The Massachusetts
Department of Public Health’s Women’s Health Network (WHN) provides screening
services to income-eligible uninsured women for the early detection of breast
cancer and cervical cancer, as well as treatment referrals on an as-needed
basis. In some locations, the WHN
program also provides diagnostic testing for cardiovascular disease risk and
risk reduction education and lifestyle counseling to decrease that risk. WHN is administered by the Massachusetts Department
of Public Health (DPH) and funded by the U.S. Centers for Disease Control’s
National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and
Well-Integrated Screening and Evaluation for Women Across the Nation Program
(WISEWOMAN) and by the Commonwealth
of Massachusetts.
Between January
and June 2005, the Department of Public Health sponsored a project to improve
WHN’s quality, cost effectiveness, and accessibility: Reviewing the Past,
Planning the Future (RPPF). Project participants examined the past ten years of
WHN program operations and developed recommendations to help the program
maximize adherence to Department, WHN, and CDC guidelines, increase enrollment,
improve client choice, decrease provider burden, and facilitate client
navigation through the system. This
report presents the recommendations that emerged from the RPPF project.
Breast cancer is the most commonly diagnosed cancer
and the second leading cause of cancer death among women in the United States.
Screening for and early detection of breast and cervical cancer reduces death
rates and greatly improves cancer patients’ survival. However, there is a disproportionately
low rate of screening among women of certain racial and ethnic minorities and
among under- or uninsured women, which creates a wide gap in health outcomes
between such women and other women in the United States.
In 1990, Congress authorized the National Breast
and Cervical Cancer Early Detection Program to address this health disparity,
giving CDC the ability to implement a national strategic effort to increase
access to mammography and Pap test screenings for women in need. The NBCCEDP is
directed to low-income, uninsured women aged 18–64 from priority populations.
The legislation authorizing the NBCCEDP also provided for public and
professional education, quality assurance, and surveillance and evaluation
systems to monitor program activities. In 2000, Congress gave the states the
option to provide medical assistance for treatment through Medicaid for women
diagnosed with cancer in the NBCCEDP.
This program was implemented in Massachusetts
in January 2004.
The CDC also offers a
cardiovascular disease risk reduction program, the Heart Disease & Stroke
Prevention Program, in conjunction with the NBCCEDP. According to the American Heart Association,
coronary heart disease is the leading cause of death for American women. One in
five women has some form of heart or blood vessel disease and, in 2001, 498,900
women died from heart attacks and other coronary events. In 1993, Congress authorized
the WISEWOMAN program in order to enable NBCCEDP participants at selected sites
to receive standard cardiovascular disease preventive services including blood
pressure and cholesterol testing, as well as counseling and education to help
women develop a healthier diet, increase physical activity, and quit using
tobacco.
The Massachusetts Department of Public Health’s Women's
Health Network (WHN) offers both the NBCCEDP and WISEWOMAN programs, as well as
referrals for Medicaid-funded cancer treatment.
The Commonwealth
of Massachusetts adds
funds to those provided by the CDC in order to allow women between the ages of
40 and 49 to receive NBCCEDP services. Massachusetts eligibility criteria for the Women’s Health
Network are: (1) Massachusetts residency; (2) household
income less than 250% of the Federal Poverty Level; (3) no other insurance that
covers the services; (4) age between 40 and 64 years old, except when specific
other high-risk factors are present.
The WHN contracts with 26
organizations across the state to provide services related to screening,
diagnosing and treating breast and cervical cancer. In addition the HDSPP program funds screening
for cardiovascular disease risk factors and education about risk factor
reduction in six organizations. Several
different staff participate in the WHN and HDSPP programs including a program
coordinator, case manager, client navigator, and risk reduction educator (for
HDSPP only). The roles of the staff vary
somewhat across sites but the same functions appeared to be addressed
collectively across all of the sites.
The case managers are key to the WHN program.
Specific NBCCEDP
services offered are mammograms, clinical breast exams, Pap tests and pelvic
exams; when needed, diagnostic services can also include radiology, biopsy,
pathology, and anesthesia. At the
locations that also offer WISEWOMAN services, women receive free screening for
cardiovascular risk factors—hypertension, cholesterol, and diabetes. These locations also provide risk reduction
education and counseling about healthy lifestyles.
The WHN serves a
diverse group of women – 56% are white-NH, 31.5 % are Hispanic, 8.8% are black
and 2.1% are Asian. Only 55.7% speak
English as their first language. Spanish
and Portuguese are the most common languages spoken after English. Approximately 30% have less than a high
school education.
Since 1993, the
Women’s Health Network has delivered screening and diagnostic services to more
than 77,000 Massachusetts
women. Between 2000 and 2001, 67% of
WHN-eligible women ages 40-64 received a screening mammogram in Massachusetts, compared to just 12% of comparable women
throughout the United States. Between 1999 and 2001, 42% of the eligible
women in Massachusetts
received a Pap test, compared to just 15% nationally. In FY 2004 alone, WHN screened over 11,000
women and these women tended to have less education than the entire state
population and were much more likely to come from racial, ethnic, and
linguistic minority groups. This record
of accomplishment suggests that the WHN has been successful in reducing
morbidity and mortality due to breast and cervical cancer among the target
populations (WHN, 4/12/2005).
The 2005 WHN
review and planning project was designed to develop procedures for an even more
successful program. In spite of WHN’s
success in delivering needed diagnostic services to thousands of women, it is
estimated that in FY 2004 at least 36,000 eligible women were not served. In addition, after a decade of increase, the
rates of participation in both mammograms and Pap testes declined in 2002-2003
among uninsured Massachusetts
women. Delivery of cardiovascular risk
reduction services was more limited: in 2004, only six of the 26 organizations
that contracted to deliver WHN services could be funded to provide WISEWOMAN
services.
Improving program
effectiveness requires consideration of the multiple, interrelated factors that
influence program functioning and client behavior (Zapka et al., 2003). The WHN Review and Planning Project focused
on seven key factors: medical knowledge
and available health care technologies for the screening and diagnosis of both
breast and cervical cancer and cardiovascular disease; the operation of health
care delivery systems; the design of case management; strategies for education,
outreach, and enrollment; sources of disparities between social groups in
health care behaviors and outcomes; options for fiscal management and business
operations.
These different
factors and the individuals who specialize in them intersect with each other
and change over time. In addition,
identification of their implications for practice must be guided by knowledge
of the WHN program and its effectiveness.
These considerations led to a review process that engaged experts from a
variety of disciplinary and programmatic backgrounds and that provided multiple
opportunities for considering diverse perspectives and new additions to
knowledge.
The RPPF project
was guided by Project Director Russell Schutt and an Executive Steering
Committee comprised of experts in the seven different areas who each had
experience with the WHN program (see Appendix).
Executive Steering Committee members chaired Task Forces of experts in
one of the seven areas and also met regularly to share insights and coordinate
efforts. At least one graduate Research
Assistant and one WHN staff member was assigned to each Task Force chair. Research Assistants recorded minutes of Task
Force meetings, searched and summarized relevant literature, and searched the
Web for information on comparable programs.
Eighty-four
health care policy experts and program leaders served on the larger project
Expert Panel and one of its seven Task Forces, chaired by one or two Executive
Steering Committee members (see lists later in this report) and assisted by at
least one DPH staff member and one graduate research assistant. Each Task Force was charged with developing
recommendations about specific aspects of the WHN program. The entire Expert Panel met first in March
2005 in order to learn about the WHN program and to develop specific objectives
and work plans. For the next three
months, the Task Forces met separately, in order to review research literature,
program experience, and relevant data and to formulate recommendations that
reflected this review. Every Expert
Panel member received evaluation research reports on the WHN program and most
task force chairs attended a special presentation about the key findings in
these reports. The entire Expert Panel
convened again in June 2005 in order to share insights and integrate
recommendations.
Identification
and implementation of efficacious changes requires careful review of research
findings, relevant theory and programmatic experience as well as informed
translation of this body of work into new program policies and procedures. In order to fulfill these requirements, the
RPPF project drew upon prior Department of Public Health-sponsored research
about WHN; other research about comparable programs in other states and about
related public health problems; and the insights of academic and program
experts. During the project, reports
from five different evaluation studies of the Massachusetts WHN program were
inspected (see Appendix), 700 person-hours were spent in a total of 34 Task
Force meetings, more than 500 scholarly articles were inspected, and
information was obtained for comparisons with 25 other programs.
In a
supplementary investigation, information was collected from WHN staff and
program directors concerning contracting organizations that have left the WHN
program. In addition, special analyses
were conducted of data available from state and federal sources when needed to resolve
questions arising during task force deliberations.
The
five evaluation studies sponsored by WHN generated analyses of data from
multiple sources: interviews with WHN
case managers, program coordinators, and DPH contract managers, focus groups
with WHN staff, two phone surveys of WHN clients, an analysis of client
records, and summaries of chart audits.
The Case
Management evaluation used a mixed methods design with data collected from WHN
staff, WHN records, and WHN clients: (1) Interviews with DPH contract managers
(N=3); (2) Interviews with all WHN case managers and program coordinators
(N=52); (3) Secondary analyses of service use data (N=3182); (4) Phone survey
of stratified random sample of WHN service recipients seen for breast or
cervical cancer test results (N=204, with oversampling of those who had
received test results indicating a high probability of cancer) (Schutt et al., 2005). Measures collected with these methods are
listed in an appendix.
- Overall, clients were very satisfied with the WHN
program and WHN case managers.
- Clients who were less educated and/or in poorer
physical and more depressed were less satisfied.
- Case managers were very satisfied with their jobs and
their service delivery.
- Case managers rated their workload as heavy,
particularly at HDSPP sites.
- Primary service barriers reported by both clients and
case managers were fear of bills and language problems.
- Case managers reported difficulties in finding clients
and maintaining contact.
- Case managers desired more training and computer
support.
- Hispanic women had lower rates of cervical cancer
screening than other participating women.
- Several contracting organizations that participate in
the HDSPP program had very long times from trigger to diagnosis for their
breast and cervical cancer clients.
- There was significant regional variation in the time
it takes to make a diagnosis after an abnormal finding, with Boston having the longest time (>30 days) and Cape
Cod and Southeastern Massachusetts having
the shortest time (<10 days).
- The time from diagnosis to treatment was similar
across Massachusetts regions, except that women served by one contractor
in the Metro West region take nearly twice as long as other women to get
into treatment after diagnosis (>50 days).
- WHN women using community health centers had a longer
time to diagnosis after an abnormal finding than women who don’t use
community health centers.
The goal of this
evaluation was to systematically solicit feedback from staff of the 26
contracting organizations with regard to the strengths and weaknesses of the
current Women’s Health Network (WHN) service delivery model. Medical Service
Sites were stratified with regard to their primary organization type, as
follows: a collaborative site,
decentralized service sites, community health centers, and hospital-based
programs. Representative staff from each
type of organization were invited to participate. Key informant interviews and
group discussions were conducted at community locations throughout the state
over an 8 month period. Discussions
were audio taped and analyzed using Ethnograph.
18 client navigators, 16 program coordinators, 4 risk reduction
educators, and 8 case managers were interviewed in various groupings. (Suri, 2005)
- Staff reported high levels of commitment and
satisfaction with their work
- Unique advantages of different types of contracting
organizations were identified: the
collaborative model reduces administrative burden on medical service
sites; the centralized model facilitates provision of more comprehensive
care; while the decentralized model and individual health centers model
facilitate community outreach
- High turnover rates among medical service site staff
were a problem.
- Contracting organizations reported excessive
paperwork and slow payment of bills.
- Some staff at contracting organizations felt there
was insufficient training for WHN and a lack of appreciation at the sites
for the client navigator role.
- Client-level barriers to effective service delivery
included client transiency, cultural and linguistic differences, fear of
screening, client fear of bills, lack of transportation and low literacy.
- Contracting organizations found that BCCEDP screening
requirements were at odds with HDSPP requirements for risk reduction
education and lifestyle counseling.
- Many participants indicated a need for collaboration
between contracting organizations.
The analysis of
eligible women and participation Women’s Health Network was conducted with data
from five sources: (1) all WHN participants from 1993 to 2004; (2)
Massachusetts data from the U.S. Census Current Population Survey from 1999 to
2001; (3) health care data collected in the annual survey by the Massachusetts
Division of Health Care Finance and Policy in 2002 and 2004; (5) mammography
screening data reported to WHN in 2003 (Kramer, 2005). Findings include:
- The 85% rate of mammography screening among MA women
in 2003 within the past two years exceeds the federal Healthy People 2010 target
of 70%, while the 88% rate of Pap testing within the past three years
almost meets the federal Health People 2010 target of 90%.
- The rate of mammography screening among MA women in
all racial/ethnic groups exceeds the federal target; the rate of Pap
testing is within five percentage points of the federal target of 90%
among MA women who are white, African-American, and Hispanic, but it is
only 66% among Asian women.
