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SUHI Project: Sinai Clinical Navigation

 

Project:

 Sinai Clinical Navigation

Introduction:

Minority women are less likely to receive timely care for mammography follow-up and cancer treatment.  In fact, there are racial disparities at every step in the diagnostic and treatment process in addition to disparities in access to quality breast health care.  As a result, minority women are more likely to be diagnosed with breast cancer at later stages, or worse, die from breast cancer compared to White women.  This has been well documented in Chicago as well as in other large cities.

Navigation improves quality of care by decreasing loss to follow-up and improving timeliness of accessing diagnostic imaging and cancer treatment.  This has been shown through research in studies using lay patient navigators.  The term lay navigators refers to a person who had little experience in breast health prior to starting our program, in essence they are community health workers who happen to work in a clinical setting. 

Prior to starting this navigation program at Sinai women were lost to follow-up after they had an abnormal mammogram.  Those seeking a diagnosis or cancer treatment were expected to navigate the system during a time of extreme uncertainty without much guidance; women would get frustrated and choose not to return for care.

The goal of any navigation program is to remove the obstacles or barriers to care.  Frequently sited barriers are financial barriers, poor communication of next steps by providers, and among many others, fear of a diagnosis.  Navigators not only assist to eliminate barriers, but they also promote a stronger imaging center.

Project Plan:

Our navigation program aims to improve breast health services by utilizing lay patient navigators to coordinate follow-up imaging after an abnormal mammogram to reduce loss to follow-up and improve timeliness of diagnoses and treatment of breast cancer.  We achieve the goals by performing a set of activities each intended to remove a barrier to care.  We escort patients throughout the system to ensure that women are not lost going between appointments.    In addition we assist women with scheduling appointments, ensuring that appointments are scheduled in a timely manner, we inform patients of the appointment times and dates to ensure that there is no miscommunication about scheduled appointments.  We provide education about the need for annual mammograms and completing the recommended follow-up.  We are available to answer questions from patients or we can provide clarity to providers regarding recommendations made by a radiologist.  We assist patient with acquiring comparison films to reduce the need for additional images.  We refer patient to financial services and if needed treatment services.  Finally, we are available as a support system before, during and after procedures.

In addition, to navigation, we have an epidemiologist on staff who conducts our evaluation and ensures that the program is meeting its goals.  In addition, as part of our program we conduct the Mammography Quality Standards Act mammography medical audit, as endorsed by the American College of Radiology.  For this component we gather mammography data and pair it with pathological finding and we can generate standard measures of quality such as cancer detection rate, percent recalled, and percent minimal cancers identified through screening mammography.

We have set the following goals for our program:  reduce the loss to follow-up after the initial abnormal image, improve timeliness of breast cancer diagnosis and treatment after an abnormal image, reduce barriers to diagnostic tests and treatment of breast cancer, and measure and improve quality of the diagnostic process.

Project Updates:

We established this navigation program in 2005 after receiving a generous grant from Avon Foundation for Women.  We considered 2005 our baseline year because we began navigation patients in 2006.  Since 2006. We have monitored 91,235 mammograms, facilitated follow-up for 10,020 women with abnormal images, and assisted 319 women with breast cancer receive treatment. Since 2010, we have had 62,250 encounters with patients for services such as: providing social support, scheduling appointments, obtaining referrals, Spanish interpretation, acquiring prior films, providing breast health education, among many other activities.

We virtually eliminated our loss to follow-up after an abnormal image.  At baseline we identified that 33% of patients were lost to follow-up after an abnormal mammogram, after the navigators started working with patients, this rate quickly dropped to 16% and it has recently dropped to <5%.  This means that 95% of our patients complete needed follow-up within 12 months. 

We have met and exceed our timeliness goals for several years.  The State of Illinois has set the standard of no more than 60 days to complete recommended follow-up after an abnormal mammogram.  Our navigators have averaged completing follow-up in about 45 days, and have done so for several years.  In addition, the state also recommends that those with breast cancer begin treatment within 60 days of a diagnosis.  Our navigators again have met this goal at <45 days.

We have been able to achieve our outcomes and maintained them for several years.  As a result we have been recently recognized for this work. In 2010 we were recognized by Modern Healthcare with a Spirit of Excellence Award.  In 2011 we were the Illinois Hospital Association Better to Best Innovation in Quality award winner for introducing patient navigators as a way to improve the quality of care provided to our patients.  Finally, alongside Helping Her Live, Sinai Urban Health Institute, and Sinai Health System our breast health programs received the 2015 Champion Health Care Provider from the Metropolitan Chicago Breast Cancer Task Force.

Although awards remind us to give thanks to those who have helped us and give us a needed ‘pat of the back’ for a job well done, we do this work to help our patients get the care that they deserve.

Publications:

Hunt BR, Kanoon J, Allgood KL, Benjamins MR.  Keys to the Successful Implementation of Community-based Outreach and Navigation: Lessons from a Breast Health Navigation Program. Journal of Cancer Education 2015; September (E-pub). DOI 10.1007/s13187-015-0904-2.

Resources:

Avon Foundation for Women

Helping Her Live