial Cancer Interventions

• Beneficial cancer interventions include proven primary prevention, early detection procedures as well as proven cancer treatments that can reduce cancer mortality rates

Key NCCCP Disparities Program Areas

• Outreach – Getting people to primary and secondary cancer prevention– Cancer awareness – Culturally appropriate– Primary prevention - Smoking cessation– Secondary prevention – Early detection

• Patient Navigation – Helping patients navigate the health care system from discovery of abnormal finding through treatment

• Why both? Early Detection procedures may need both programs to

reduce disparities

OUTREACH PATIENT NAVIGATION REHABILITATION

Spectrum of Activities in Reducing Disparities in the Community

Abnormal findings on

screening tests

Diagnosis Treatment Survivorship

Smoking cessation

Early detection tests:

Mammography and clinical breast exam

Pap Smear

Colorectal cancer screening

Prostate Specific Antigen (PSA) test

Cancer Prevention / Early Detection

Medical resolution of abnormal findings from early detection tests through to

diagnosis and treatment, if necessary

Factors affecting Disparities at the Community Level

• Culture– Language, beliefs, perceptions, traditions

• Socio-Economic Status (SES)– Health insurance status, literacy

• Social Determinants (Community Conditions)– Living environment, transportation

• Social Injustice– Discrimination

Outreach - Phase I Infrastructure Development

ACTIVITIES• Establish Baseline data by

population groups • Community needs

assessment• Identify community leaders and

organizations• Identify culturally appropriate

materials & delivery systems

• Identify hospital resources

• Survey recommendations of primary care providers and/or Clinics

METRICS• Identify cancer information and

delivery systems• Screening rates, smoking status• Number and types of partnerships

• Existing of materials (create as needed), delivery systems established

• Programs, staff, screening capacity, smoking cessation

• Screening referrals, treatment referrals

Outreach - Phase 2 Implementation

ACTIVITIES• Form community partnerships

to reach disparate populations with educational activities

• Increase culturally appropriate cancer educational activities

• Increase screening recommended by primary care providers/Clinics

• Increase primary and secondary prevention use

METRICS• Number and types of

partnerships formed and educational activities

• Number of screenings resulting from educational activity

• CME Credits earned• Number of patients referred

• Number of participants in primary & secondary prevention activities

Outreach - Phase 3 Evaluation

ACTIVITIES• Understand effects of

educational activities• Link receipt of educational

materials to screening behaviors

• Assess the role of the community-based organizations

• Examine the impact of primary care provider/Clinic education

METRICS• Patients’ & Provider feedback

on educational activities• Number of screenings resulting

from educational activity

• Number of patients referred from community-based organizations activities

• Compare referrals form PCP receiving CMEs to others

Research Questions

• Can increasing community partnerships and their education increase utilization rates?

• Can increase in primary care provider/ clinic recommendations increase utilization rates?

• Can increase in outreach resources and capacity increase utilization rates?

Resources

• Community Network Program (CNP) – Cancer Education, Research and Training in Diverse Populations

• Goal: Increase access and use to beneficial cancer interventions

• Resources for• Culturally appropriate cancer educational materials• Practices for reducing disparities• Community Partnerships

Resources

• 25 Community Network Program Grantees– 8 African American – GA, NC, SC, AL, MO, MI,

TN, AR – 4 American Indian – MN, WA, OK, AZ– 2 Asian – CA, PA– 4 Hispanic – TX, CO, DC, WA– 3 Pacific Islander – HI, CA, Samoa– 4 Underserved – MD, MA, FL, KY

Resources

• Minority Institution/Cancer Centers Program (MI/CCP)– Increase the number of underrepresented

minority scientists engaged in cancer research– Improve the effectiveness of NCI-designated

Cancer Centers in cancer disparities research– Promote community-based outreach

– Resources for• Community Outreach

Resources

• 6 Minority Institution/Cancer Centers Partnership Program (MI/CCP-U54)– 1- Hispanic - TX-PR– 1 - American Indian - AZ– 3 - African American - GA-AL MD-DC TN– 1 – African Carribean - NY

Patient Navigation

and

NCI Patient Navigation

OUTREACH PATIENT NAVIGATION REHABILITATION

Spectrum of Activities in Reducing Disparities in the Community

Abnormal findings on

screening tests

Diagnosis Treatment Survivorship

Smoking cessation

Early detection tests:

Mammography and clinical breast exam

Pap Smear

Colorectal cancer screening

Prostate Specific Antigen (PSA) test

Cancer Prevention / Early Detection

Medical resolution of abnormal findings from early detection

tests through to diagnosis and treatment, if necessary

NCI Patient Navigation

• Begins at abnormal finding from a screening test

• Resolution of abnormal finding• Diagnosis• Initiation of treatment for cancer• Completion of initial treatment• Stage at Diagnosis

Patient Navigation

• Factors– Primary Care Providers/Clinics – Abnormal finding– Patient

• Barriers– Patient Navigator

• Solutions to barriers– Health Care System (Hospital)

Primary Care Provider

Cancer Care

Use

Cancer Care Barriers

Health Care System Barriers

Reimburse-ments

Lack of facilities

Scheduling Appointme

ntsFragmentation of care

Staffing

Social Injustice

Risk promoting behaviors

Cancer is a

“death sentenc

e”

Poor image of health care

Lack of cancer info Cultural Barriers

Fear & Stigma of Cancer

Cancer is “Punishment”Rely on

folk medicine

Language Issues

Patient Barriers

Comorbidities

Child- &Eldercare

Lack of Insurance

Transportation

Inflexible clinic hours

Low IncomePoor EducationTrust

Lack of family support

Lack of cultural

sensitivity to patient

Radical Profiling

Communication issues

PatientCompliance

Lack of Recommend-ations

InsuranceTrustComorbidit

ies

Research Questions for Patient Navigation

• What are the patient barriers and what are the solutions to those barriers?

• Does navigation affect time to resolution of abnormal finding to diagnosis, to treatment?

• What is the overall impact of patient navigation on reducing health disparities?

Resources

• NCI Patient Navigation Research Program

• Evaluate the efficacy of patient navigation interventions from abnormal finding to reduce or eliminate disparities in clinical outcomes related to lack of timely access to quality care in minority and underserved groups

• Determine the cost-effectiveness of patient navigation interventions

Resources

• Patient Navigation Research Program• 9 PNRP sites

– 3 Hispanic – TX, FL, CO– 1 American Indian – OR– 3 Underserved – OH, NY, MA– 2 African American – IL, DC

Metrics/Quarterly Reports

• Metrics tied to Year 1-3 activities• Quarterly reports should monitor progress

towards achieving year 1-3 activities and should discuss plans for improving performance when achievement is delayed – problems and potential solutions should be highlighted

• Performance will be measured by assessing how activities are achieved per year and in what timeframe

Research Questions on NCCCPPolicies on Disparities

• How do NCCCP hospitals implement the policy “those screened for cancer will receive treatment”?

• How do NCCCP hospitals allocate 40% of the funding to disparities?

• How do NCCCP hospitals provide health care for the uninsured? the underinsured?

Outreach and Patient NavigationTopics for Orientation

• Outreach – CNP perspective – CRCHD staff – Phases– Examples

• Outreach – CIS perspective• Patient Navigation – CRCHD staff

– General introduction• Barriers• Solutions

– Patient Navigation Research Program