Clinics Corner

NH Breast & Cervical Cancer Program (BCCP) Overview

Transcript of video:

Welcome to the New Hampshire Breast and Cervical Cancer program (BCCP) overview. This training is intended for clinic staff as well as our community partners. My name is Stacy Smith and I'm the public health program nurse and I am joined by my co-worker Chandra Zambruno. Hello my name is Chandra Zambruno I am the cancer program coordinator for the Breast Cervical Cancer Program. And I will leave it to Stacy to kick us off. So let's get started. The objectives for the training include learning about the BCCP history and providing a high level overview of the program, understanding eligibility and requirements for enrollment, understanding coverage services and how to find CPT codes, learning about BCCP partners including vendors and screening sites, and knowing what forms and resources are available and how to access them.

So what is the NBCCEDP? The NBCCEDP stands for the National Breast and Cervical Cancer Program. It is funded by the Centers for Disease Control and prevention (CDC) and it is referred to as the BCCP in New Hampshire. The program assists low to moderate income, uninsured, and underinsured individuals gain access to free breast and cervical cancer screenings, diagnostic services, as well as treatment services. When needed the program also provides patient navigation services to help individuals overcome barriers and get timely access to quality care. The program is located in all 50 states as well as the District of Columbia and many U.S territories as well as American Indian and Alaska native tribal organizations.

A little bit about the history of the NBCCEDP. In 1990 Congress enacted the Breast and Cervical Cancer Mortality and Prevention Act. This directed the CDC to create the National Breast and Cervical Early Detection Program. In 1996 New Hampshire received CDC funding to begin implementing the National Breast and Cervical Cancer Program. In the year 2000 Congress enacted the Breast and Cervical Cancer Treatment Act this allowed states to offer women diagnosed through the free screening program access to treatment through Medicaid. In 2010 the Affordable Care Act was passed. This expanded insurance access and coverage in the marketplace and reduced uninsured and underinsured individuals. BCCP was still available for those unable to obtain coverage. In 2014 New Hampshire expanded medicaid. This expanded insurance access for low-income individuals in New Hampshire further reducing uninsured rates. However BCCP still was available for those not eligible for Medicaid expansion. In 2022 New Hampshire began its newest five-year Cooperative agreement cycle with CDC to continue to provide breast and cervical cancer screenings and diagnostic services.

As far as eligibility for BCCP in New Hampshire individuals must be at or below 250 percent of the federal poverty level, they must also be a resident of New Hampshire or certain border counties in Maine, they must also be uninsured or underinsured meaning they have co-pays or deductibles that are a financial barrier. U.S citizenship is not a requirement for BCCP in New Hampshire it is not any data that is collected or asked however if an individual is diagnosed they would not be eligible for Medicaid if they were not a U.S citizen or a permanent U.S resident with green card status.

This is an example of our latest 250 federally poverty level (FPL) guidelines. As you can see they are quite moderate so for example a family of four can gross up to $69,375 dollars a year and still qualify for the program. At the top of the slide you will see there is a link to the most up-to-date and current FPL guideline charts these are updated on a yearly basis and posted to our website and distributed to our partners. Eligibility continued so for BCCP enrollment individuals should re-enroll every 12 months as long as they continue to meet eligibility criteria. Regarding breast cancer screenings mammography screenings generally begins starting at age 40 for average risk individuals through around age 74. And this is all based on a case-by-case basis depending on an individual's risk or high risk criteria. Individuals are also eligible for a yearly clinical breast exam beginning at age 21. For cervical cancer screenings, screenings generally begin at age 21 through approximately age 64. Again this is always based on an individual's health history and high-risk criteria. Regarding clients who reach the age of 65 if they are not eligible for Medicare Part B which covers preventive health services they are eligible to continue to enroll in BCCP to have their recommended screenings covered based on their own health history and risk factors.

Regarding transgender individuals - Female to male clients who were born female but are in the process of transitioning as long as they still have breasts and or a cervix should continue to have regular screenings. Male to female individuals who are taking hormones are eligible for regular breast screenings. This is because long-term use of hormones does show to increase the risk of breast cancer among these individuals.

