Breast and Cervical Cancer Control Navigation Program

Transcription

1 Breast and Cervical Cancer Control Navigation Program E.J. Siegl, Program Director Ann Garvin, BCCCNP Lead Nurse Consultant Debbie Webster, BCCNS Navigation Consultant

2 A Total Group Effort BCCCNP Team E.J. Siegl Ann Garvin Debbie Webster Susan Harris Mike Carr Angela McFall Sam Burke Tory Doney Gwen Murphy Denise Koehn Sandie Richardson

3 Other support. CRC Support Mary Lou Searls WW Support Robin Roberts Viki Lorraine Dilhara Muthukuda Comp Cancer Support Patty Brookover Polly Hager Sarah Mott Steve Springer Amy Stagg Beth Trierweiler

4 Before we begin. We know this is new information for all of you We know that this is A LOT of information to present in a short period of time We get it! We have been immersed in redesigning this program for the last 4 months AND we still don t have all the answers! But, that s ok we will figure it out together

5 Breast/cervical screening/diagnostic services provided to low-income clients, ages Total # of clients enrolled in program: BCCCP: 509,160 FP: 17,776 Cancers Diagnosed: Breast: > 4400 (3100 invasive), Cervical: 311 CIN 2/CIN 3: 10,363 Since 2001, BCCCP has enrolled > 7950 clients in MTA for cancer treatment Each year all CDC Clinical and Program Performance Indicators have consistently been met

6 Healthcare Changes 2014

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8 2015

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10 FY /2014: Reevaluate FY 15 Caseload Target- 20, /2014: Expanded program eligibility criteria 3. 12/2014: Shift in program focus to providing primarily diagnostic follow-up, outreach, and navigation 4. 1/2015: CDC 60/40 waiver for 2016; --NO waiver for Program currently has unobligated money in direct service dollars for 2015 (> $2.5 million will be returned to CDC)

11 5. 1/2015: CDC policy changes- BCCCP can provide -Services for insured clients with high deductibles -Navigation ONLY services to insured clients 6. 2/2015: CDC Re-application for 2016 funds requested: New Caseload target: 10,000 New Navigation Services target: /2015: Change in agency caseload requirement 100% coordination awarded if 50% caseload attained

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14 Goal for FY 2016: Develop and Implement a Navigation Program Effective July 1, 2015 Purpose: Assist clients in: Overcoming barriers Accessing the healthcare system Receiving needed screening, diagnostic, and/or treatment services

15 Transition BCCCP to

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17 What are barriers to care? Barriers are problems that get in the way of a person getting the health care they need.

18 Barriers to Care Many different types of barriers can interfere with the client getting screening, follow-up and treatment services. Barriers to care will be different from person to person and community to community. Clients can have 1 barrier, lots of barriers, or no barriers at all. Barriers an change over time and new barriers may develop during the course of care

19 System: Client no showed for one appointment and had to reschedule 2 other appointments because she could not get out of work Barrier = Employment Issues Communication: Client has seen this provider in the past and was unhappy with care Barrier: Communication Issues with Provider Psychosocial: Client keeps avoiding making an appointment for biopsy Barrier = Fear of Cancer Diagnosis Financial: Client not making an important for an Ultrasound because of high insurance deductible Barrier = Inadequate Insurance

20 What s the difference? BCCCNP Caseload Services BCCC Navigation Services 1. Identify Barriers 1. Identify Barriers 2. Needed Screening and/or Diagnostic Services Provided to Client 3. Program PAYS ($$) for at least ONE Screening or Diagnostic Service. 2. Needed Screening, Diagnostic, OR Treatment Services Identified for Client 3. Client ASSISTED with obtaining needed services or treatment through insurance.

21 BCCCNP Caseload Services Effective October 1, Increase in coordination/navigation to $175.00/enrolled client --TO COUNT IN CASELOAD: client MUST receive at least ONE BCCCNP paid service (screening OR diagnostic) during FY No separate FP caseload: FP clients WILL count towards agency caseload and be reimbursed $175.00/FP client

22 BCCCNP + FP = Total Caseload Total agency Caseload = 100 # BCCCNP clients Enrolled # FP clients Enrolled Total # clients Enrolled Agency achieved 100% of caseload Will receive $17,500 Coordination/ Navigation ($175/client)

23 3. Changes in Case Management Effective 10/1/15: Diagnostic Navigation (DN) will replace Case Management (CM) CASE MANAGER Title replaced by BCCCNP Navigator $95.00 CM Reimbursement WILL END 9/30/15

24 4. CM name changed not requirements Diagnostic Navigation provided to ENROLLED uninsured/underinsured clients requiring screening/diagnostic services for identified abnormality. Reimbursement for Diagnostic Navigation INCLUDED in $175.00/client for coordination/navigation

25 Diagnostic Navigation Navigator Responsibilities for ENROLLED clients: Planning, implementing, and coordinating of clinical services, that are required for timely and appropriate follow-up care for an identified breast/cervical abnormality. Client Referrals Clients with abnormal screening results requiring Diagnostic Navigation may be: Referred by a BCCCNP provider Self-referred or Referred from a non-bcccp provider

26 Diagnostic Navigation CDC Clinical Indicators of Timeliness and Completeness will continue to be evaluated for all abnormal results requiring IMMEDIATE follow-up Monthly, Ann Garvin will: Monitor missing data for follow-up of abnormal results in MBCIS Send Abnormal Follow-up Report to agencies listing missing data (replaces Case Management Report)

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28 BCCCNP Caseload Services: Underinsured Clients 139%-250% FPL Caseload Services Continuum of Care Enrollment: Barriers/Service Needs Assessment: Navigation Begins Provision of Program Services to client Termination of Care in Program: Navigation Ends

29 BCCCNP Caseload Services: Enrollment Underinsured Clients 139%-250% FPL 1. Identify underinsured client eligible to receive BCCCNP reimbursed breast/cervical diagnostic services. 2. Enroll the client in BCCCNP. (Same procedure as before- NO change in forms) 3. NAVIGATION BEGINS Assess/address potential barriers to receiving services.

