CMs ensure low-income women get follow-up
Study shows 35% reduction in diagnostic delays
Low-income women with abnormal mammogram results are more likely to receive appropriate diagnostic procedures in a shorter time frame when a case manager guides them through follow-up care, a study has shown.
The proportion of women experiencing a diagnostic delay greater than 60 days decreased from 33% to 23%, a 35% reduction, after the case management interventions were introduced.
"Case management to assist women in overcoming logistic and psychosocial barriers to care may improve time to diagnosis among low-income women who receive free breast cancer screening and diagnostic services," says Rebecca Lobb, ScD, MPH, of the Centre for Research on Inner City Health at St. Michael's Hospital, Toronto, and co-author of the report published in the March 22 issue of Archives of Internal Medicine.1
The median time from an abnormal mammogram to diagnostic reduction decreased by eight days after the case management program was implemented.
"Our study demonstrated that most of the women who participated in the program received follow up after an abnormal mammogram within the time recommended by Centers for Disease Control and Prevention [CDC] clinical guidelines," Lobb says.
The researchers studied 2,252 Massachusetts participants in the National Breast and Cervical Cancer Early Detection Program, which funds breast cancer screening and diagnostic services for low-income, under-insured women.
The women in the study were in a program administered by the Massachusetts Department of Public Health with funding from the CDC.
"The low-income population tends to experience multiple barriers to the early detection of cancer and timely follow-up. They have lower educational levels and don't usually have a regular health care provider. This population is culturally diverse, and often cultural beliefs factor into their failure to seek health care. The case management process provides women with support to reduce anxiety, coordinates patient-doctor communications, and reduces barriers to care," Lobb says.
The Breast and Cervical Cancer Early Detection Program is a screening program to make sure that eligible low-income, under-served, and under-insured women get breast examinations and mammograms. A case manager intervenes when a woman has an abnormal mammogram and ensures that she gets the appropriate follow-up, such as an ultrasound and/or breast biopsy, as recommended by her physician.
Beginning in July 2001, all Massachusetts participants with an abnormal mammogram finding were offered case management. In 2004, free breast cancer treatment was offered to eligible participants in Massachusetts through a Medicaid expansion program called the MassHealth Breast and Cervical Cancer Treatment Program. The case managers funded by the Department of Public Health Women's Health Network program helped the women apply for the free treatment, but often were not able to follow them through treatment, due to mandate restrictions, says Mary Lou Woodford, RN, BSN, MBA, CCM, care coordination program director for the Women's Health Network at the Department of Public Health.
In Massachusetts, the Department of Public Health does not provide direct services but contracts with local organizations that provide the services, Woodford says.
To identify participants in the program, outreach staff throughout the state visited community-based organizations to inform them about the program and how they could participate.
"Their primary job was to educate community-based organizations about the program so that they could educate women in their respective communities. The regional outreach staff also provided education to providers in their regions so they could refer women who presented at the doctor's office without health insurance," Woodford says.
Organizations participating in the Women's Health Network program were primarily hospitals and community health centers. In rural areas, home health agencies acted as intermediaries and coordinators of the program by subcontracting with rural providers.
The case managers who worked with the women typically were employed by the hospital or the health center and took on the coordination of follow-up care as part of their regular duties.
"For most organizations, there wasn't enough volume for the organizations to hire a case manager on a full-time basis. In some cases a nurse case manager enrolled participants, determined their eligibility, and educated them in addition to coordinating care for the women with an abnormal finding," Lobb adds.
The program originally started as an early detection program, Woodford says.
"We funded 42 organizations around the state to do outreach and recruit women to enroll in the program. The case managers ensured that women who had an abnormal finding got follow-up exams, but that was where the program ended. It created a lot of angst for everyone because the case managers often couldn't follow the women through treatment," she adds.
After health care reform was passed in Massachusetts in 2008, the majority of women in the program had access to health insurance and no longer needed free care, prompting the department to look at a different way of providing services, Woodford says.
"Health care reform in Massachusetts ensured that a great number of people had access to health insurance for the first time, but just because they had insurance, they didn't necessarily get the examinations," she adds.
In spring 2008, the Department of Public Health launched a care coordination model, which gives funding to organizations to hire a multidisciplinary team to ensure that eligible women receive screening and follow-up care.
The new program includes two other CDC-funded programs Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN), which screens women for cardiovascular risk and provides lifestyle behavior interventions to reduce their risk, as well as the Colorectal Cancer Control Program, which provides education and screening for colorectal cancer.
"Most of the funding that comes to the health department comes in silos. The Massachusetts Department of Health has worked really hard to develop and implement a program for women that eliminates the silos and focuses on the whole person," Woodford says.
For the new care coordination model, the health department contracted with primary care providers and gave them funding to hire community health workers to serve as patient navigators and clinical staff to serve as case managers to coordinate care.
"We knew that in order to meet the needs of a racial and ethnic diverse population, we needed people on the team who understood the culture and language of the population we served. We moved to a model that supported the community health workers as an integral part of the team," Woodford says.
Most of the RN case managers in the program are Caucasian and speak only English, while the community health workers have the same ethnic and cultural backgrounds as the community they serve.
"In the new model, we began to incorporate the community health workers as patient navigators, but when we surveyed the case managers, they reported that they were not utilizing the navigators, partly because they didn't understand their role and partly because they were uncomfortable about what the patient navigators were telling the patients," she says.
The initial role for the community health workers was to schedule appointments and assist the patients through the screening and follow-up process, but many times, they spent a lot of time translating for patients who didn't speak English.
"They weren't trained as medical translators, and they started to interpret things and advocate for the patient," Woodford says.
The department developed a 45-hour training course for the community health workers. The training includes how to communicate with patients, how to communicate with clinicians, confidentiality issues, education on health topics, and medical translation challenges.
The case managers attended a 12-hour training course to educate them about what the community health workers were learning, cultural competency, health literacy, and team-building.
The training included education on the Case Management Society of America's practice guidelines that require them to complete an assessment and plan of care and monitor what happens, as well as education on appropriate breast cancer and cervical cancer follow-up guidelines.
Almost 20,000 women are enrolled in the program today, Woodford says.
"In the new model, the case managers' involvement doesn't stop once the person is directed to treatment. They stay with the people throughout the treatment regimen and work as a team with the community health workers, the providers, and the patients to ensure that the continuum of care is completed," she says.
Reference
- Rebecca Lobb, ScD, MPH; Jennifer D. Allen, ScD, MPH, RN; Karen M. Emmons, PhD; John Z. Ayanian, MD, MPP. "Case Managers Help Low-Income Women Receive More Timely Breast Cancer Diagnosis" Arch Intern Med 2010;170(6):521-528. Published online March 16, 2010 (doi:10.1001/archinternmed.2010.22).
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