An overview of some of the services provided through BCCP. Screenings include office visits, clinical breast exams, mammograms, screening breast MRIs for high-risk individuals, pelvic exams, Pap tests, and HPV tests. Some of the diagnostic services that are covered through BCCP include diagnostic mammograms, breast ultrasounds, surgical consultations, gynecological consultations, a variety of breast biopsies, colposcopies and cervical biopsies.

Enrollment into Medicaid is an option for those diagnosed through the program as long as they are eligible for Medicaid. And treatment for those individuals would include anything from chemotherapy to radiation surgery, reconstruction, hysterectomy, LEEPS, cones, in hospital facility fees, meds, and supplies. Additional services for clients enrolled in BCCP include patient navigation and community health worker staff. These staff help address issues such as cost, transportation, and language barriers for clients. They also assist clients with scheduling appointments in real time. Additionally they reach out beyond the clinic to engage with eligible clients within their communities

There are over 100 codes reimbursable through the BCCP for services and those include surgical services, radiological services, pathology, and laboratory services, and evaluation and management services as well.

This is a great visual that shows all of the screening sites where an individual within New Hampshire can enroll in BCCP to receive breast and cervical cancer screenings. There are over 30 screening site locations located throughout the state all the way up from Colebrook New Hampshire distributed throughout the state of New Hampshire down to two screening sites located within Nashua.

At each of those 30 plus screening sites we have a point of contact who we refer to as the BCCP site coordinator and this individual is responsible for coordinating BCCP pre-services within their geographic area including enrollment, paperwork, and whatever data needs are required for submission to the administrative BCCP office located at the Division of Public Health in Concord New Hampshire.

In addition to the over 30 BCCP screening sites statewide. There are also over 144 active vendors and these are facilities that BCCP has agreements in place with for referrals and reimbursement of additional BCCP services. These are facilities such as mammography and imaging facilities, hospitals, surgical centers, pathology facilities, laboratories, breast cancer centers women's health centers, and gynecological and breast surgeon consultants. How do individuals hear about the breast and cervical cancer program? The number one referral source is providers. It is really important for providers across the state to be aware of the program and how to refer. We encourage sites with new providers or staffing changes to let us know if we can assist with any initial or refresher trainings on the program. The second most common referral source is family and friends, so word of mouth because of this we utilize marketing campaigns and education opportunities to share information about the program. Some of the campaigns we've done in the past include social media, radio, newspaper, and bus advertisements. We also try to leverage community partnerships and events to help spread the word about the program and we encourage and support clinic sites to share information in their local areas and reach out to us if support is needed in those efforts.

One of the key ways to increase cancer screening rates is implementation of evidence-based interventions (EBI) at Clinic sites. The Community Preventative Services Task Force provides details on EBI strategies and effectiveness of interventions on increasing breast and cervical screenings. This chart shows a snapshot of interventions and how effective each has been shown to be in studies. The top of the chart provides a key showing the most effective and recommended with the green circles to those that are not recommended or in fact are recommended against.You can see on the chart some interventions have yellow diamonds indicating they are not as effective as those with the green circles for specific screening types. Interventions with the most green circles for breast and cervical are the highest recommended and those are the ones we encourage clinics to adopt into their workflow as priority for EBI implementation. There is a more in-depth overview video on EBI and outreach so we encourage you to view that as well for some additional guidance and specific resources.

The bccp offers a variety of materials that can be used to spread word about the program within clinics and in the community as well. We encourage clinics to order materials for their locations to post inside their clinic locations, to use for outreach, and to share with community partners within their local areas. The left side shows an example of our poster which is available for ordering in a couple different sizes. In addition to posters we have rack cards heart-shaped flyers and postcards that are used generally for sending patient reminders from clinic sites. We have over 13 language translations available. The order form shown in the middle allows our partner clinics to select materials branded to their locations or you can choose materials with our general BCCP contact info. The generic material is often used in locations such as community events or places where folks reached may not necessarily be coming to one specific clinic and may be interested in other locations. Lastly the sheet on the right provides a quick glance of income guidelines as well as clinical breast and cervical screening types recommended by age group. This chart is available to clinic staff by request.

