Project Option: 1.9.1 project option - The Expansion and Enhancement of Comprehensive Breast Care Services to an Indigent and Underserved Population in the University Breast Care Center (UBCC)
Unique Project ID: 84597603.1.4
RHP Performing Provider / TPI : TEXAS TECH HS CTR FAMILY MED / 84597603
Project Description:
The University Breast Care Center began operation in 1994 providing comprehensive breast care for the Region’s medically indigent women with breast disease. Currently twenty-five (25%) of patients seen there have no third party insurance, and the majority of the remainder have only Medicaid. Collectively, the Center provides care for approximately 1/3 of the women in the El Paso area with a new diagnosis of breast cancer, and is the primary provider of care to women with breast disease who lack health insurance. The adjacent University Hospital mammogram facility performed nearly 12,000 mammography exams in the year ending May 2012, of which approximately 70% were screening exams and the remainder diagnostic.
El Paso County is located on the U.S. Mexico border in far west Texas. El Paso County, which represented the overwhelming majority of patients in Region 15, has a population of 721,598 individuals of which 81% identify themselves as Hispanic. Seventy-five percent of individuals age five and over speak a language other than English at home. The citizens of El Paso County, by far the most populous of the two counties in our region, experience many disparities: 25% of families report annual income below the poverty level and 39% of residents lack health insurance of any kind.
After 18 years, the UBCC continues to be unique in El Paso. It is the only program incorporating screening, diagnosis, treatment and education in a single location, providing care women of our Region with breast disease. Our program has evolved and is now dedicated to providing quality, comprehensive and integrated care for diagnosis, treatment, and education to all women in the Region with breast diseases and specially Breast Cancer as well as developing a clinical and laboratory program to study the prevention, early detection, and treatment of breast cancer. The program has undertaken the significant process of applying for accreditation by The National Accreditation Program for Breast Centers (NAPBC) through the American College of Surgeons, and has submitted their application for accreditation. We anticipate a site visit in DY2 and full accreditation after that.
Baseline: The primary surgical support to UBCC is its founder, a general surgeon. Furthermore, access to this surgeon is delayed: with the time to 3rd new patient visit currently at 25 days. In the case of breast and oncology surgeons, there is a single fellowship trained surgical oncologist, in private practice, in Region 15. There are no breast fellowship trained surgeons in Region 15. This situation mirrors the crisis in surgical care throughout our Region. A 2010 health needs assessment, sponsored by the Paso del Norte Foundation and which serves as primary guidance informing the Region 15 RHP documented that the area is underserved in 18 of the 24 assessed specialties and surgery was the second greatest numerical need1. There is a need for approximately 50 surgeons in our RHP and more than 95 when including our traditional referral areas including southeastern New Mexico and Juarez. Given the high demand for surgical services in our Region as a manifestation of these provider shortages, and the payor mix of UBCC, it is not reasonable to expect the private community will be able to meet the needs of our current patient population, nor will it recruit surgeons with specific fellowship training in oncology or breast surgery to care for this population, and it will not likely invest in the Quality of Life initiative included in this proposal.
Project Goals: This project will accomplish three goals:
1) Expand and enhance access to specialty care for women with breast disease through the addition of a fellowship trained breast surgeon or surgical oncologist to the staff of the UBCC
2) Develop a fellowship program in breast surgery to address a critical regional shortage of surgeons,
and provide increased access to surgeons with special expertise in breast surgery
3) Establish a survivor’s program in the UBCC, with an emphasis on objective measures of quality of life, and strategies to improve this metric.
The recruitment of a fellowship trained breast surgeon or surgical oncologist provides a level of expertise to our indigent and Medicaid population that is essentially unavailable to them currently. Leveraging this resource, the establishment of a fellowship in breast surgery represents the best solution to the long term provider shortage in our region, since most West Texas medical residents stay within a 75 mile radius of their training site to set up practice2.