- A large number of eligible women are still not served
and the number served has declined in recent years.
A client
satisfaction survey was conducted by DPH staff in the summer of 2003. A proportionate stratified random sample was
drawn from the entire WHN client population, with clients who had at least 12
years of formal schooling sent a mailed questionnaire and those with fewer
years of schooling interviewed by phone. The overall response rate was 30%,
resulting in an N of 1348 clients (Ooi, 2003). The survey analysis revealed
that…
- Clients reported high levels of satisfaction.
- Many clients did not recognize the WHN program name.
- Family members and friends were primary sources of
program awareness
- There seemed to be insufficient explanations of
privacy rights to clients
The Women’s
Health network (then called “the Massachusetts Breast and Cervical Cancer
Initiative”) also surveyed client satisfaction in February 1998. This short survey was mailed to 881 clients
at 11 of the 36 BCCI sites at that time.
These eleven sites were selected to represent clients from diverse
geographic and demographic backgrounds as well as different types of
sites. The overall response rate was
62%, resulting in an N of 533 clients.
Results were consistent with those obtained in the 2003 survey.
- More than 90% of the respondents indicated
satisfaction in response to about half of the 13 satisfaction questions,
including those pertaining to respectful treatment, quality of care, and
agreement to return again for screening.
- Satisfaction was somewhat lower with processing
procedures, including explanations about exams and understanding test
results, with 75-80% indicating satisfaction.
- White respondents were more likely to state that they
would return for screening the next year than were African American
respondents.
- Clients felt respected by their physicians, but 35%
had not received information on the importance of Pap smears and 28% had
not received information on breast self-exams.
- Several respondents reported poor treatment by staff
in relation to testing procedures and several had received unexpected
bills for their medical services.
The audit of client service charts was based
on a 5% sampling of records from March
2003 to November 2004, with the criterion that at each service site, at least
10% of the records, but no more than 30 records were reviewed (Karacek, 2005).
- More than 90% of service sites were in compliance
with almost all documentation requirements.
- ¾ of the NBCCEDP cases have the required written
clinical referral; 4/5ths of those at the HD&SPP sites have
the required Healthy Heart participation form.
- 3/4ths of sites have case manager education,
evaluation, and discharge documents.
- Overall, documentation is less adequate for HDSPP
cases.
- 3/4ths of clients have most of their lab test results
and 3/4ths have an ATPIII risk score, but just half have a smoking
assessment in their file.
- 2/3rds of HDSPP clients had a signed risk reduction
document in their files and 2/3rds had a doctor’s evaluation, but only 1/3rd
had a 6-month followup document.
- The rates of screening and followup were somewhat
below program standards, with almost a 20% point gap for followup after
abnormal Pap test result.
- The timelessness of breast cancer diagnoses exceeded
standards, but timelessness was below standards for cervical cancer diagnosis
and for both breast and cervical treatment (although findings differed
between 2003 and 2004).
- 7 sites with Heart Disease & Stroke Prevention
services were below standard in screening and intervention, but met the
timeliness standards for case management.
Additional
investigations were conducted in response to questions raised during the RPPF
process.
Women’s Health
Network staff and some Contracting Organization representatives were
interviewed to learn about the reasons that some Contracting Organizations left
the WHN program. Additional information
was obtained from available records.
Twenty Contracting Organizations have left the WHN program, and five
others have been subsumed within larger contracts. Several reasons for leaving WWHN were were cited frequently; some of these differed by type of
Contracting Organization (Gall, 2005).
- A large multi-site Contracting Organization left WHN
due to inadequate reimbursement for outreach and other services, as well
as difficulties in securing the data required by WHN from an immigrant
population served at multiple sites.
- Several small community hospitals reported inadequate
staff to meet the requirements of the WHN program.
- Many community health centers reported problems with
processing bills as required by WHN.
- Community health centers reported difficulty in
recruiting and retaining registered nurses as case managers.
- Community health centers were able to allocate only a
fraction of a staff member’s time to the WHN program, and so there was no
single strong advocate for the program.
- Some community health centers had difficulty serving
sufficient numbers to meet WHN requirements.
- Several community health centers joined a multi-site
program alliance that reduced the administrative burden of the program.
- WHN offers WISEWOMAN sites insufficient training and
support to provide lifestyle behavior change.
- WISEWOMAN service guidelines conflict with the
practice standards of some local providers.
- Case managers have difficulty negotiating for needed
services identified in the WISEWOMAN program when these are not
reimbursable through WHN.
- Considerable administrative burden created by
WISEWOMAN requirement of multiple service appointments during the year.
- Clients are often deterred by complex scheduling and
long hours required for WISEWOMAN services.
- Multiple health and family problems and fear of
incurring unpaid bills diminish client participation in WISEWOMAN.
Three DPH staff
managed WHN contracts in 2004 with 26 organizations. All three contract managers were interviewed
in late spring and summer 2004, in order to learn about their experiences in
managing the contracts and the types of issues that arose with contracting organizations
that they identified as relatively successful and unsuccessful. Although these interviews were conducted in
order to provide background required by the Case Management Evaluation project,
they were analyzed separately for the RPPF project (Gall, 2005).
·
Successful contractors are able to adapt program
requirements to agency characteristics, such as by integrating enrollment and
billing functions and in relations with primary care providers.
·
Successful contractors understand the role of
WHN, are willing to meet DPH standards, and maintain good records.
·
Successful contractors are able to recruit and
train sufficient numbers of staff who meet DPH standards and are culturally and
linguistically competent and who are flexible and willing to learn.
·
Successful contractors provide clear role definitions
and integrate staff functions as useful.
·
Contractors judged by contract managers to be
unsuccessful do not value the role of WHN, are unable to adjust usual
procedures to WHN requirements, and have difficulty meeting reporting
requirements. Community health centers
have particular problems in these areas.
·
Unsuccessful contractors have difficulty meeting
capacity targets and/or have easier access to alternative programs.
·
Unsuccessful contractors have difficulty
recruiting and retaining appropriate staff.
·
Unsuccessful contractors have high levels of WHN
staff turnover, schedule insufficient time for the program activities, and do
not provide opportunities for professional orientation and development.
·
Unsuccessful contractors have difficulty
connecting with medical providers and gaining required data from them.
·
Funding for lifestyle interventions for HDSPP
clients needs to be increased to cover more than just tobacco cessation.
·
Contracting organizations need more orientation
and training about WHN is needed.
·
Several client-level barriers impede service
delivery linguistic and cultural differences, immigration status, poverty, and
competing demands due to work and family.
The UMass Boston
Center for Survey
Research phone survey of WHN clients revealed substantial levels of depressive
symptoms (Schutt et al., 2005). RPPF
staff interviewed a psychiatric oncologist at Beth Israel/Deaconess Medical
Center in order to learn about ways to improve referrals for women with symptoms
of depression (Cruz, 2005). Her
observations, summarized below, informed several Task Force recommendations.
·
Low motivation and suicidal thoughts associated
with depression reduce the likelihood of follow-up.
·
Screen new clients for depression with a simple
paper and pencil test—the Beck Depression Inventory--that can be distributed in
the waiting room of medical providers.
·
Depression is a treatable illness.
·
Some cultures don’t talk about mental illness,
which impedes treatment.
·
Educating patients and other family members is
the best way to reduce service barriers due to stigma.
·
Provide WHN staff with a one–hour training
session about depression, how to respond to it, and where to refer women for
it.
·
Mental health services for low income women can
be covered by free care, sliding fee scales at community mental health centers,
and pharmaceutical company programs.
Data were
also analyzed from the Massachusetts Behavioral Risk Factor Surveillance Survey
and the Cancer Registry. They provided
more information about program coverage and women’s needs.
·
Asian women have lower rates of cervical cancer
screening than white, black and Hispanic women (66.5% vs. 88% all women).
·
Boston has higher
age adjusted-rates of cervical cancer than all other regions of Massachusetts
·
Death rates from cervical cancer for the years
1998-2002 were 4.5 per 100,000 for NH-black women and 1.8 for NH-white women.
·
Black women in Massachusetts have the highest death rates
from breast cancer.
·
Women with less than a HS education, with less
than $25,000 in income, from Western Massachusetts and from Boston have the highest rates of
cardiovascular disease risk factors and cardiovascular disease.
·
Black women have the higher death rates from
cardiovascular disease than all other Massachusetts
women.
Task
Force members reviewed more than 500 research articles and reports as they
formulated recommendations. This review
process identified influences on health care behavior, highlighted effective
program approaches, and specified options for system operations.
A large body of
literature on breast and cervical cancer screening indicates that the
effectiveness of different methods varies, in part in relation to client
characteristics.
·
Older women are less likely to have their
cancers detected through clinical breast exams (Bobo and Lee, 2000; Bobo,
Lawson, and Lee, 2003).
·
Women in the WHN have slightly longer times from
diagnosis to treatment than other breast cancer patients and are less likely to
receive radiation therapy after partial mastectomy (Liu et al., 2005).
·
Disparities in cancer screening are widening
among groups with no usual source of care (Swan et al., 2003).
·
Women referred for atypical glandular cells due
to severe cervical lesions (CIN 2 or worse) should be tested for HPV DNA in
order to rule out HSIL, AIS, or carcinoma (Derchain et al., 2004).
·
Screening results vary between racial and ethnic
groups (May et al., 2000; Schootman and Fuortes, 2001; Bernard et al., 2001).
·
Film mammography is the currently most cost
effective method, compared to digital mammography, CAD, MRI, and ultrasound.
A growing body of
research on WISEWOMAN projects identifies some of the bases of program
effectiveness.
·
WISEWOMAN has been effective in reaching
disadvantaged and minority women at high risk of cardiovascular and other
chronic diseases (Will et al., 2004).
·
Comprehensive screening lowers the prevalence of
hypertension (Stoddard et al., 2004).
·
Lifestyle counseling can result in increased
physical activity (Stoddard et al., 2004).
·
Lifestyle counseling produces only a
statistically insignificant reduction in coronary heart disease risk after one
year, in spite of higher cost (Finkelstein, et al., 2002).
·
Integration of WISEWOMAN services within
community health centers would improve the centers’ effectiveness (Mays et al.,
2004).
·
Research is necessary for monitoring and
improving programs but can create burdens on program staff (Viadro, Farris, and
Will, 2004).
Literature on
breast and cervical cancer services has identified several sources of
socioeconomic disparities and has emphasized the value of several strategies
for reducing barriers to health care.
·
African-American and Hispanic women underutilize
mammography and women of low SES are less likely to be diagnosed with early
stage breast cancer.
·
Misconceptions about screening procedures
reduced participation by many Hispanic women.
·
Low income women in a mammography and Pap test
screening and follow-up program with depressive or anxiety disorders had more
characteristics that create barriers to screening and follow-up testing.
Providers should
use multiple strategies for reducing these disparities:
·
Provide cultural competency training to all
health care professionals (Wolff et al., 2003).
·
Use contextually appropriate methods of
delivering health care information (Wolff et al., 2003).
·
Recruit, retain and promote a diverse health
care staff (Wolff et al., 2003).
·
Use community-based patient navigators to help
underserved populations engage with the health care system (Freeman, 2002;
Frelix et al., 1999; Freeman, Muth, and Kerner, 1995; Psooy et al., 2004).
·
Engage lay community leaders and peers in health
promotion programs (Horowitz et al., 2004; Wolff et al., 2003; Kiger, 2003).
·
Collect sociodemographic data to allow
measurement of health disparities (Wolff et al., 2003).
Literature on
reducing disparities in cardiovascular disease morbidity and mortality
identifies similar strategies as effective.
·
Provide culturally sensitive and targeted health
education materials (Para-Medina et al., 2004).
·
Focus educational materials on patients’ about
misconceptions concerning health (Association of Black Cardiologists, Inc.,
2004).
·
Educate providers about health care disparities
(Lurie et al., 2005).
·
Support lifestyle changes to improve health
(Stoddard, 2004).
·
Use vouchers and discount programs to encourage
exercise and weight loss (Will et al., 2004).
·
Involve community members in developing and
delivering health promotion programs (Becker et al., 2005).
Research on
enrollment, outreach and education in cancer screening programs has highlighted
the effectiveness of several particular approaches:
- Use community health workers who come from similar
cultural backgrounds as the prospective patients (Centers for Disease
Control and Prevention, 1997; Kiger, 2003; Navarro et al., 1998).
- Use group activities to encourage women to discuss
health concerns
- Use one-to-one outreach involving cancer survivors
and other peers
- Partner with religious groups (Centers for Disease
Control and Prevention, 1997; Kiger, 2003).
- Develop media campaigns that target the desired
social groups (Amhad et al., 2004; Centers for Disease Control and
Prevention, 1997; Kiger, 2003).