And lastly here's a list of resources to reference for more detailed information about the BCCP program.  The top has a link to our website and the BCCP policy and procedures manual. You also have links to covered codes for reimbursement through the program. And the community guide link offers more specific EVI details for those interested. You can find our contact information on the website along with lots of other program details that are updated regularly. Please feel free to reach out to us with any questions you have or training needs that we can assist with and I just wanted to say thank you for watching the overview.

BCCP Evidence-Based Interventions and Outreach

Transcript of video:

Hi! I'm Chandra Zambruno coordinator for the New Hampshire Breast and Cervical Cancer Program. The purpose of this video is to provide an overview of evidence-based interventions (EBI) and outreach strategies that are effective for increasing breast and cervical cancer screenings. This video and overview is intended for clinic staff particularly those who do work with the BCCP. Objectives for this overview include: to learn what an EBI is and why they're important, to learn which EBI strategies are most effective for increasing breast and cervical cancer screenings, and lastly to understand the importance of community partnership and outreach to increase cancer screening. One of the key ways to increase cancer screening rates is implementation of evidence-based interventions or EBIs at the clinic level. Here is the high level overview provided by the CDC of priority evidence-based strategies as they relate to breast and cervical cancer screenings. On the left you can see a list of EBI activities and an illustration at the bottom of how EBI interventions and outreach go hand in hand to reaching patients and increasing screenings. The middle portion shows short-term outcomes that result from implementing those activities. These include increasing both patient and provider knowledge and awareness of breast and cervical screening, recommendations as well as guidelines for and the importance of breast and cervical screening, and who should receive them. Overall the end goal of doing evidence-based interventions is to ultimately increase completed breast and cervical cancer screenings and overall breast and cervical cancer screening rates for your health system. The Community Preventive Services Task Force is an independent panel of public health and prevention experts who issue guidance on which evidence-based interventions and community interventions work well and which do not based on scientific evidence. Their recommendations and details can be found within the community guide which is linked here and will be provided in the resource list available to you as well. This chart taken from the community guide shows a snapshot of interventions and how effective each has been shown to be in research as they relate to breast and cervical cancer screening. The top of the chart provides a key indicating the most effective and recommended interventions with the green circle and those that are not recommended. You can see some interventions on the chart have yellow diamonds which indicate they're not as effective for increasing those specific types of screenings. Interventions with the most green circles for both breast and cervical cancer are the highest recommended and those are the ones that we encourage clinics to adopt as a priority into their workflow. EBIs are grouped in general categories of client-oriented interventions and provider oriented interventions. Here are some examples of client-oriented interventions client reminders are a focus EBI priority for BCCP they're so effective for getting patients scheduled and screened. These can include offering to schedule patients for screening during a visit, sending reminders about appointments, and providing support and education around screening. Reducing structural barriers can include reducing the amount of paperwork or steps that it takes for patients to schedule screening. Some clinic sites offer occasional extended or flexed hours to schedule screenings when able. This helps to capture patients who may not be able to get in during regular hours due to work or other obligations. Providing assistance with common barriers such as transportation and translation needs is also very important and an impactful way to get patients into screening. Other examples of client-oriented EBIs include small media usage to spread messaging about the program and the importance of screening this can include creating videos with information about screening and putting information into existing newsletters at your clinic location. Education about the importance of screening and what to expect can be done with patients either one-on-one or in group settings and we encourage you to reach out if you encounter a specific common barriers to screening at your site as BCCP funding can be used to help address these. Provider oriented EBIs are activities that help to remind providers about patients who are due for screening and also to track screening numbers. Providers have a lot to keep track of so provide a reminders about cancer screening specifically can be very helpful these can be done by adding notes into patient charts or electronic health records to flag patients due or overdue for breast or cervical screening and to remind providers of follow-up that's needed. A printed list of patients who are due for screening can also be made available to providers on a regular basis as an added reminder. Provider assessment and feedback helps to track how