Using Public Health & Afrocentric Approaches for Increasing Cancer Screening in Primary Care O. Nnorom, MD L. Gebremikael, E.D. TAIBU N. Shi, PA
CFPC Conflict of Interest
Disclosure of Commercial Support Presenter Disclosure Presenters:
Onye Nnorom, Liben Gebremikael, Nan Shi
Relationships with commercial interests: • • • •
Grants/Research Support: None Speakers Bureau/Honoraria: None Consulting Fees: None Other: None
Context: Health disparities & Vulnerable communities
Interventions based on broad population-based (i.e. Geoffrey Rose) approaches … “may have led to unintended exacerbations of health disparities.” TAIBU CHC is an example of an organization that uses a vulnerable communities approach to address health disparities. “A focus on vulnerable populations is complementary to a population approach and necessary for addressing social inequalities in health”
Frohlich KL1, Potvin L. Transcending the known in public health practice: the inequality paradox: the population approach and vulnerable populations. Am J Public Health. 2008 Feb;98(2):216-21.2007.
Overview Background
– TAIBU Cancer screening Taskforce
phase 1 (2013) – internally-focused Methods
(PDSA, Afrocentric values) Results (MSAA Indicators)
Phase 2 (2014+) – community-focused
Think
Tank – promising practices
TAIBU VALUES
WE BELIEVE: Equity is essential to the achievement of a healthy community Quality service is integral to our community Cultural competence is a key component in how the organization functions The community’s success lies in within its inherent strengths and assets
WE RECOGNIZE: The prevalence of Anti-black Racism and its impact on the way the community accesses and receives services
WE ARE COMMITTED TO: Cultivating an environment free of discrimination of any type
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Clinical Programs 
PRIMARY HEALTHCARE: o Hypertension Management Program in partnership with the Heart & Stroke Foundation o Sexual Health Clinic in partnership with Toronto Public Health o Diabetes Education Program o
Specialized Primary Care services for Adults with Sickle Cell Disease
o o o
Chiropody Social Work Nutrition Support
Health Promotion Stand up for Health – innovative program targeted at youth to learn about the social determinants of health in a fun and experiential environment.
• Elders Program – UBUNTU • L.E.A.R.N. afterschool program • Physical activity programs
TAIBU - Cancer Screening
Cancer Screening rates (Dec 31, 2012): • • •
PAP offered: 53% FOBT offered: 22% Mammography offered: 21%
Cancer Prevention Taskforce • • • • •
Deva Nicholas, MD Nan Shi, PA Nancy Akor, RN Patricia Wright, NP Onye Nnorom, MD (Lead)
Engage staff using PDSA & Afrocentric model of care
Plan, Do, Study, Act
Iterative process Continuous Quality Improvement Learn as we go!
Afrocentric values approach:
Focus on the collective/community Need to identify those who got screened so we can find those who didn’t, and save lives! Not about indicators, LHIN/MOHLTC, or bonuses (FHTs, not CHCs!)