- Send mobile mammography units to places in the
community frequented by the target groups, with particular attention to
reaching women who have limited access to fixed screening sites
- Collaborate with supermarkets and other popular
stores to deliver information as part of the shopping experience
- Include in outreach materials such incentives as
discount coupons
Literature
reviewed about case management provided some background about the WHN case
management program as well as some indicators of the effectiveness of
particular case management approaches.
·
Congress added case management services were
added to the NBCCEDP in 1998. These
services are to be provided by credentialed or licensed staff (Women’s Health
Network, 2005).
·
The Women’s Health network uses standards
developed by the Case Management Society of America. These standards emphasis a
holistic and client-centered approach focused on effective linkage of clients
to needed services (Women’s Health Network, 2005; Case Management Society of
America, 2002).
·
Poor women are particularly in need of case
management services due to lack of knowledge about and access to the health
care system (Kasper and Ferguson,
2000).
·
Research indicates that nurse case managers
improve follow-up for breast abnormalities by reducing barriers and improving
patient trust (Bastani, Yabroff, and Glenn, 2004).
·
Case managers can reduce ethnic and income
disparities in health behaviors and outcomes (Engelstad et al., 2001).
·
“Full service case management” involving
provision of all needed clinical and support services and a personal
relationship with clients is more effective in engaging clients in treatment
and improving outcomes than is broker case management or a hybrid model
(Bedell, Cohen, and Sullivan, 2000).
·
A case management team approach increases
service efficiency and cost-effectiveness, particularly for chronic disease
patients (Galvin and Baudendistel, 1998).
·
Older breast cancer patients have special needs
for managing coexisting medical conditions and activities of daily living
(Jennings-Sanders and Anderson,
2003).
Research on health care systems has
several implications for the WHN program.
·
Centralization and integration of health care
networks is associated with improved service delivery, higher levels of system
performance and greater efficiency in operations (Bazzoli et al., 2001).
·
An integrated information system improves health
care program management (Shapleigh, 1993).
·
Well-planned outcome evaluations should be a
component of WISEWOMAN programs (Finkelstein and Wittenborn, 2004).
·
WISEWOMAN programs impose difficult burdens in
terms of research and reporting, and work requirements (Viadro, Farris, and
Will, 2004.)
·
WISEWOMAN requirements are difficult to
integrate with BCCEDP programs.
Planning, training and support re essential (Viadro, Farris, and Will,
2004).
Although
federal regulations mandate some common features in NBCCEDP and WISEWOMAN
programs throughout the United
States, specific administrative and service
delivery elements can vary among states, territories, and tribes. Task Force members examined NBCCEDP programs
in several other states in order to consider alternative approaches to
achieving particular program goals.
Other public health programs that used different techniques for outreach
and enrollment were also examined.
Case
Management
Models
of case management used for the NBCCEDP differ among states, although there is
little evidence concerning the efficacy of the alternatives.
·
Case management models vary in the degree of
centralized control, ranging from decentralized program (eg. Michigan and New York), to regionally or locally
controlled case management programs (eg. Nebraska),
to centralized (Maine),
and mixed models (Washington). Case management models also vary in the
number of contracting organizations responsible for case management and in the
method of reimbursement for case management—payment per client or by program
capacity.
·
NBCCEDP case management programs across the
nation encounter similar challenges (Lantz, 2004): the desire of case managers
to deliver a broader range of services than client tracking, complaints about
caseload size and inadequate CDC funding; and the need for case managers to
wear multiple “hats.” Programs also
report difficulties in finding qualified and experienced staff and providing
sufficient training.
Outreach, Enrollment, Education
Programs throughout the country
have used innovative methods to reach, enroll,
and educate uninsured, low-income women in need of breast
and cervical cancer screenings. One
method is partnering with local corporations.
·
Safeway supermarkets worked with California programs by
printing mammography screening information on grocery sacks and Stop and Shop
supermarkets collaborated with Rhode
Island by setting up booths with program
information. Michigan coordinated a sweepstakes campaign
with Kmart for women who had gotten a mammogram.
·
Several grantees used coupons or vouchers to
encourage women to get mammograms, keep appointments, or fill out surveys. Gas coupons were particularly effective as
they rewarded and motivated clients and reduced the cost of their
transportation. Providing coupons also
provided a means to track clients. In South Carolina clients
filled out a 2-part coupon with their contact information and detached $5 for
groceries or Burger King.
Several states rely on lay health
workers or volunteers to get the message out.
·
Maryland
trains employees working in the community, such as at laundry facilities and
hair salons, to be able to answer program questions and give provider
referrals.
·
New
Mexico coordinates with community residents to host
“Home Health Parties,” where program staff deliver presentations about cancer
and cancer screenings. These parties
have been successful with communities of color and other special populations
because they offer flexibility to adjust the style, message, setting, and
approach to accommodate cultural preferences.
·
Washington
D.C.’s programs employ lay health
navigators (LHN), who live in community and share the same language, culture,
and beliefs. These navigators work with
women who might not other complete scheduled appointments, encouraging them to
attend screening appointments, accompanying them appointments (when necessary),
providing counseling, listening to fears, and giving appointment reminders. Research shows women served by the LHN were 5
times more likely to complete breast cancer screening exams on the scheduled
appointment date than women not served by the program.
Others look to media outlets,
especially for targeted populations.
·
California
utilizes multiple diverse sources.
Television, billboards, in-store promotions, and press events entice
women over 40 to get free screenings by portraying breast cancer a relentless
time bomb. For the Latina community a local Spanish radio
station produces a monthly talk show, which reinforces messages and includes
testimonials of survivors, family members, and physicians. For the Vietnamese community a video was
created that uses Vietnamese actors and themes, opposed to dubbing an English
video, and tells a story of how one woman who gets regular screenings convinces
another to overcome her fear and embarrassment.
Additionally, a free Vietnamese newspaper publishes no-cost articles
written by program staff that explains screening, testing types, and service
sites.
·
Connecticut
allied with a credible, visible local disc jockey to reach an African American
target audience in New Haven. The DJ has hosted program directors and gives
weekly updates on the total number of women getting screened and urges women to
take advantage of the program.
·
Nebraska runs television and radio commercials
about the consequences of women who only focus on taking care of their family,
and neglect taking care of their own health.
·
Washington
created the first screening effort directed at lesbians by including
partnerships with lesbian press and involving visible, respected, and vocal
members of the local lesbian community.
Placing mobile mammography has also
proved to be an effective method.
·
An outreach and portable screening program was
created in New Jersey. Here program staff make monthly visits
educating women at such settings as senior housing complexes, beauty parlors,
and supermarkets. During the visits
staff schedule mammography appointments for when the portable mammography returns
2 weeks later.
·
New
York funded 5 new mobile mammography units that
travel the state visiting churches, grange halls and other community
sites. This has been particularly
helpful for reaching geographically isolated women who are unable to use fixed
service sites.
Another documented way to reach
target populations is through collaborating with religious organizations.
·
Minnesota
sponsors a church-based even to discuss women’s fears and encourage the African
American community to get screened and/or tested. This past year 38 churches participated in
“Cancer Awareness Sunday”.
·
South
Carolina sponsors “Pink Ribbon Sunday,” where church
members are encouraged to wear ribbons with an attached card detailing state
specifics on breast cancer, ways to detect it, and the public health screening
program’s phone number. Churches are
also given a guide on how to approach breast cancer as a family issue.
States employ multiple strategies
to reduce disparities in screening by race/ethnicity and language and by
removing financial barriers. For
example:
- Hawaii’s
program uses culturally attuned outreach workers to educate and persuade
them to use the free services.
- Ohio’s
program partners with advocacy groups to target underserved populations,
such as Asians, migrant workers, Hispanics, and African-Americans. These organizations provide translation,
outreach and transportation services.
- Montana’s program
has created an American Indian women’s health task force to represent
reservations and urban communities and grassroots coalitions in each
community. With the representatives
meeting regularly and the formation of the grassroots coalitions in
several communities, screening rates for this population has increased
threefold.
Some other public health program examples
are:
- The Special Service for Groups, Inc. and Orange
Country Asian and Pacific Islander Community Alliance in California
provide health education to community members, provide cultural
sensitivity information to health care providers, share cultural and
health practices of the respective communities, assist with culturally and
linguistically appropriate patient navigation, and education communities
on the impacts of policy changes on health access.
- Access Community Health Network in IL collaborates
with African American and Latino churches to provide comprehensive,
bi-lingual educational sessions.
- The Boston Public Health Commission in MA created
“The Breast Friends Program” to increase awareness of the importance of
breast cancer early detection, especially among African American
women. “Parties” are conducted in
women’s homes, churches, schools, and health centers that provide a safe
and supportive setting to discuss strategies to detect breast cancer at an
early stage and learn where to seek help if necessary. Community women are trained in basic
breast health education, including breast cancer risk factors and early
detection methods. The party
leaders spread the word of breast health and refer women to free
mammography services on the city of Boston’s
mobile mammography van.
Systems
and Fiscal Operations
Massachusetts’s NBCCEDP program is similar
to that offered in several other New England
states:
·
Connecticut,
Rhode Island,
Maine, and New York have basically
the same eligibility criteria.
o Rhode Island’s
additional state funding also permits focusing on age groups not prioritized by
the CDC.
o Rhode Island and New York clients may
also apply for Medicaid to cover treatment services.
NBCCEDP programs
in different states provide some alternative models for system operations and
fiscal management. Program directors
from four other states provided information to the RPPF.
·
Michigan
has a decentralized program, in which the state contracts with local agencies
that provide screening services themselves or contract with local providers for
screening. Outreach and improvement is
centralized, with the state dealing directly with 700 clinical providers
throughout the state. However, billing
is handled centrally, with the state processing all claims and submitting them
to a national organization. Program
representatives feel that transmitting data to the national provider to
determine if a woman is in the system is costly and would prefer to do it
themselves.
·
Maine
has a very centralized program. Medical providers contract directly with approximately
125 primary care sites, but there is central enrollment for almost all clients
through a toll free line, which gives consumers the option of selecting a
provider. This method has been found to
work well. Case management services are
also very centralized, with just one full time case manager for the entire
state (another has been requested).
Medicaid is used to process claims, although with diminishing
success. The claims payments and
database reports are not linked and missing data reports are often sent from
providers.
·
Nebraska’s
program has over 600 contracts with private providers. The state uses
centralized billing and data processing, with the 4 biggest providers entering
claims and data online and the others doing it by hand. Provider-specific case management services
are supplemented by six individuals who are paid to provide case management
services when needed to manage larger caseloads. There is no active outreach
program, due to insufficient program capacity for additional clients.
·
Washington
state’s program is decentralized. Six prime contractors manage contracts with
providers, who then subcontract with community health sites. Different private contractors use different
approaches to case management. Each
private contractor is responsible for oversight of administration and for case
management services. Difficulties are
reported in timely processing of claims for payment. Seventy-four percent of the funds is for care
and 26% for case management, rather than the preferred 60% - 40% formula.
·
New
York’s program is decentralized, contracting with 53
local contractors. Local health
departments and hospitals are responsible for coordinating a local partnership
for services that involves coordination, outreach, data management, fiscal
management, and case management. Most
service providers use an online system to enter data. A report is generated each month to request
reimbursements for contractors. The
state provides more than twice as much funding for the program than does the
CDC, but program representatives feel the program is underfunded and
overburdened with paperwork.
The next
sections begin with summaries of program procedures and requirements pertinent
to the work of each task force and then present the detailed recommendations of
each task force as well as the rationales for each recommendation.
Chair: Keith Merlin, MD, Brockton Hospital
RA: Andrea Gnong, University of Massachusetts Boston
DPH:
Ruth Karacek, RN, MPH, CCM, Department of Public Health
Members:
Ronald Burkman, MD, Baystate Medical Center
Barbara Cashavelly, RN, MSNT, Massachusetts General Hospital
Linda Clayton, MD, MPH, Executive
Office of Health & Human Services
Sarah Feldman, MD, MPH, Brigham
& Women’s Hosptial
Karen Freund, MD, MPH, Boston Medical
Center
Gerald Garlitz, RT, Dana
Farber Cancer Institute
Annekathryn Goodman, MD,
Massachusetts General
Hospital
Judi Hirshfield-Bartek, RN, MS,
OCN, Beth Israel Deaconess Med Center
Daniel Kopans, MD, Massachusetts General Hospital
Manlio LoConte, MD,
Saints Memorial Hospital
Lisa McCoy, MD, MPH,
American Cancer Society
Doris Moore, Department
of Public Health
Sylvie Ratelle, MD, MPH,
Department of Public Health
Shali Sanders, NP,
Health & Continence Institute
Susan Schwarz, RN, Great Brook
Valley Health
Center
Susan Troyan,
MD, Beth Israel Deaconess Med Center
·Program guidelines
mandate prompt follow-up of all women with abnormal screening results. WHN funds case management services to support
this requirement. Women who were screened
for and found to have breast or cervical cancer, including pre-cancerous
conditions, through the Women’s Health Network, are eligible to apply for the
MassHealth Breast and Cervical Cancer Treatment Program, a Medicaid program.
