Transcript Patient Navigation for Cervical Cancer in Kentucky

Patient Navigation for Cervical
Cancer in Kentucky
ACCN Research Roundtable
October 8, 2008
Carol R White, MPH
Mark Dignan, PhD, MPH
Nancy Schoenberg, PhD
This project is supported by the National Cancer Institute, CA120606
Presentation Objectives
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Provide an overview of a new patient
navigation program in Appalachia Kentucky
Provide preliminary study findings
Introduction
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The Patient Navigation Program (PNP) is a five-year,
NCI-funded study
The primary goal of the PN is to reduce the
disproportionate burden of cervical cancer
experienced by rural Appalachian women by
increasing adherence to recommended follow-up
treatment after abnormal Pap test results
A secondary goal is to explore the utility of using PNs
in public health departments to reduce the number of
women who are lost to follow-up
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The project is being implemented in two Area
Development Districts, Kentucky River and
Lake Cumberland
Specific Aims
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Improve our understanding of the barriers to follow-up
Recruit, train, and utilize lay health workers works as
patient navigators (PNs) in local health departments’
cervical cancer screening and follow-up treatment
programs, in collaboration with Nurse Case Managers
Increase the proportion of women who adhere to
recommended follow-up, by developing a PNP and using
input form women who do not follow-up after abnormal
results
Evaluate the efficacy of the PN intervention
Phases of the PNP
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Phase I
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Phase II
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Identify barriers/assets that affect women’s receipt
of diagnostic and treatment services for cervical
cancer
Develop and implement the PNP program
(intervention)
Phase III
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Conduct program evaluation
PNP Activities
Local Health Department
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Notifying
A patient with an abnormal Pap test is notified
and asked to come to the health department to
learn more about her results
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Counseling
The Nurse Case Manger counsels the patient and
then refers her directly to the PN for study
enrollment and follow-up
Patient Navigator
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Describes the research program; if a patient
is interested, the PN enrolls her using an
informed consent process
Interviews the patient, administering a
baseline interview
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Develops a specific plan to assist the women
in obtaining recommended follow-up
including:
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Scheduling appointments
Making phone calls or sending reminder letters to
the patient about her follow-up appointments
Providing other types of assistance as need to
ensure care is obtained
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Conducts follow-up interviews at 6 and 12
months, assessing the effectiveness of the
intervention
Key Accomplishments
(Jan 2008 to Present)
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IRB Approval
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UK received IRB approval from Kentucky Cabinet
for Health and Family Services and UK
Key Informant Interviews
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Completed interviews with key informants to
understand barriers/assets to recommended
follow-up
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Patient Navigators Hired
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2 in Kentucky River District Health Department
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2 in Lake Cumberland District Health Department
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PN Training
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Local Health Department Training – to learn
standard follow-up procedures for women with
abnormal Pap tests and learning patient tracking
system
Patient Navigation Training – to learn about other
patient navigation programs; training provided
Fran Feltner, Director, Kentucky Homeplace
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Human Subjects Training – to meet UK and state
requirements
Resource
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UK Training Manual – documents all aspects of the
project and includes all study materials
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Project Implementation
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PNs are assigned to one county to recruit/enroll
50 patients; once 50 are enrolled, the PN will
move to another county
PNs and UK staff meet weekly to review project
activities
Preliminary Study Findings
Key Informant Interviews
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Lead Investigator – Nancy Schoenberg, PhD
Co-Investigator – Shelli Deskins, PhD
Research Assistant – Maria Gomez, MPH
Research Design
Research Approach
 Key informant interviews
Sample (N=23)
 7 health department staff and 16 patients
from 2 rural counties in Appalachian
Kentucky
Interviewers
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Health psychologist and anthropologist
Major Questions Asked
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Why don’t women receive follow-up care upon
detection of a Pap test abnormality?
What were patients personal experiences with the
follow-up process?
What are the roles and characteristics desirable in
a Patient Navigator Program?
Why Women Don’t Get Follow-Up to
Abnormal Pap Tests
Health Department Staff
Patients
Logistics/
Resources
Transportation; finances; lack of
availability of physicians;
distances/proximity of care; clinic
hours and appointment
availability; lack of health
insurance; childcare availability;
economic—SES; and difficulty
contacting patients for follow-up
No transportation; lack
of availability of
healthcare provider;
scheduling conflicts with
childcare, work, etc.;
financial problems; lack
of insurance
Patient
Factors
Patient demographics
(generational issues:
socioeconomic status, patient
level of education);
language/communication issues;
psychosocial/emotional issues
Psychological/emotional
(fear, denial, shy, guilt);
lack of perceived need;
lack of social support;
stress/too much going on
Why Women Don’t Get Follow-Up to
Abnormal Pap Tests
Health Department Staff
Cultural Issues
Prevention and early detection
not a priority; increasing migrant
and Hispanic population and
shortage of interpreters;
healthcare providers don’t always
understand culture; family culture
influences follow-up
Patients
Procedure characteristics
Hassle, time consuming,
uncomfortable, stressful
Patients’ Personal Experiences
with Abnormal Pap Result &
Follow-Up Care
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History: many abnormalities, procedures
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Notification: received calls and letters
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Reaction to notification:
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Fear
Dr. and family eased fear
Family either encouraged follow-up or discouraged
follow-up
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Treatment experiences:
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A lot of back and forth between specialists
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Care complicated by pregnancy
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Lack of resources challenges care, both personal
(lack of health insurance) and community
resources (long wait times before you get into Dr’s
offices)
What Should the Patient Navigation
Program Look Like?
Characteristics of Navigators
Health Department Staff
Psychosocial characteristics
adventurous, tenacious, “people
person”
Communications skills
effective/persuasive
communicator, Spanish speaker
Special skills
knowledgeable about follow up
procedures, computer literate
Personal characteristics
female, resident of area
Patients
Expertise
has life experience, is
educated, knows what to do
Communications
skills/personality
friendly, easy to talk with, nice
Special skills
dependable, ensures
confidentiality, has experience
with abnormals herself
Personal characteristics
female, resident of area, mom
like or younger
What Should the Patient Navigation
Program Look Like? Role of Navigators
Health Department Staff
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Conduct home visits
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Provide patient education
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Patients
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Provide emotional support and
encouragement
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Facilitate logistics of follow up
care, including arranging
transportation, making physician
appointments, finding childcare
Interact effectively with health
department workers, nurses,
physicians, patients
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Help with logistical tasks: assist
with forms, paperwork; arrange
transportation; help make
appointments; provide
reminders of appointments
Support and encouragement:
goes to homes, appointments if
needed; makes phone calls;
and sends letters of
encouragement
Provide education: importance
of follow-up, treatment and
testing procedures; inform
patients of risks
Acknowledgements
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PI – Mark Dignan
Co-Investigators
 Shelli Deskins
 Fran Feltner
 Nancy Schoenberg
 Brent Shelton
 Carol White
Research Assistant
 Maria Gomez
Physician Consultants
 Chris Desimone
 Gilbert Friedell
Kentucky River and Lake Cumberland District Health
Department Staff
Lee County Health Department Staff
Perry County Health Department Staff