The development of a fellowship de novo is a time consuming and expensive process. More importantly, given current access times are at 25 days, it is important to bring on an additional surgeon with specific training in the care of oncology patients, at the same time we develop this fellowship application. The Society of Surgical Oncologists, not ACGME, is the accrediting body for a breast fellowship.
The number of cancer survivors is growing for several reasons, including early detection, more accurate diagnosis, and more effective treatment 3, 4 . Breast cancer survivors comprise the largest proportion at 22% of all survivors; right now there are more than 2½ million breast cancer survivors in the United States 4. However, at least one third of survivors experience ongoing physical, psychological or financial consequences of their cancer diagnosis and treatment 5, 6. Appropriate follow-up care is often not delivered and the psychosocial needs of cancer patients are often not addressed 6 .Also, many patients finish their primary treatment for cancer unaware of their heightened health risks and are ill prepared to manage their future health care needs6. Barriers that patients face in receiving appropriate care include a fragmented and poorly coordinated health care system, an absence of a focus of responsibility for follow-up care, and a lack of guidance on how cancer survivors can maximize their own health outcomes. Barriers that health care providers face in delivering care include not having necessary tools to provide consistent quality care, lack of a delivery system supports that would allow them to overcome some of the obstacles posed by fragmented cancer care, and lack of adequate reimbursement of many services in survivor care 7. Furthermore, extended cancer survival is a relatively new phenomenon, so the current pace of research and development of effective models of care lags behind the need.
Hispanic patients may have additional needs compared to breast cancer survivors from other ethnic groups. A recent exploratory research at the University of Chicago including 989 newly diagnosed breast cancer patients suggested an association between psychosocial stress post-diagnosis (in the form of fear, anxiety, or isolation) and breast cancer aggressiveness8. The rate of post-diagnosis psychosocial stress was about two-fold higher in Hispanics. Also, social/environmental stress could affect epigenetics, such as DNA methylation, and increased stress can impact immune function adversely9. Therefore, specific stress-reduction strategies should be recommended. Another study including 117 Hispanic Breast cancer survivors at the University of Texas, San Antonio found that Hispanic breast cancer survivors have a high rate of depression and that, piled on other barriers like cost factors and underinsurance, prevents many of them from getting screenings for other cancers like colon cancers(only 5% get appropriate screening)10. This is significant because 10% of all new cancers are diagnosed in cancer survivors and second cancers are the 6th leading cause of cancer deaths, highlighting the need for regular screenings in cancer survivors. One of the explanations provided is that many Hispanic breast cancer survivors equate their cancer to a death sentence, and many do not want to “bother” their physicians for screening. We surveyed 65 of our breast cancer survivors and noted that around 35% consider their general health fair or poor, and 50 % of them feel their physical health or emotional problems interfere with their social activities[1] [data on file, to be presented in CPRIT conference, Austin, TX October 25, 2012], using a validated Health related survey RAND/HSF-3611, Spanish version12.
Based on this and similar research we feel that Hispanic breast cancer survivors should not only get the oncology follow-up treatment they need, but should also be screened for depression and other stressors and their individual’s need explored (for example concern about cancer recurrence or sexual issues) and should receive appropriate education and coping strategies. Also, another study looking at the characteristics of 111 breast cancer patients in our center showed that median Body Mass Index (BMI) Index is high 35.5 (range 18-50.4) and many of our Hispanic breast cancer patients in El Paso are diagnosed at a younger age (32% were diagnosed at younger than age 50 years)13.
Based on the data above, we believe that our breast cancer survivors would be best served in a comprehensive survivorship program as proposed in this grant application that would focus on their specific needs and address their dietary, cultural and lifestyle habits. Evidence suggests that interventional proactive programs developed for women who have completed treatment for breast cancer addressing survivorship issues like psychological well-being and functional wellness are useful for a successful transition to survivorship following breast cancer and have a significant potential to improve recovery and quality of life for survivors of breast cancer 14-17.