- Eligibility criteria: Massachusetts
residency, and 40-64 years of
age, and uninsured (have no
health insurance) or underinsured (insured but insurance does not cover
breast and cervical cancer screening services, and not eligible for MassHealth (Medicaid), and meet income guidelines (an
income at or below 250% of Federal poverty guidelines), and are willing to enroll in the
program.
- Under certain circumstances, some younger women (18+) and older
women (65+) who are at high risk may qualify for enrollment. Under certain circumstances, men
may qualify for enrollment if they are referred by a physician who, based
with an abnormal clinical finding, has referred the man to rule out breast
cancer.
- Citizenship
and Immigration status will not be used as criteria to include or
exclude women from enrolling in WHN who are otherwise determined eligible
under these guidelines. All
applicants will be asked, however, and must provide, information about
their citizenship and immigration status as part of the WHN application
process.
- Citizenship and Immigration status will be used as
criteria to include or exclude women from enrolling in the MassHealth
Breast and Cervical Cancer Treatment Program.
- WHN-BCCEDP funds may
be used to reimburse for one
annual screening office visit for each participant. The annual screening office visit should
include a clinical breast exam (CBE) and pelvic examination, a Pap test
and mammogram at appropriate intervals as described in the relevant clinical guidelines, and teaching
of breast self-exam (BSE). In
addition, the program funds screening tests (mammogram and Pap test) and
diagnostic tests (diagnostic imaging, biopsy, and pathology).
- WHN contracts with 26
health care organizations statewide to deliver program services. Contracting organizations must ensure
that women with abnormal screening
examinations or test results (abnormal findings) are referred to a medical
provider for appropriate diagnostic examination(s) and clinical follow-up
in accordance with clinical guidelines. This is assured through the
provision of professional case management services and clinical tracking
services.
- Organizations contracting
with WHN must have a tracking
system that ensures that eligible BCCEDP women are screened for breast
and cervical cancer services, that all screening test results are reported
to the project, that women obtain medical referrals for needed diagnostic
services, that women complete all diagnostic tests.
Screening and Diagnostic Criteria and Procedures
1) Present criteria
and procedures relevant and appropriate
·
Abnormal Pap or significant cervical lesion
·
Abnormal mammogram or abnormal CBE findings
Rationale: The present criteria and procedures utilized
in the WHN for the diagnosis and management of cervical and breast cancers are
consistent with evidence-based guidelines promulgated by recognized nation
professional organizations. In addition,
they are in agreement with the recent Centers for Disease Control statement
position on these issues. The present
criteria for entering at the diagnostic stage remain relevant and
appropriate. They are consistent with
CDC and other professional guidelines.
In summary, for cervical diagnostics, an abnormal Pap smear or significant
cervical lesion would qualify. In breast
disease, an abnormal Mammogram or abnormal findings on clinical breast
examination would meet diagnostic criteria.
This present criteria for cervical and breast cancer are sufficient in
light of recent CDC reviews of the program.
2) Maintain priority
for high-risk groups, i.e.:
·
Infrequently or never screened women
·
Cervical: > 5 lifetime partners, smoking, STD
history
·
Breast: family history, nulliparity
Rationale: Continued
emphasis on high-risk groups, especially those who have not received screening
or those women have not been recently screened remains a priority. The risk factors for cervical cancer are well
established and include more than 5 sexual partners over a lifetime, smoking,
and history of sexually transmitted disease.
Similarly for breast cancer, family history and nulliparity are known
risk factors.
3) Continue annual
cervical and breast exams
Rationale: An annual
examination is considered an integrally important part of the assessment of
women for cervical and breast cancer. As
such it should remain a requirement.
Eligibility
4) Request additional
funding and policy changes from legislators to allow inclusion of adolescents
and undocumented aliens (long term):
Rationale: There
should never be a woman in the Commonwealth
of Massachusetts who
cannot get care for breast or cervical disease because of her age or residency
status. The committee strongly
recommends that funding be available and policy changes made so that age and
residency requirements are dropped for entrance at the diagnostic or treatment
stage.
·
Include women younger than 18 for screening and
treatment when they are not eligible for screening and treatment when they are
not eligible through other programs.
Rationale:
At present, the program has a minimum age of 18. Yet there are women under 18 who do not
qualify for MassHealth and require diagnostic and treatment services. Therefore, age requirements for entry at the
diagnostic level should be removed.
·
Recommend that MassHealth regulations be changed
to allow treatment services for undocumented aliens.
Rationale:
The MassHealth Breast and Cervical Cancer Treatment program does not provide
services to undocumented aliens.
5) Request additional
funding to treat and manage any gynecologic condition detected (long term):
·
Consider specific legislative budgetary line
item
·
Consider coverage of other serious conditions
Rationale: The
annual examination allows additional opportunity to diagnose and treat issues
related to breast and cervical disease, not to mention other medical disorders.
This opportunity does present some challenges however. The Women’s Health
Network was and is designed to only address issues related to breast and
cervical disease. In the course of an examination other serious medical
conditions may be identified. These medical problems may require further
testing and treatment. The limitations of the program preclude coverage for
these services. The providers in the program face ethical, medical, legal, and
logistical problems in insuring these problems are properly addressed. The
committee would strongly recommend requesting additional funding for the
treatment and management of, at a minimum, any gynecologic condition discovered
during the screening and diagnostic evaluation. To effect these needed changes,
legislative action may be required to create fiscal support for such
activities. Consideration for a specific legislative budgetary line item has
been offered as a possible mechanism to permit funding and to monitor cost.
Certainly a major
consideration in the implementation of the program revolves around cost
considerations. As a public health program, the committee strongly recognizes
the need to do the greatest good for the largest number of women possible in
the most cost effective method. Yet the strength of the program lies in the
individual attention given to each woman who participates in it. As pressures
on cost-containment rise, we must not forget our primary mission to improve the
health of each individual woman who entrusts us with her care.
Technology
6)
Attend to latest technologies, i.e.:
·
HPV testing, either stand-alone or as adjuvant
test to Pap
·
HPV vaccines
·
Breast imaging techniques such as MRIs
Rationale: Our current protocols need to continue to be reevaluated in
light of new scientific advances and technologies to insure the women in the
program continue to receive high quality cost-effective care. As evidence of
new technologies such as Human Papilloma Virus vaccine or Breast Magnetic
Resonance Imaging emerge, the program must be flexible enough to adopt
evidence-based proven advances in a timely fashion.
7) Offer genetic
testing to all appropriate patients (long term):
·
National Comprehensive Cancer Network Guidelines
·
Offer enrollment to all identified as high
genetic risk
·
Only opportunity to empower highest risk women
·
Expensive but effective in reducing future costs
Rationale: At the
present time, there is genetic testing available for appropriate women who
develop breast cancer or who may be at risk for the development of disease. The
committee believes that genetic testing, in accordance with the National
Comprehensive Cancer Network guidelines, should be offered to all appropriate
patients. Individuals identified as high risk for genetic cancer should be
offered enrollment in the Women’s Health Network program. While it is
recognized that genetic testing is a potentially expensive endeavor, it
provides the only opportunity to empower women who may be at the highest risk
of developing breast or ovarian cancer a chance to proactively address their
genetic risk thereby decreasing future costs – emotional and financial. The
committee understands the limitations of the present program but does believe
genetic testing is cost-effective and a standard of care in appropriately
selected patients.
8) Keep up with
evidence-based technologies and approaches by:
·
Creating expert panel to review guidelines at
least annually
·
Including cervical and breast disease experts,
clinicians, technologists, DPH representatives
Rationale: Medicine is constantly changing and there are new
technologies and therapies on the horizon. Human Papilloma viral testing as
either a stand-alone or adjuvant test to a Pap smear is now clinically
available. Vaccines for HPV are now in clinical trials. New modalities for
breast imaging such as Magnetic Resonance show potential promise. To insure the
Women’s Health Network incorporates the latest evidence-based technologies and
approaches, the committee recommends the DPH create an expert panel to review
the guidelines at least annually. The panel should include experts in cervical
and breast disease, clinicians, technologists, and representatives from the
DPH. The broadest possible perspective on the issues will provide the best
vision for the future.
Chair:
John Ayanian, MD, MPP, Harvard
Medical School
RA: Gina
Gentile, University
of Massachusetts Boston
DPH: Mary Lou Woodford, RN, BSN, CCM,
Department of Public Health
Members:
Chava Chapman, MD, Boston Medical
Center
Anita
Christie, RN, MHA, CPHQ, South
Shore Medical
Center
Paula
Johnson, MD, MPH, Brigham & Women’s Hospital
Jewel
Mullin, MD, MPH, Mason
Square Neighborhood
Health Center
Nancy
Norman, MD, MPH, Fenway
Community Health
Center
Laurel
Radwin, PhD, University
of Massachusetts Boston
Theresa
Trainor, LPN, BS, CPHQ, Mass PRO
Heather
Ursini, RNC, Mary
Lane Hospital
Janet
Yardley, MD, Framingham
Community Health
Center
- The Heart Disease and Stroke Prevention Program (HDSPP) requires
that the women are between the ages of 40 and 64 and already enrolled in
the Breast and Cervical Cancer Early Detection Program (BCCEDP).
- Patients are screened
using National evidence-based clinical guidelines aimed at modifiable
cardiovascular disease (CVD) risk factors.
These risk factors focus include hypertension, abnormal
cholesterol, poor dietary intake, low levels of physical activity,
overweight and obesity, tobacco use and diabetes.
- HDSPP funds
may be used to pay for one screening office visit and up to two
follow-up office visits per year for each woman enrolled. The following tests will be reimbursed
by the program: resting pulse,
screening blood pressure, confirmatory blood pressure, height and weight
measurements, automated blood chemistry, fasting blood glucose, fasting
lipid panel, urinalysis, paper and pencil tests, interviews or
computerized methods that measure level of physical activity, dietary
intake and smoking status. If the woman
is diabetic, hemoglobin A1C testing is also covered.
- Women with
abnormal findings require both clinical follow-up and clinical
tracking. Case management services
are required for all women identified with ATP III risk scores of
≥20%. Women are notified of
test results and at least 3 attempts at notification must be documented in
the WHN record.
- For all
enrollees, contracting organizations must arrange for referral to
medical services, provide clinical tracking services, provide risk
reduction education services, and report the following data using the
Department’s automated information system (AIS): screening test, date of
test, findings for each test; risk reduction education (RRE) session date,
length of session, and topic of session; ATP III risk score, lifestyle
assessment scores and date; lifestyle intervention plans and date; and
other lifestyle interventions by date and topic.
- All women enrolled in the HDSPP program are offered risk reduction education services
annually. 100% of enrollees are expected to receive risk reduction
services. There is a 6-month reassessment and follow-up of lifestyle
intervention.
- Contracting organizations must have a system in place
to track and remind enrollees to return for annual re-screens.
Lifestyle assessments must be conducted and individualized intervention
plans must be developed and documented.
Data Collection & Patient Tracking
1) *The WHN should provide case managers with basic tracking
systems to support more complete and consistent program-wide monitoring of key
information, including participants’:
- Initial
and follow-up CVD risk score and its risk factor components
- Completion
of follow-up risk re-assessments and counseling visits
- Eligibility
& enrollment in MassHealth, Free Care, and/or drug assistance programs
Rationale: This data
system would expand on the currently collected “Minimum Data Elements” (MDE)
database to allow more complete monitoring of program participants.
2) *The WHN should provide case managers with a data system
for tracking whether each participant who has hypertension, hyperlipidemia,
diabetes mellitus and/or is a current smoker has:
- A
program for obtaining free or reduced cost medications for hypertension,
hyperlipidemia, diabetes mellitus, and/or smoking cessation
- A
program for obtaining free or reduced cost supplies for glucose monitoring
(i.e. glucometer, lancets, test strips) if a participant has diabetes mellitus
Rationale: Each
participant in the WHN Heart Disease & Stroke Prevention program with one
or more established CVD risk factors (hypertension, hyperlipidemia, diabetes
mellitus, and/or current smoking) should be tracked in a local site database
with summary reporting to the WHN program.
This database should record their primary care provider, access to
medications, and ability to diabetes supplies if relevant.
Risk
Stratification & Intensity of Follow-up Services
3) *The frequency of follow-up visits for risk re-assessment
and risk reduction counseling services should be explicitly tailored to
participants’ initial level of CVD risk:
- High-risk
patients (e.g. 10-year CVD risk score >10%) contacted every 2-3 months
- Medium-risk
patients (e.g. CVD risk score 5-10%) contacted every 6 months
- Low-risk
patients (e.g. CVD risk score <5%) contacted every 12 months
Rationale: The WHN
manual stipulates that Heart Disease & Stroke Prevention programs must
provide annual risk reevaluation sessions for all clients and also a 6 month
re-assessment of the lifestyle interventions for nutrition and physical
activity. For those with ATP III risk groups scores >20%,, case
management and tracking services are also required, but frequency of contact is
not stipulated. High-risk patients would
benefit from more frequent follow-up visits (every 3 months) to assess their
ongoing risk status, and low-risk patients may only require annual follow-up to
determine whether their risk status has worsened.