Assessment – data & literature Review
Ask staff if TAIBU indicators valid Assess vulnerability (Black pop-cancer risk)
Quick
data
Literature Review
Identify barriers, solutions
Cancer
Age-Adjusted Death Rates per 100,000 Persons by Race & Hispanic Origin: U.S.,
2005
From: CDC, OHMD. Black or African American Populations. Slides. http://www.cdc.gov/omhd/Populations/BAA/BAA.htm#Disparities Original Source: CDC, OMHD, 2007 report. http://www.cdc.gov/omhd/Populations/BAA/BAA.htm
Colon, Rectum & Anus Cancer
Age-Adjusted Death Rates per 100,000 Persons by Race & Hispanic Origin: U.S.,
2005
From: CDC, OHMD. Black or African American Populations. Slides. http://www.cdc.gov/omhd/Populations/BAA/BAA.htm#Disparities Original Source: CDC, OMHD, 2007 report. http://www.cdc.gov/omhd/Populations/BAA/BAA.htm
Breast Cancer
Age-Adjusted Death Rates per 100,000 Persons by Race & Hispanic Origin: U.S.,
2005
From: CDC, OHMD. Black or African American Populations. Slides. http://www.cdc.gov/omhd/Populations/BAA/BAA.htm#Disparities Original Source: CDC, OMHD, 2007 report. http://www.cdc.gov/omhd/Populations/BAA/BAA.htm
Prostate Cancer
Age-Adjusted Death Rates per 100,000 Persons by Race & Hispanic Origin: U.S.,
2005
From: CDC, OHMD. Black or African American Populations. Slides. http://www.cdc.gov/omhd/Populations/BAA/BAA.htm#Disparities Original Source: CDC, OMHD, 2007 report. http://www.cdc.gov/omhd/Populations/BAA/BAA.htm
Situation: Health disparities & vulnerable communities ď‚› Under-screened
population/communities (SES, education, culture, marginalization)
ď‚› Potentially
at increased risk (race/genetics)
Planning • •
Goal/Objectives:
Increase the Cancer Screening rates at TAIBU, and beyond • Obtain accurate data, target under-screened clients • Reduce barriers to screening • Educate and empower the community
Evidence-Informed Activities (lit review & exp)
Barriers: health education, beliefs, other health conditions, gender of provider/tech, provider time constraints
Promising practices: culturally-relevant educational sessions, videos, facilitating transportation, provider reminders, audits
Doing – Provider Education
Provider Guideline Review package Instructions on how to enter cancer screening data into EMR (Purkinje/NOD)
TAIBU staff education session • Dr. Onye Nnorom: Overview • Dr. Sheila Mae Young, CCO Primary Care Lead for CE-LHIN: Guidelines Review • Ms. Aggie Mazzucco: Barriers & Promising practices to screening in immigrant populations
Doing – Audits Cancer •
•
Screening Audit
Review of clients overdue for screening in EMR Corrected if tests in chart indicated they had colon, breast, cervical CA screening recently or did not qualify
TAIBU Cancer Screening Audit (2013)
Total charts reviewed: 603
Patient need FOBT test: 244 Patient need Mammography: 135 Patient need Pap smear test: 224
Purkinje
Where to find the information: Reports Previous record CPX
TAIBU Cancer Screening Audit (2013) Data
correction (tests that were done but were not entered into EMR):
Pap Smear done within 3 years: 24 FOBT done within 2 years: 64 Mammography done within 2 years: 48
Doing – Addressing client barriers Identification
of nearest OBSP site (female technicians) – 1333 Neilson= less travel
Call-back
program (pilot)
Provider audit of patients overdue for screening Front-desk: calls - Nancy (RN) & Nan (PA) performed pap, ordered FOBT, mammogram Medical directives, training, checklists
Study – the Results – MSAA Indicators Test Offered
Ending Dec 2012
Ending July 2013
Ending Dec 2013
FOBT (colon)
22%
39.9%
43%
Pap (cervical)
53%
53.1%
48%
46.8%
46%
Mammogram 21% (breast)
We also obtained informal feedback about the callback program
Act - Phase 2 – Optimization & Community engagement
Improved Call-back program (longer duration, NOT during Ramadan) Basic info for clients - Pamphlets, signs KTE (town halls, community education) Repeat data correction (2013-2014) due to EMR change Start tracking actual outcomes (% test completed, diagnosed, treated, connected with culturallyappropriate support groups) Considering: letters, staff reminders
[Future PH-relevant research] Population
health assessment (TAIBU clients at time of intake, DoH) for program planning Flu vaccine – exploring reasons for declining vaccination KTE – topic area: Black women - breast and cervical cancer risk & screening awareness
THANK YOU!!! TAIBU
Community Health Centre Cancer Screening Taskforce CCO AOHC & ALPHA
Group Discussion: Promising Practices Examples/ways
that PHUs/PH practitioners can work with CHC’s to:
Increase cancer screening in underscreened/vulnerable communities Improve chronic disease prevention in vulnerable communities (diabetes, CVD, etc.) Positively impact social determinants of health in vulnerable communities