providers are doing with recommending cancer screening and related follow-through. It's important to regularly review clinic policies and practices around cancer screenings at your clinic location. Some clinics utilize regular provider meetings to review individual provider screening numbers. Clinics can also review their clinic-wide breast and cervical screening rates to set goals to increase those year over yea. To maximize the impact of EBIs a multi-component strategy is highly recommended. This means implementing two or more EBIs into your workflow at the clinic level ideally these will cover those that increase community demand for screening community access to screening and EBIs that increase provider delivery of services. You can see how the EBI interventions we've seen listed are grouped here under each type. Workflows should also include interventions to reduce structural barriers such as expanding access to screening through adding hours or additional locations as we we reviewed assisting with scheduling and addressing common barriers consistently. If you're having challenges related to addressing client barriers to screening again please reach out to discuss how the BCCP can help support your clinic with this. Here's a high level overview of community outreach and partnership as it relates to breast and cervical screening. As we reviewed on the EBI logic model chart in the beginning EBI implementation at the clinic level and community outreach go hand in hand in reaching priority populations and increasing screening rates. On the left hand side are activities that are recommended. This begins with identifying and connecting with partners in your local area to help reach priority populations regarding breast and cervical screening. Staff who do outreach can review and discuss the types and importance of screening and who's eligible to get those screenings. Individuals engaged during community outreach should ideally be tracked for follow-up to connect them to follow through with screening completion at a clinic site. Sometimes this can of course be challenging but whenever possible to have even a basic way to track participants initially interested or engaged in the community it's the best way to connect back with them for follow through ultimately. Community reach can also be a great opportunity to offer culturally competent education and support such as bringing translated materials about the program or engaging clinic staff who speak other languages to attend community outreach when possible. Community outreach and partnership is an important part of ensuring equitable access to cancer screening and health care overall and it's a top priority of the program. Connecting with appropriate partners training clinic staff to do outreach, linking community members to clinics for follow-up, and tracking follow-through are all really important on the way to increasing screening rates over time. Community partnership especially done consistently leads to increased knowledge of and access to screening and increased follow-through and completion of breast and cervical screening. As with EBI implementation strategies the goal is to see increased breast and cervical cancer screening rates overall. Here's a list of some activities and outreach done and proven to be successful by other programs. Some of these are repeats of what we've already reviewed but these highlight that these can have real world success in practice. Clinics who have access to mobile vans for any type of health services can utilize those to share BCCP and breast and cervical screening information, provide education about screening, schedule screening while in the field for patients to follow up at the clinic and follow through after. Existing health and community fairs are a great place to visit or table with program information and materials BCCP offers various materials which are available on request for community outreach. Partnership with community-based organizations who work regularly with priority populations is key. Some examples of partners that other clinic sites have utilized and engaged with are local food pantries, social service agencies, faith-based groups or organizations, popular local stores such as grocery stores dollar general stores, or others that are particularly popular in your local area. Some clinics attend local community meetings that gather local partners on a regular basis for discussion resource sharing which is a great way to spread information about the program and about screening. Overall community outreach and partnership doesn't have to be a significant added lift. Collaborating with partners is a really great way to establish bi-directional referrals and to reach individuals who may otherwise not be reached. This leads to increased screenings and potentially lives saved from breast and cervical cancer over time by catching cancer early through screening. Lastly here's a list of resources to reference for more detailed information. There's a link to our webpage at the top for more on the New Hampshire Breast and Cervical Cancer Program and the eligibility. You also have links to the community guide the CDC's screen out cancer campaign and a page on increasing outreach to underserved groups. All of these offer specific EBI and outreach details and guidance. You can find our New Hampshire BCCP staff contact information on the website along with other program details that are updated regularly. Please reach out to us with any questions you have or EBI and Outreach related items we can assist with such as training and thank you so much for watching this overview.