Clinical Services
4) *A brief screening
tool for depression should be added to the initial CVD evaluation for all
program participants.
Rationale: Depression
is an important comorbid condition that can adversely affect CVD outcomes and
impair individuals’ ability to follow lifestyle modifications and treatments to
reduce CVD risk. Brief screening tools
are readily available and could guide referrals for primary care or mental
health services (e.g. MHI-5 survey questions from Berwick et al. 1991).
5) *Glycosylated
hemoglobin testing should be retained as a covered Heart Disease &
Stroke Prevention service for women with diabetes mellitus or glucose
intolerance.
Rationale: Recent
studies have shown that glycosylated hemoglobin levels are an independent
predictor of CVD risk among women with diabetes mellitus or glucose
intolerance.[Ann Intern Med 2005 refs]
The Massachusetts WHN program has previously received CDC approval to
include this test as a covered service, so this coverage should be
retained.
6) *Liver function testing
(e.g. ALT) should be added as a covered service for women with
hyperlipidemia who may require lipid-lowering medications.
Rationale: Women with
hyperlipidemia may be eligible for lipid-lowering medications that could have
higher risk or be contraindicated in patients with chronic liver disease, such
as hepatitis C or alcoholic hepatitis.
Basic liver function testing will identify most of these women.
7) **C-reactive
protein (CRP) testing should be considered as an additional covered service
in the initial CVD risk assessment.
Rationale: If ongoing
randomized clinical trials demonstrate that women age 40-64 with elevated CRP
levels and normal lipid profiles benefit from treatments to lower CVD risk
(e.g. lipid-lowering therapy, aspirin), CRP may be a useful screening test to
add for risk stratification.
Referrals for
Primary Care, Medications, and Medical Supplies
8) *Each site participating in the Heart Disease &
Stroke Prevention program should provide the WHN with a written summary of
local primary care providers (e.g. community health centers, hospital-based
clinics, and/or private physicians’ offices) to which participants with CVD
risk factors can be referred for medical evaluation and treatment. This summary should be updated annually and
reviewed by WHN staff in the Massachusetts Department of Public Health.
Rationale: WHN sites
participating in the Heart Disease & Stroke Prevention program have a
varied set of arrangements for helping participants obtain needed primary care
and medications. Case managers and
program staff are actively focused on arranging primary care referrals and
access to medications through a series of ad-hoc arrangements. At a program based at a community health
center, for example, primary care services are readily available on site. In contrast, a VNA-based program works with
both community health centers and private physicians’ offices for needed
referrals. As part of the WHN Heart Disease
& Stroke Prevention program oversight, these arrangements for primary care
services, medications, and medical supplies should be explicitly documented by
participating sites and reviewed with WHN central staff, and WHN central staff
should assist sites in ensuring that adequate referral resources are in
place.(Mays et al. 2004)
Heart
Disease & Stroke Prevention Program Expansion
9) **State funds should be sought for expanding the Heart Disease
& Stroke Prevention program beyond the current 7 participating WHN sites to
allow more WHN sites to provide CVD risk assessment and counseling services.
Rationale: The current
WHN sites are making strong efforts to enroll as many women as possible, but
they can screen only a small proportion of potentially eligible women
state-wide [could add some BRFSS data here].
Footnotes
*Short-term recommendation to be implemented within 1 year
**Longer-term recommendation to be implemented with 3-5
years
Co-chairs:
Gail
Gall, MS, RN, University
of Massachusetts Boston
MaryJoan Ladden, PhD, RN, Harvard
Pilgrim Health Care
RA: Elizabeth R. Cruz, University of Massachusetts
Boston
DPH: Gail Chaffee, RN, CCM, Department of
Public Health
Members:
Nashira Baril, Boston Public Health Commission
Maura
Lessard, RN, BSN, CRRN, CCM, Marketing Educational
Management
Services
Eileen
Manning, RN, BS, Dana Farber/ Partners Community Care Breast
&
Cervical Screening Collaborative
Lois
McCloskey, DrPH, Boston
University School
of Public Health
Sharleen
Moffatt, RN, BSN, Franklin County Home Care Corporation
Beth Paronich, MSW, LICSW, Jordan Hospital
Donna Peltier-Saxe, RN, MSN, Dana
Farber/ Partners Community Care
Breast
& Cervical Screening Collaborative
The Case
Management Task Force reviewed current procedures and regulations concerning
the delivery of case management services and formulated recommendations for
changes concerning both the Breast and Cervical Cancer program and the Heart
Disease and Stroke Prevention Program.
- Contracting
organizations have the responsibility to ensure that women with abnormal
findings are referred to a medical provider for appropriate clinical
follow-up in accordance with clinical guidelines. Case management is the program component
that links patients with the broader health care and social support
systems. Timely and adequate
follow-up of abnormal results is assured through the provision of case
management services.
- The process of case management involves identifying,
brokering and sustaining diagnostic and treatment resources that ensure
the provision of essential medical services to at-risk WHN-enrolled
women. These activities include
assessment of the barriers to receive timely and appropriate care, and
development of a case management plan to address and attempt to resolve
these barriers.
- Women must agree to the provision of case management
services and this consent must be documented in their WHN medical record.
- Case management is a WHN-covered service that is paid
for through the cost reimbursement portion of the DPH contract with the
contracting organization; they cannot be billed by a medical provided or
women cannot be billed for these services.
- Case managers must link women with cancer to the
MassHealth Breast and Cervical Treatment Program. If the woman is not eligible for this,
the case manager must link her to free or low-cost treatment services
within the same expected time frame.
- Termination of case management services:
o For
BCCEDP: No cancer diagnosis; Initiation of treatment for cancer or precancerous
condition; Successful enrollment in the MBCCTP; Refusal of services; Moved out
of state; Lost to follow-up; Ineligible for services
o For
HDSPP: ATP III 10 year Risk score falls below 20%; Refusal of services; Moved
out of state; Lost to follow-up; Ineligible for services
- Case management is a professional service provided by
credentialed and/or licensed staff.
“Case manager” shall mean a person or entity holding current
licensure in Massachusetts or national case management certification, and either have a BA/BS or higher
in health and human services or be a
registered nurse, licensed in Massachusetts, with an associate degree, a 3
year hospital diploma, or a bachelor degree or higher
Case Management structure
1) Create a
client-centered model, adaptable to a variety of health care organizations, so
that case management service can meet the unique needs of WHN clients.
·
Case management services should continue to be
decentralized and managed by contracting agencies.
Rationale: WHN clients
come from diverse ethnic and cultural backgrounds and have multiple health,
mental health, and social needs. Case managers need partnerships with
providers/ organizations in that community to facilitate client access. Sites need the flexibility, within specific
parameters of CDC and DPH guidelines, to implement case management services
that best fit the needs of their population.
·
Case management services should be team
structured.
Rationale: Team structure provides opportunity to maximize the
personnel resources of the contracting agency to provide services. For
contracting agencies in which there are more than one staff members providing
case management, program coordination, and client navigation, the teamwork
should provide the clients a range of resources including clinical and cultural
competencies as well as access to brokerage services.
2) Clearly describe
the expectations for case management service to WHN vendors. The expectations
to be described in the contract include:
·
Administrative support for CM
·
Minimum time for CM services based on enrollment
capacity and client caseload characteristics.
·
Qualifications of CM
·
Training requirements to be supported by the
site, such as site specific orientation, ongoing training, and team
development.
Rationale: Because each WHN site will meet the needs of their clients
differently, the expectations for case management services should be clearly
described in the contract so that supports are standard across the network and
sites are accountable for these components.
3) Create regional
case management networks to enhance collaboration and stimulate best practices.
Rationale: Maximize
the experience and skills of the case managers and client navigators by
encouraging them to share resources, encourage collaboration, and develop best
practices in WHN case management. This network would benefit from client
participation.
Case Manager Qualifications
4) WHN Case Managers
should be licensed health care professionals with a set of defined core
competencies and skills. Case managers without a nursing background should be
part of a team that includes a health professional able to make decisions based
on clinical data. In small provider sites, where the team approach cannot work,
the nurse is the key to successful CM
This differs from the current DPH statement of criteria. The
TF recommends deleting the phrases: “and
either BA/BS or higher in health and human services, or RN licensed in MA, with
AD, diploma, or BS or higher” from the 2005 Policy and Procedure Manual.
The case managers should
have a defined set of core competencies and skills including:
·
Ability to
interpret medical/ health data related to clients
·
Ability to
integrate cultural and ethnic disparities into assessment, plan, and
intervention
·
Computer skills, including Excel, Access, and
web searches
·
Communication skills; verbal, written, in
person, and by telephone
·
Problem solving skills with creativity and
flexibility
·
Ability to effectively interface with PCPs and
specialists on behalf of the client
·
Ability to identify and secure relevant
site/organizational, community, and
state resources for the client and her
family
·
Ability to lead and work as part of a team
·
Ability to advocate for WHN services within the
organization
Rationale: While many
would argue that nurses are the optimal case managers for the WHN program, Massachusetts faces
challenges in recruitment and retention of nurses. WHN sites need flexibility
in recruiting from a larger pool of eligible, licensed case management staff
(social workers, nutritionists, health educators, etc). Consideration should be
given to increase recruitment from members of WHN target populations. If the
case manager is not a nurse, she/he should function as part of a team to ensure
medical or nursing supervision of clinical decision making.
Case Management Training and
Resources
5) Create a case
management orientation program (WHN 101) that is multimodal and has separate
tracks for each level of staff (case managers and client navigators). Additionally, establish a mentoring program
that connects experienced staff and newcomers.
Topics include:
·
How CM operates in WHN
·
Awareness and respect for the unique needs of
women in WHN
·
Clinical issues related to breast and cervical
cancer, and CVD
·
Expectations and responsibilities of case
managers, client navigators, and program coordinators
·
Standard assessment techniques, including
general and mental health
·
Local, regional, and state resources
·
DPH and other case management specific supports
·
Working as a team including delegation,
supervision, and role issues.
6) Establish a
professional development series that includes the voices of, and is intended
for all who work with WHN clients (case managers, client navigators, outreach
staff, DPH and agency staff). The series should be interactive and driven
toward improving case management services, job satisfaction, staff retention,
and client satisfaction. Professional development topics include:
·
Professional development topics:
·
Best practices in case management for breast and
cervical cancer and heart disease & stroke prevention
·
Understanding how clients’ experiences and
backgrounds, including racism and disparities, influence their health care
choices
·
Cultural competence
·
Assessment of psychosocial response to potential
cancer and CVD diagnoses.
·
Enhancing clients’ self management skills
·
Integrating clients’ perspective into care
·
Negotiating care boundaries
·
Refining communication skills for various
situations
·
Negotiating with providers
·
Managing time and prioritizing work areas
·
Managing stress
·
Brokering access to wider health, social, and
financial support services.
·
Behavior change theory and practice
·
Evaluation strategies at the agency level
Rationale for items 5 & 6: The success
of the WHN depends of the effectiveness of case management services. To
optimize their skills, case managers and client navigators need not only a
basic orientation to case management and WHN but also mentoring, training, and
resources across the professional development continuum.
Heart Disease & Stroke Prevention Case Management
7) Increase funding
for the WISEWOMAN program to pay for recommended diagnostic testing, adequately
reimburse providers, and support continued intervention for client behavior
changes.
Rationale: The program
cannot be effective at the current level. It has experienced significant loss
of contracted service providers and is unable to attract new contractors as
presently designed. Enhanced funding is
needed to connect patients to primary and specialty care. Because fear of bills is an important issues
deterring participation, the program needs to guarantee reimbursement of a
broader range of services
8) Provide training
for WISEWOMAN staff to support their roles as lifestyle coaches. Support
nutrition and behavior change counselors at DPH for the entire program to
access.
Rationale: Coaching clients on lifestyle
change is a critical part of the WISEWOMAN program and role of case managers
and client navigators. To enhance effectiveness, they need specific skills in
behavior change theory, client empowerment, and self-management for the
particular cultures represented by WHN clients.
Community health workers with skills in specific behavior change
coaching may be best utilized at specific sites.
9) Streamline
WISEWOMAN reporting and data collection based on clinical and field-service
needs.
Rationale: These
activities should support rather than drive the program and not detract from
the case management staff’s ability to delivery quality and timely services.
Each agency has its own paper work as well as WISEWOMAN records. For many in
the field, the paperwork is repetitive and not clinically valuable, thus a
barrier to effective services. New systems should be developed in consultation
with those in the field who will use the systems.