Challenges: Our primary challenge will be to recruit a surgeon with the desired fellowship training to our program. We believe the vision of the program is compelling, and together with commitments the performing provider has made in research related to breast cancer, will be highly appealing to a candidate.
Relationship to Regional Goals: This project meets our Regional goals of expanding access to specialty care and the services offered with our community, and enhance the Region’s ability, in a very significant manner, to care to patients with a chronic disease such as breast cancer and its sequel. It will enhance the Regional goal of overcoming socio-economic and monetary barriers to accessing healthcare in our Region
5 – year expected outcome for patients and providers: At the end of DY 5, we anticipate that nearly all patients with breast cancer seen in the UBCC will have access to a fellowship trained breast surgeon or surgical oncologist, that there will be a functioning fellowship program in breast disease, and that we will be able to, using objective measures, demonstrate meaningful improvements in the Quality of Life of survivors of breast cancer.
Rationale:
We chose Project Option: 1.9.1. encompassing elements a-c. In addition, our proposal includes the development of a survivors program addressing Health Related Quality of Life for survivors of Breast Cancer which did not readily fit into Option 1. We propose to address quality initiatives through the requirements of accreditation by The National Accreditation Program for Breast Centers (NAPBC), and those requires by the accrediting body for the breast fellowship. In addition, we will participate in RHP sponsored learning collaboratives.
The metrics we propose reflect these goals. They are focused on developing the infrastructure in terms of personnel to develop a Breast fellowship without impacting current access to the UBCC, planning and submission of the required elements to obtain approval for a fellowship, deploying the survivor’s program and improving access times as measured by the time to 3rd next available appointment
Community Need: This project addresses community need CN.2, access to secondary / specialty care.
How the Project represents a new initiative or significantly enhances an existing delivery system reform initiative: As noted, the Region’s access to fellowship trained breast surgeons or surgical oncologists is extremely limited. The specific recruitment of this specialty to our program represents a significant enhancement to a well establish breast care program. Quality of Life in survivors of breast cancer is an area in which we have obtained pilot data to demonstrate the need, but simply have no funding to be able to add this service to our program with this waiver. As such, it too represents a significant enhancement to an existing program.
Related Category 3 Outcome Measures: We have chosen OD-10, IT-10.1 Quality of Life as a standalone outcome measure. The importance of quality of life in cancer survivors is addressed in our narrative and is the reason why we chose this milestone. This will directly reflect the impact the survivor’s program has had on eligible patients. Improved quality of life, as addressed in the narrative above, is an important aspect of the spectrum of cancer care, and an area that Hispanics are at particular risk of facing challenges in restoring a normal quality of life following treatment for breast cancer.
Relationship to Other Projects and Measures:
This project reinforces 84597603.1.2 Implement a Chronic Disease Management Registry proposal since breast cancer will be one of the initial disease managed in the registry. It also links directly to 84597603.2.1 The Development of a Primary Care Medical Home in a Health Professions Shortage Area since many of these women will require ongoing primary care. Linkage through our enterprise EMR will facilitate seamless communication between primary care, the UBCC, and the survivor’s program.
Relationship to Other Providers’ Projects in the RHP: No other providers are contemplating a project specifically aimed at breast cancer; however several entities are proposing initiatives to increase primary care access. We believe that these initiatives will enhance referrals to the UBCC
Plan for Learning Collaborative: We will participate in RHP sponsored learning collaboratives.
Valuation: The Performing Provider considered a series of factors in establishing a valuation for each project. These included the amount of human resources required to meet the milestones of the project, through new hires as well as the assignment of existing support personnel such as Information Technology, EMR and administrative support. We considered what non personnel resources would be required, such as equipment specialized for a certain specialty, and what, if any, additional space would be required to house the initiative. We considered timing issues related to when we had to add resources compared to when a corresponding milestone could be achieved. We also considered the amounts of potential professional fee revenues the project may generate, and offset these against resource demands.