Additional Recommendations
10) Establish a
quality improvement and innovation fund to test new ideas in care improvement.
Rationale: Case managers in the
field have a unique and valuable perspective. Innovation usually comes from
within the field. New ideas need support to be tested and evaluated. Such
investments cold add to the quality of services as well as satisfaction of both
clients and staff.
11) Encourage and support case manager
certification
Rationale: Establishes a baseline credential and competency for the
program and serves to support the Case Managers in the field and give them access
to further resources for professional development
12) Support the designation of client navigators
as community health workers (CHWs).
Rationale: The DPH has just issued a report
on CHW, defining the role and reporting on characteristics of CHWs in MA. Designating the client navigators as CHWs
would reinforce their value as members of the case management team and keep the
WHN program in alignment with DPH policies.
Chair: Judy
Ann Bigby, MD, Brigham & Women’s Hospital
Consultant:
Cathy
Romeo, VNA Care Network, Inc.
RAs: Elizabeth R. Cruz, University of Massachusetts
Boston
Rachelle
Pierre, Harvard Medical School
DPH: Janice Mirabassi, MA, Department of
Public Health
Members:
Jane Cloutterbuck, PhD, RN, University of Massachusetts Boston
Dora
Gutierrez, MD, Latin American Health Institute
Nancy
Keating, MD, MPH, Harvard
Medical School
Karen
Lasser, MD, MPH, Cambridge
Health Alliance
Lidia
Schapira, MD, Massachusetts
General Hospital
Darrell
Smith, Brigham & Women’s Hospital
The Disparities
and Barriers Task Force considered the sources of health care disparities and
barriers to health care access as well as techniques that could reduce
disparities and barriers.
Categorical Nature of Program
1) The WHN should
coordinate with other DPH programs to meet the needs of women with depression.
Rationale: In WHN,
women with depressive symptoms are less likely to follow-up with abnormal
results.
2) The WHN program
should evolve into a primary care based model of comprehensive women’s health
for those uninsured. The CDC and MA DPH
should increase funding for diagnostic and treatment services (long term).
Rationale: The
categorical nature of the program requires several administrative structures
that are burdensome or difficult to implement.
Women present with health needs that are not related to the WHN or
WiseWoman covered services and providers respond to these needs because they
want to ensure that women get the care they need and they feel an ethical
obligation to do so.
Cultural competence
3) WHN contracts
should require providers to demonstrate an awareness of disparities, especially
the issues unique to women, and describe the programs and policies that
encourage and sustain cultural competence.
Sites should demonstrate how they will meet unique needs of specific
populations (e.g. availability of interpreters).
Rationale: There are cultural differences in health
risk, incidence, mortality, patterns of health care use, and health
values. Policies need to be attentive
and sensitive to in order to effectively reduce such disparities.
4) Clinical site
evaluations should include benchmarks that adequately assess cultural
competence.
Rationale: It is important to collect data on
race/ethnicity, country of birth, length of residence, socioeconomic status,
and language preference to measure any gaps in health outcomes and to measure
any reduction in health disparities.
These data must be shared with the community and incorporated into
program changes.
5) The WHN program
should diversify staff to better reflect the population being served. This includes have specific recruiting
strategies to open up positions and exploring a model of case management not
requiring nurse case managers.
Rationale: There is a lack of racial/ethnic/linguistic
concordance between case managers and the population serviced. The nursing pool lacks
racial/ethnic/linguistic diversity and many duties assigned to the case manager
do not require nursing skills or training.
6) The WHN should
regularly assess patient experiences and use these results to improve programs.
Rationale: Research
shows that patient satisfaction is a predictor for returning for care and
recommending services to others. Recent
WHN evaluations show that non-English speakers are less satisfied and clients
were less likely to recommend the program to non-English speakers and disabled
women.
7) The WHN should use
community health workers/patient navigators for outreach, follow-up, and
re-screening.
Rationale: Research
shows that patient navigators who are racially and culturally similar to the
clients they serve and are familiar with patients’ communities have been shown
to have a significant effect of rates of biopsies for abnormal findings and
timeliness of diagnosis.
Fear of bills
8) The WHN should
develop marketing strategies that address fear of bills up front so more women
will participate.
Rationale: Task Force
members believe that women’s experiences with free health care has caused them
to be skeptical of programs that are free.
Women inform others in their community about their experiences in the
health care system. Learning that some
women get bills even though the program is free deters others prom
participating.
9) The WHN should
screen women for other programs upon intake.
Rationale: Women who
are eligible for WHN may be eligible for other programs as well. Additional coverage would help to prevent
women getting bills for services that are not covered by WHN.
10) The WHN should
develop materials that adequately inform women of the limitations of the
program and covered services. Such
materials should be language and literacy appropriate.
Rationale: Women are
not adequately informed of which services are covered and they are fearful of
receiving bills for non-covered services.
11) The WHN should
improve access to WHN staff that can help problem solve when women receive
bills.
Rationale: This would
prevent women from being so fearful to receive bills, help them find methods to
pay for a bill they cannot afford and ultimately not dissuade them from
continuing services.
12) The WHN should
work with providers to identify ways to deliver non-covered services without
women getting a bill.
Rationale: Providers
are not educated about all the limitations of the program and consequences of
providing non-covered services. Also,
there is a lack of resources to address CVD risk factors.
13) The WHN should evolve into a primary care based model of
comprehensive women’s health (Long term).
Rationale: A comprehensive care model would eliminate
many of the barriers to getting service including fear of bills for non-covered
services.
Logistics
14) The WHN should mandate providers to include hours on the
week-ends or evenings. An option
includes exploring ways to encourage those with extended hours to
participate.
Rationale: Most clients cannot get services during
normal business hours (Monday – Friday, 9 – 5) because they need to work and do
not have sick time.
Limited number of sites; administrative burden
15) The WHN should
set up processes to streamline systems.
Rationale: Reports
from drop-out vendors suggest the need for a more “user friendly” model.
16) The WHN should
increase incentives for site participation, including increasing reimbursement
(Long term).
Rationale: Enrollment
in WHN has declined even though the uninsured have increased in number. 25 programs dropped out of the WHN program
(with 5 subsumed into other contracts) for a variety of reasons. While not all reasons can be directly
attributed to WHN, changes in the program such as upgrading screening to
include case management services, adding the WISEWOMAN program with risk
reduction education, and updates in technology (information, billing, and
enrollment) contributed to the decrease in participating vendors. Reports from case managers state that
administering the WISEWOMAN program is extremely labor intensive and that DPH
does not adequately fund their programs.
Outreach and transient population
17) The WHN should increase outreach efforts, such as
including in site contracts, targeting specific populations, and strengthening
the role of the community health workers.
Additionally outreach workers should reassure immigrant populations of program
intent.
Rationale: In 2000 the
WHN programs were forced to discontinue its outreach program. Since then screening and re-screening rates
are lower than desirable. Even though
there has been an increase in the number of uninsured and under-insured women,
the numbers of clients have declined over several consecutive years. In FY 2004, it is estimated that only 23% of
eligible women were screened. For
example, between 1999 and 2001, only 42% of eligible women 40-64 years old
received a Pap test and between 2000-2001 only 31% of eligible women 40-64
years old received a mammogram. Only
66.5% of Asian women reported having a Pap test in 2002, compared to the 88% of
all MA women. Within the program there
is a significant transient population.
Immigrants need to verify their status and provide SSN for new the new
enrollment process.
Efforts to reach
underserved populations that focus on using existing community and social
networks (such as faith based organizations) are often more effective in
recruiting underserved women for screening procedures than efforts that are
developed solely out of a health care institution. Identifying trusted community members to
outreach helps to build trust.
Chair: Rachel Wilson, MPH, Brigham & Women’s
Hospital
RAs: Sophy Nun-Hoeger, University of Massachusetts
Boston
Swapna
Reddy, JD, MPH, Brigham & Women’s Hospital
DPH: Heather
Nelson, PhD (ABD), MPH, Department of Public Health
Members:
Gayle Bagley, American Cancer
Society
Carol Brayboy, Boston Public Health Commission
Jennifer Cochran, Department of
Public Health
Sally Fogerty, MEd, BSN, Department
of Public Health
Gail Fortes, YWCA Southeastern
MA
Sally Hooper, MSW, LICSW, Massachusetts General Hospital
Donaldo Macedo, PhD, University of Massachusetts Boston
Susan Madden, Division of Health
Care Finance & Policy
Janet
McGrail-Spillane, American Cancer Society
Lisa
Renee Sicilano, Massachusetts
Public Health Association
Karen
Webber, VNA Care Network, Inc.
John
Wei, MD, Lahey Clinic
- Women can call the toll free line to learn more
information about the program and about participating sites.
- Medical providers in the community are encouraged to
refer income-eligible women into the program.
- Through the WHN Training Institute there are free and
low-cost professional education programs for outreach staff, client
navigators, community health workers, clinicians, and medical
professions.
- A representative list of training offerings from
previous years include: Breast self exam; Clinical breast exam; Outreach
strategies; Conducting effective peer-education sessions; Cultural
competence; Breast, cervical and cardiovascular health for community
health workers; CME/CEU; AIS.
- The WHN develops and distributes free health
promotion materials through the Massachusetts Health Promotion
Clearinghouse. These materials are
appropriate for clinic waiting areas, to distribute to medical providers
and in the community; and as handouts to patients. Formats include posters, pamphlets, and
electronic media. These materials
are free of charge. Selected
publications are available in several languages.
Outreach Structure Recommendations
1) The primary focus
and funding for WHN outreach should be targeted toward community outreach at
the local level, using the below 3-tiered strategies:
Rationale: The number of clients served by the WHN has
declined steadily since 2000. While
other factors may have contributed to this decline, it is important to note
that this was also the year that funding for outreach was eliminated. When government funding streams change,
outreach is often the first program component to be reduced. When outreach is conducted locally, instead
of centrally, outreach activities may be more likely to be sustained.
·
Use site specific outreach by Community Health
Workers (CHWs) and Peer Educators. This
involves each medical service site being responsible for and funded to
specifically conduct (or subcontract) outreach to the communities serviced by
their center. To address previous
problems of outreach referrals made only to the site conducting the outreach,
language should be included in each contract that specifically requires sites
to refer clients to agencies that have the capacity and infrastructure to best
address the specific needs of the clients (i.e. geography, language, specific
services offered). This should also be
reiterated in trainings and regional meetings and assessed through evaluation. [Note: WHN site subcontracts for outreach
should be processed centrally by DPH, but managed locally by the site.]
·
Rationale:
CHWs are recognized consistently in research and practice as the most effective
method of outreach. Peer educators can
be an effective supplemental tool for CHWs to convey messages through oral
networks in the community. Additionally,
the use of CHW’s can help to reduce cultural and linguistic barriers and
alleviate client fears of breast and cervical cancer screening that may prevent
women from enrolling or re-enrolling.
·
Rationale:
Currently, WHN sites that subcontract out to others are overburdened by the
administration and paperwork necessary.
Centralized subcontracting can help to reduce this burden and streamline
processes.
Enlist community
programs to reach target populations that may be particularly high-risk and/or
hard to reach through other methods.
This method should only be utilized if evaluation indicates that a
population is not being reached and that the local outreach workers do not have
the capacity to do so.
·
Rationale:
An aggressive strategy is needed to assure that sites are located in ways that
maximize access by target populations.
The importance of site location can be seen in the reduction in Chinese
speaking clients from 2003-2004 following the discontinued participation of a
primarily Chinese-speaking WHN site.
Have a DPH
Outreach Coordinator(s) to oversee local outreach staff and coordinate their
work to maximize effectiveness.
Responsibilities should include, but not be limited to: convening
regular mandatory regional meetings for outreach (and other) WHN staff,
coordinating outreach to assure that all target populations are being reached,
collecting evaluation data, and providing technical assistance, training, and
support to outreach staff. They should
also be responsible for working with central WHN staff to assess progress in
reaching statewide outreach goals.
·
Rationale:
WHN site surveys report that there is a great need and desire to meet
regionally, especially to discuss and share outreach methods.
2) Strategically locate medical sites in the
communities where target populations seek care.
DPH must review and actively purse such targeted participation.
Rationale: Local ties,
cultural/linguistic diversity, and community partnerships are fundamental to
conduct the most effective community outreach.
·
The number
of clients served by the WHN has declined steadily since 2000. While other factors may have contributed to
this decline, it is important to note that this was also the year that funding
for outreach was eliminated.
·
Local
ties, cultural/linguistic diversity and community partnerships are fundamental
to conduct the most effective community outreach.
·
CHW’s are
recognized consistently in research and practice as the most effective method
of outreach. Peer educators can be an
effective supplemental tool for CHW’s to convey messages through oral networks
in the community.
·
The use of
CHW’s can help to reduce cultural and linguistic barriers and alleviate client
fears of breast and cervical cancer screening that may prevent women from
enrolling or re-enrolling.
·
WHN site
surveys report that there is a great need and desire to meet regionally,
especially to discuss and share outreach methods.
·
When
government funding streams change, outreach is often the first program
component to be reduced. When outreach
is conducted locally, instead of centrally, outreach activities may be more
likely to be sustained.
·
Currently,
WHN sites that subcontract out to others are overburdened by the administration
and paperwork necessary. Centralized
subcontracting can help to reduce this burden and streamline processes.
·
An
aggressive strategy is needed to assure that sites are located in ways that
maximize access by target populations.
·
The
importance of site location can be seen in the reduction in Chinese speaking
clients from 2003-2004 following the discontinued participation of a primarily
Chinese-speaking WHN site.
Educational Materials Recommendations
Education of potential clients
should rely less on written materials and more on oral networks and “word of
mouth”. This will require a
reallocation of funds to support the education methods recommended below. Business sized cards with a local WHN phone
number, available in multiple languages, should be the primary written material
used by outreach workers and other community groups. An assessment of how the WHN toll-free number
is being utilized and its cost-effectiveness should be conducted and compared
to reliance on local phone numbers.
Rationale
·
27% of WHN
clients have less than a high school education.
·
20-30% of
WHN clients surveyed heard of the program through a family member or friend,
particularly among Portuguese and Spanish speakers.
·
Surveys
report that almost all WHN medical sites expressed concern about MDPH’s
toll-free number not being answered and delays in responding.
Educational Methods Recommendations
The primary methods recommended
for public education include:
(1) The use of community health workers and peer educators
(2) Partnerships
with local social, community and religious organizations
(3) Local,
targeted, culturally specific media campaigns (i.e. Latino radio)
Rationale
·
Research
indicates that these are the most effective outreach methods available.
·
See
rationale for outreach structure re: CHW’s above.
·
These
methods are relatively lower in cost than other options, such as large media
campaigns.
Evaluation Recommendations
Because some clients may enroll in WHN after contact with
more than one outreach worker, evaluation of outreach should be measured in a
way that recognizes and records all contacts that lead to a client’s
enrollment. Outreach should be evaluated
based on simple reports submitted to outreach coordinators on a regular basis,
which include the following data:
(1) Description
of referrals made, with information on race, ethnicity and language of
referrals, as well as where the woman was referred to, and the reason for the
referral (which will allow for outreach coordinators to assess whether
referrals are being made to sites with the capacity and infrastructure that
best serve the client).
(2) Type
and method of outreach methods, appropriate category indicated (i.e. initial
contact, follow-up).
(3) Number
of contacts made through outreach methods, by whom and through what role.
It should be the responsibility of outreach coordinators to
gather this information. WHN central staff should use this information to
compare the outreach contacts and referrals to the pool of eligible women to
determine who is still not being reached and who is being reached most
effectively. Women referred to WHN
should also be tracked to determine if they ultimately enroll in the program. Successful outreach and methods should be
shared at regional outreach meetings.
It is important to recognize that local community outreach
is a long-term investment that involves building relationships and
networks. Therefore, the new outreach
structure will most probably not show immediate results and assessment must
take place over a period of years.
Rationale
·
Evaluation
is necessary to determine what methods are most effective, what populations are
being reached and not reached, to share successful methods, and to provide
oversight to determine if referrals are being made to the sites with the
capacity and infrastructure that best serve the client.
·
Evaluation
can help to identify trends in referral patterns and changes in community
demographics.
·
Evaluation
is important for effective coordination, oversight, and accountability.
·
Collection
of data from all points of outreach and referral can help to reduce the
competition that has been a problem in the past.
Staff Training & Support
Staff Role Recommendation: Outreach/Navigator Role
The roles of the Client Navigator
and Outreach Worker should be clearly defined and recognized as part of the
health care team. Given the
similar roles and background required of outreach workers and client
navigators, we strongly recommend that these roles be combined whenever
possible. This would result in
continuity through initial contact, referral, enrollment, health care services
navigation, follow-up, and re-enrollment.
Rationale
·
WHN staff,
particularly client navigators, reported a lack of appreciation and recognition
by their teams for their contributions and confusion about the appropriate
boundaries between their role and that of the case managers. This boundary could become even less clearly
defined with the inception of an outreach worker, if the roles are not combined.
·
Outreach
workers may be more likely to feel integrated in the medical services delivery
team if their role is combined with the client navigator, where she will have
more interaction with medical site staff.
·
The
combination of the client navigator and outreach worker roles will most likely
increase enrollment, enhance client trust, streamline care, and could result in
increased repeat visits and re-enrollment.
WHN staff training
All staff at participating WHN
sites that are involved in client enrollment must be fully trained in WHN and
in cultural and linguistic competency.
This includes training for financial and registration staff at each
site, as well as providers and administrators who may refer women into the
program (for improved “in-reach”). Cross
training should also be conducted, in order to protect against gaps in service
during staff transitions and to foster an appreciation for other WHN site staff
roles.
Rationale
·
Without
knowledge of the program, it will be difficult for financial and registration
staff to effectively recruit women into the program and answer their questions,
especially if the Virtual Gateway is to be used increasingly as a recruitment
tool.
·
Virtually
all contracting organization staff reported the need for more consistent
training of staff to maximize the understanding of WHN Program guidelines and
foster more collaborative relationships.
·
Almost all
medical site staff reported challenges in getting adequate WHN training to stay
current and conveyed interest in cross-role training.
·
28-45% of
WHN patients reported referral by a health care worker; however some site staff
report that providers sometimes fail to understand the WHN program restrictions
so that women get charged for services they can not afford.
Regional Meetings
Regional meetings with outreach
workers and others involved in WHN enrollment and care should be held at least
quarterly. Meetings should be
coordinated by the DPH outreach coordinator(s).
Meetings should be interactive, as opposed to presentation and reporting
format, to stimulate active participation to address barriers and facilitate
more collaborative relationships. The
meetings should be mandatory and can provide a forum for:
- Identification
of staff training needs
- Providing
staff trainings
- Sharing
of information, techniques, and resources
- Staff
recognition, support and technical assistance
- Regional
coordination
- Evaluation
data collection, dissemination, and discussion
Once a year, this meeting should be opened up to other
outreach workers in the community that may be working on other issues with the
same population.
Rationale
·
Medical
site staff report significant variations in the approaches to “in reach and
outreach” activities used at various sites and little opportunity to share
approaches.
·
Medical
site staff have recommended that MDPH should seek ways (verbally and in
writing) to acknowledge the work of particular contracting organization staff
and to ensure that client navigators are well
integrated into their medical service sites.
·
In the
past, attendance by WHN site staff at regional meetings was not mandatory and
was therefore limited.
Enrollment
Information Collection
Recommendation
Continue to collect
client information at each individual medical site. When possible, Client Navigators or Outreach
Workers should assist in the collection of information from potential WHN
clients for submission and processing.
The person collecting information from the client should inform her that
the information will be shared with government agencies responsible for funding
the program, but that it will be kept private and will not be used against them
in any way (i.e. immigration, billing).
Rationale
·
Clients
report fear of bills, dealing with insurance, distrust of the system, lack of
system knowledge, scheduling, and transportation as barriers to services.
·
Clients
are asked for sensitive and private information, such as citizenship and
income.
·
For these
reasons, it is best to have information processed locally, and not by a
centralized authority that may be less trusted.
·
It is
ideal to have the enrollment process facilitated through a personal
interaction, where trust can be established, as opposed to the more impersonal
method of enrollment by phone or computer.
·
Client
Navigators/Outreach Workers are likely to come from a similar background and
speak the language of the client, thus engendering the trust of the client and
putting her more at ease than someone of a different background/role.
·
Non-English
speaking clients with less education are more likely to report feeling that
their privacy rights were not adequately explained to them.
Enrollment Processing
Recommendation
While eligibility should continue
to be determined by the site at which the woman presents, the client enrollment
information that is collected should be submitted and processed centrally,
through electronic means whenever possible.
In order to avoid delays in scheduling and the provision of care to
clients that may result from centralized approval, “presumptive eligibility”
should be determined immediately at the medical site so services can proceed
without disruption.
Rationale
·
Currently,
verification and enrollment take place at each individual site, which restricts
the client from receiving care at any other sites. Central processing will allow women to
receive care at any participating WHN site, providing increased flexibility and
thus patient satisfaction.
·
Centralized
enrollment processing will allow for centralized data collection, tracking and
evaluation.
·
The current
practice of site-specific enrollment processing has resulted in a lack of
standardized verification procedures across institutions. Centralized enrollment can help to
standardize operations and streamline procedures, which can result in improved
efficiency, reduced duplication and paperwork, and ultimately cost-savings.
Virtual Gateway Recommendations
The Virtual Gateway should be used
to outreach to and enroll eligible women who are receiving care at a WHN
medical site but have not yet been introduced to the program. Ideally, when a person is asked to provide
enrollment information for MassHealth/Free Care via the Virtual Gateway, the
computer will prompt the person entering the information to screen for eligibility
in all state assistance programs listed, including WHN. At a minimum, registration and financial
staff at WHN sites should be trained about WHN and prompted to ask women who
are completing the MassHealth/Free Care application if they are willing to also
check for WHN eligibility.
Rationale
- All uninsured
women will be required to complete an application for MassHealth/Free
Care, creating a new opportunity to introduce WHN to potential new
clients.
- WHN eligibility questions can be added
to the MassHealth/Free Care questions with little extra effort.
- Virtual gateway can outreach to women
who otherwise might not be reached.
Separate
task forces considered the operation of the WHN within the context of the
larger health care delivery system and the specific procedures and regulations
concerning fiscal management and business operations.
Chair: John
Lowe, III, PhD, Simmons
College
Consultants:
Howard
Koh, MD, MPH, Harvard
School of Public Health
Christine Judge,
MS, Harvard School
of Public Health
RA: Maria Tracy, MA, University of Massachusetts
Boston
DPH: Hillary Sugrue, Department of Public
Health
Liz
Welch, Department of Public Health
Members:
Karen
Edlund, Department of Public Health
James
Fitchett, MA, ProVentive, Inc.
Oscar
Gutierrez, PhD, University
of Massachusetts Boston
Craig Johnson, MS, Executive
Office of Health & Human Services
Deborah
Klein-Walker, PhD, MEd, Abt Associates, Inc.
Phyllis
Kornguth, MD, PhD, Harvard
Medical School
Anne
Levine, Dana Farber Cancer Institute
Tracy
Miller, JD, Department of Public Health
Laurie
Robinson, MTS, U.S. Department of Health &
Human Services
The Health Care Delivery Systems Task
Force developed a framework that is designed to realign provider and WHN
policy, process, plan and information technology initiatives to better serve
women participating in the WHN. The
framework organizes the recommendations by goals, objectives and strategies, in
response to the problems identified by participants, and services to introduce
the specific Task Force recommendations.
The Health Systems Workgroup
identified four primary goals for the Women’s Health Network. These goals state in general terms the direction
that the WHN should follow to improve the service experience for women and make
it easier for providers (physicians, hospitals, health centers, VNAs, etc) to
deliver services.
- Improve
Access/Choice – Women in WHN should have access to a broad array of WHN
providers. Improved access would be
characterized by improved administrative convenience for providers as well
as an expanded choice of providers for women participating in the program.
- Improve
Continuity – Women should be able to obtain services from alternative WHN
provider sites without a loss of continuity of services under the WHN
program. Women also should be able
to obtain all needed primary care services at the point of service; and
providers should be paid for all services rendered.
- Enhance
Quality – Women should receive high-quality, evidence-based services from
appropriately credentialed health service providers.
- Enhance
Cost Effectiveness – WHN providers should receive timely payments for the
full cost of participating in the program.
WHN should ensure that the greatest possible number of eligible
women receive WHN services based on available resources.
In order to achieve the goals
identified above, the WHN must successfully implement the following critical
success factors.
- Decouple
administrative and programmatic processes and data - Administrative
overhead is often cited as a barrier to provider participation. WHN must establish a model that
encourages more providers to participate.
- Timely
Payment for Service (De-link Data and Payment) - The current process
requires the completion of all diagnostic services in a case prior to
paying a claim for any component piece.
Many providers cannot absorb delayed payment. WHN needs to develop capability to
reimburse for services rendered closer to date of service for component
pieces, implying a change in protocol, guideline etc.
- Flexibility
to Absorb new programs – The WHN system must be designed in a way to integrate
and support new CDC categorical programs, such as colorectal cancer screening.
The addition of such programs will further the goal of continuity of
services.
Objectives[T1]
The Task Force specified objectives -- specific targets -- that
the WHN should achieve by 2008. Upon adoption, these objectives can be
elaborated on to identify WHN requirements including the need for collection of
additional data as well as the need for integration of information with WHN and
non-WHN programs and other agencies.
- Increase
the % eligible women served by 15%
- Increase
the # visits/screenings by 15%
- Increase
access to primary care (# WHN women with a PCP)
- Decrease
the % provider administrative cost
- Decrease
the time between bill and payment by 50%
- Decrease
the time from diagnosis to treatment by 25%
- Decrease
the time for State-program eligibility determination by 50%
- Cover
the provider cost of doing business with the WHN
The following matrix can be used to demonstrate the
relationship of strategies and objectives, including key strategies in support
of multiple objectives. This along with other
factors was used to assess the “criticality” of individual strategies. [T2]
|
Goals
Access/Choice
Capacity
Cost Effectiveness
Quality
|
Objectives
|
|
% Eligible
Women Served
|
#
Visits/Screenings
|
#
Providers in System
|
Access to
Primary Care
|
% Admin
Cost to Provider
|
Time to
Pay
|
Time from
Diagnosis to Treatment
|
Time to
MassHealth Determination
|
Cover the
Cost of Doing Business
|
|
Strategies
|
Administrative Simplification
|
↑
|
↑
|
↑
|
↑
|
|
|
|
|
|
|
Streamline/Integrate Business Processes
|
↑
|
↑
|
↑
|
|
↓
|
↓
|
↓
|
↓
|
|
|
Broaden Access to
Virtual Gateway
|
↑
|
↑
|
↑
|
|
↓
|
↓
|
↓
|
↓
|
|
|
Staffing Alternatives
|
↑
|
↑
|
↑
|
|
↓
|
|
|
|
↑
|
|
Prime Contractor Model
|
↑
|
|
|
↑
|
↓
|
↓
|
↓
|
|
|
|
Link to Primary Care Provider
|
↑
|
↑
|
↑
|
|
|
|
↓
|
|
|
The strategies developed by the
Task Force are the pattern of objectives, policies, functions, processes and
plans that indicate how the WHN should function over time. Upon adoption, the strategies the Task Force identified
can be further developed into specific actions to realize the strategy and
achieve WHN objectives.
|
Strategy
|
Criticality
|
Planning Horizon
|
|
Evaluate and Implement Administrative Simplification
|
High
|
Tactical
|
|
Evaluate the impact of administrative simplification on
the overall financial impact on providers participating in the WHN
program. Develop and implement
strategies to simplify and integrate transaction processing, to make doing
business with WHN seamless/transparent to participants and providers.
Realign existing state business processes, including
eligibility determinations and evaluation of alternative claims processing…
Leverage the Virtual Gateway for Provider Access to
Information
|
|
Evaluate and Implement Staffing Alternatives
|
High
|
Tactical
|
|
Evaluate the opportunity to redefine staffing requirements
including the requirement for Case Management staff (e.g. staffing patterns
related to outcomes). Identify
alternative staffing models for Case Management… Assess the potential positive impact of
administrative simplification initiatives … -- funds/reimburses full cost of
participation in program.
|
|
Replicate the Prime Contractor Model
|
Low
|
Strategic
|
|
Investigate whether a prime contractor model can be used
for transactional services, including data collection, case management and
outreach.[T3]
|
|
Link Participants to Primary Care Providers
|
Medium
|
Strategic
|
|
Need to go beyond breast and cervical cancer screening and
WISEWOMAN…. Including one annual
physical and/or other categorical programs.
|
Government Financing
1) The Commonwealth of Massachusetts should continue to
supplement its match of the CDC contribution to WHN.
Rationale: Massachusetts’s performance on percentage of
eligible women screened by the WHN is greatly enhanced by this supplement (in
2001 for women aged 40-64 67% in MA compared to 12% in US), compared to the
national average. The state should
increase this supplement if outreach successfully increases the number of
eligible women enrolled in the program.
Government Administrative
2) The Commonwealth
of Massachusetts should continue to streamline its administrative processes via
the Virtual Gateway.
Rationale: Rapid
determination of eligibility for and enrollment in state programs, particularly
MassHealth and WHN, improves women’s access to primary care, screening, and
continuity to care. This rapid
determination of eligibility for and enrollment in state programs also enhances
provider payments for services rendered and may increase the number of state
participating providers.
3) The Commonwealth
should require women applying for enrollment in state programs to apply for all
programs (i.e. MassHealth, WHN, Uncompensated Care Pool).
Rationale: This policy
would enable the system to assign women to the appropriate program based on
percentage of poverty guidelines, which may free up additional resources to
target uninsured and underinsured women.
WHN System Tactical (shorter term)
4) Decouple
administrative and programmatic processes and data.
Rationale:
Administrative overhead is often cited as a barrier to provider participation and
a cause of providers leaving the program.
Simplified and integrated transaction processing (billing and claims)
should expedite provider payments for services rendered and may increase the
number of providers participating in state programs. Also, DPH and WHN need a flexible system to
be prepared to support potential new CDC categorical programs such as
colorectal cancer screening.
5) Evaluate
alternative claims processing vendors, e.g. MassHealth and/ or Blue Cross.
Rationale: Several states successfully employ an
“insurance” model for NBCCEDP and WISEWOMAN billing and payment (e.g. ME,
MI). This would also expedite provider
payment for services rendered and may increase the number of providers
participating in state programs. DPH
would be able to maintain control over programmatic aspects f the program (case
management, data collection, and outreach).
6) De-link data
collection and payment.
Rationale: Many
providers cannot absorb delayed payment due to WHN data reporting
requirements. Other states have done
this and maintained CDC performance requirements for data reporting. Additionally, de-linking is consistent with
the separation of claims and program elements, discussed above.
7) Evaluate impact of
proposed “Reform” legislation on MassHealth eligibility and Uncompensated Care
Pool payment policy.
Rationale: A dramatic
increase in MassHealth eligibility may decrease the number of women eligible
for WHN. If this decrease is realized,
it may require a shifting in strategy to underinsured or to uninsured
populations that are more reluctant to medical consumers, including the
undocumented population. Fewer eligible
women and more interest in provider participation may enable WHN to target
services to areas or populations of service disparities. Also capping Uncompensated Care Pool payments
may dissuade providers from billing that and push them to look to alternative
payment sources for WHN covered services.
8) Evaluate and
implement staffing alternatives for case management related to outcomes.
Rationale: Varied staff (licensed and non-licensed)
carriers out case management functions.
Providers should have flexibility based on performance rather than
degree. The cost of licensed staff
unnecessarily increases administrative costs.
WHN Systems Strategic (longer term)
9) Leverage Virtual
Gateway beyond determination of program eligibility to allow for provider
access to information for facilitating the ability of women to move among
providers and to simplifying and integrating the collection of data.
Rationale: This would improve continuity of care, patient choice, integration with MassHealth,
particularly when a woman becomes eligible for MassHealth Treatment Act. In general, the state law is not going to
limit the use of these data among EHHS agencies or within WHN provider
agencies, provided it is shared for eligibility, provision of services, and
care coordination. Also, in general,
HIPAA is not going to limit the use of these data among providers, for
treatment, payment, health care options, and health oversight. In circumstances
where data sharing is not permitted under state law or by HIPAA, sharing can be
effectuated with the consent of the women involved.
10) Replicate the
Prime Contractor Model.
Rationale: The model
may increase the number of providers able to participate in the program, if
regional or prime contractors are available to complete some of the
administrative components. Also contract
alternatives for case management, data collection, and outreach may enhance WHN
performance vis a vis CDC requirements.
11) Increase access of WHN participants to primary care.
Rationale: WHN is an
effective mechanism to get women into the health care system. The public health philosophy to provide
complete health coverage is imbedded within its model. By creating a flexible model that will absorb
additional categorical programs, the WHN will move in the direction of more
complete coverage.
Co-Chairs:
Brooke
Harrow, PhD, University
of Massachusetts Boston
Mary
Neagle, MSW, Dana Farber/ Partners Community Care Breast &
Cervical
Screening Collaborative
RA: Robin Estabrook, University of Massachusetts
Boston
DPH: Maria
Arguedas, Department of Public Health
Liz
Welch, Department of Public Health
Members:
Christine Ballas, Executive Office of
Health & Human Services
Josie
Bouvier, Visiting Nurse Association of Cape Cod
Barbara
Farrell, MS, RN, Baystate
Medical Center
Atilla
Habip, MBA, ProVentive, Inc.
Sandra
Johnson, Boston Medical Center
Susan
Madden, Division of Health Care Finance & Policy
Caroline
Washburn, Division of Health Care Finance & Policy
- Each contracting agency must bill on a monthly basis,
submitting bills on the 15th of every month, for the previous
month’s expenses.
- Each contract agency must submit the following forms:
Monthly Expenditure Report (MER); Personal Summary Report (PSR); Service
Delivery Report (SDR); Payment Voucher (PV).
- Cost reimbursement is a set amount of funding that is
awarded to a contract agency for the fiscal year. Each contractor has a distinct cost
reimbursement award based on the services and/ or capacity they agreed to
provide in their RFR application and in their contract. Cost reimbursement funds should be used
to cover the following expenses: Staff including the program coordinator,
client navigator, case manager(s), risk reduction educator(s) and
lifestyle counselors; Travel; Supplies; Direct care consultants; and other
program expenses.
- There are 26 WHN Contracted Medical Sites throughout
the Commonwealth.
- WHN medical services contractors have open order
contracts, and WHN reimburses for specific clinical services using a list
of covered services that are reimbursed based on Medicare urban unit
rates. Agencies receive
reimbursement as services are provided and billed to WHN.
o They
cannot bill for medical services provided to more than the assigned annual
capacity (programs that wish to exceed their annual capacity must receive prior
written approval from WHN).
o They
cannot bill for a procedure until they receive a final result and bill from the
clinician/agency rendering the services.
o Programs
must bill in accordance with the WHN Business Rules.
o Programs
must accept WHN unit rate reimbursement payment in full.
o WHN
funds cannot be used to balance the bill.
WHN Mission
1) WHN should focus
its own resources on truly “value adding” public health activities: outreach,
education, case management, and quality of care.
Rationale: the
administrative burden for WHN is overwhelming and is so burdensome that some
medical sites are unable to participate.
This leaves gaps in geographic, cultural and linguistic capacity. Focusing on public health activities instead
of administrative tasks would allow for better care and more access for
clients, ability to focus on care for providers, and more resources to focus on
servicing clients for WHN/ DPH.
Intake, Enrollment, and Eligibility
2) WHN should outsource intake, enrollment, and eligibility
to EOHHS via the Virtually Gateway system.
Rationale: This would
enable clients to receive the program with the highest benefits for which they
are eligible. This would enable
providers to have a known, routine process and a common eligibility
database. This would enable WHN/DPH to
standardize processes for state funded programs, lower administrative costs,
track women as they enter and leave programs, and receive maximum federal
financing.
Billing
3) WHN should
outsource claims processing. Process
claims through MassHealth for appropriate payers.
Rationale: The current
WHN fiscal and business operations are duplicative and have little capability
to work with other state and federally funded programs that many WHN
participants use. Processing claims
through MassHealth would make for fewer bills to patients, standardized billing
and faster payments to providers, and more accuracy and efficiency and maximum
federal funding for WHN/DPH.
Contracting
4) WHN should expand
its provider base to all MassHealth providers.
In the short term this could be handled by adding an attachment to
MassHealth provider contracts that potential WHN providers would fill out.
Rationale: This would
result in more access and choice for clients.
Additionally there decentralized medical sites could be associated with
less time to diagnosis. Providers would
have simpler and centralized contracting.
And there would be an elimination of redundant activities for WHN/ DPH.
Further Study
5) Test and evaluate
the assumptions that: (a) medical data can be uncoupled from paying claims; (b)
technical capacity is sufficient to meet the requirements of outsourcing; (c)
providers will agree to these changes.
Rationale: The changes required to adopt these new
approaches may exceed the capacity of current regulations and/or technology.
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2003 . “A Framework for Improving
the Quality of Cancer Care: The Case of Breast and Cervical Cancer Screening.”
Cancer Epidemiology Biomarkers & Prevention 12:4-13.
Project Timeline
Detailed Literature Reviews
Literature Summaries
Background on Other Programs
Detailed Recommendations with Priority Rankings
Background Presentations (March 9)
Research Presentations (April 7)
Virtual Gateway Presentation (April 7)
Task Force Presentations (June 1)
Task Force Meeting Minutes
Project Timeline
- Executive
Steering Convened ~ January
26, 2005
- Expert
Panel kick off meeting ~ March 9, 2005
- Expert
Panel Data Presentation - April 7, 2005
- Task Force Meetings (March to May)
- Expert Panel Recommendations - June 1, 2005
- WHN Strategic Planning Committee Convenes
- June 17, 2005
- Review
of Recommendations ~ Summer 2005
- Public Report of WHN changes _ (WHN Model
design)
- Writing of RFR Fall 2005
- Release and Review of RFR ~ January to
March, 2006
- Implementation of new contracts ~ July 2006