30 BCCCNP Caseload Services: Enrollment Underinsured Clients 139%-250% FPL 4. Schedule for diagnostic services based on Medical Protocol (Timeliness/Completeness Evaluated) 5. Bill client s insurance first. 6. Obtain EOB. 7. Bill BCCCNP for services not covered by insurance.

31 BCCCNP Caseload Services: Provision of Care Underinsured Clients 139%-250% FPL 1. Obtain diagnostic service results from provider and enter in MBICS. 2. Monthly report of missing diagnostic results sent to agencies by Ann Garvin, Nurse Consultant Final results: No cancer diagnosis: NAVIGATION ENDS Refer back to PCP for further follow-up If co-pays/deductibles still a barrier to receive short-term follow-up procedures (I.e. 6 month mammogram) re-enroll in BCCCNP

32 BCCCNP Caseload Services: Termination of Care Underinsured Clients cont. 1. Cancer Diagnosed: Treatment covered by Insurance 2. Cancer Diagnosed: Treatment NOT covered by Insurance -- MTA Option to Enroll -- Referrals to ACS and BCCNS Navigation consultant

33 Caseload Services Questions Enrolling Underinsured Clients

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35 BCCCNP Caseload Services: Uninsured Clients </= 250% FPL Caseload Services Continuum of Care 1. Enrollment: Barriers/Service Needs Assessment: Navigation Begins 2. Provision of Program Services AND 3. Referral for Insurance: HMP, Marketplace 4. Termination of Care in Program: Navigation Ends

36 BCCCNP Caseload Services: Enrollment Uninsured Clients </= 250% FPL 1.Identify eligible clients. 2.Enroll the client in BCCCNP. (Same procedure - NO change in forms) 3.Assess/address potential barriers to receiving services. NAVIGATION BEGINS

37 BCCCNP Caseload Services: Provision of Care Uninsured Clients </= 250% FPL 1. Arrange/refer for needed screening and/or diagnostic services. 2. Based on income refer to HMP or Marketplace (if during open enrollment).

38 BCCCNP Caseload Services: Termination of Care Uninsured Clients </= 250% FPL Work-up of Abnormal Results 3. No Cancer Diagnosis NAVIGATION ENDS 4. Cancer Diagnosis -- Enroll Client in MTA as per policy guidelines -- For Breast Cancer Clients : Referrals to ACS and BCCNS Navigation Consultant (Debbie Webster) Navigation Ends when Treatment Begins

39 QI Improvement/Evaluation Data will be collected, analyzed, and evaluated on: The number of clients enrolled in the BCCCNP; goal is 10,000 clients for FY 2016 Timeliness and completeness of care for follow-up of abnormalities This is nothing new we are doing this now!

40 Caseload Service Questions Enrolling Uninsured Clients

41 Coming July 1, 2015!!!!

42 Outreach Navigation Services

43 Build a bridge to care

44 Outreach Navigation Reimbursement Requirements Agency eligible to receive $60.00/client after the client: Completes breast/cervical screening and/or diagnostic procedure(s) Begins cancer treatment (through MTA or own insurance) or Re-enrolls in MTA at yearly redetermination date

45 Outreach Navigation Reimbursement Requirements Information from each client encounter is documented on individual Navigation Services Encounter Forms Client data from the Encounter Form needs to be documented in MBCIS TWO client encounters MUST be documented in MBCIS before the agency is reimbursed for navigation services

46 Billing for Navigation Services Authorization for reimbursement automatically generated after Navigation End Date entered in MBCIS Agency to bill CPT G9012 (Coordinated Care; Case Management Services Not Elsewhere Classified (NEC) July 1 September 30, 2015 use ICD-9 code V65.49 Beginning October 1, 2015 use ICD 10 code Z71.89 (Other specified counseling).

47 Billing cont. For those agencies that billed Medicaid for client navigation prior to July 1, 2015: Cannot DOUBLE BILL BOTH Medicaid and BCCCNP for Outreach Navigation Services BCCCNP should be billed for Navigation Services

48 If an Outreach Navigation Service client receives an abnormal screening result but has a high-deductible can she be enrolled in BCCCNP for Caseload? Yes, Client can receive diagnostic services through BCCCP. Client WILL count in agency s caseload and agency will receive $ for client. Agency will NOT be reimbursed an additional $60.00 for client.

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50 Outreach Navigation Services Insured Clients </= 250% FPL Continuum of Care for clients Intake: Barriers/Service Needs Assessment Navigation Begins Provision of Navigation Services Termination of Navigation Services Navigation Ends

51 Outreach Navigation Services: Intake 1. Perform Needs Assessment* to identify: - Screening/Diagnostic and/or Treatment Services required (new/re-enrolling BCCCP MTA clients) - Potential barriers 2. Document socio-demographic information, services required, barriers identified on Intake Assessment Form

52 Outreach Navigation Services: Intake 3. If HMP client, ask if client has completed personal risk assessment. FIRST ENCOUNTER DATE - Navigation Begins 4. Explain services BCCCNS Navigator can provide based on information obtained from client Obtain Client Verbal Acknowledgement

53 Client Verbal Acknowledgement Informed Consent Not Required Based on the information that you are telling me, here is what I can do for you. Explain navigation services that can be provided to the client based on your assessment and confidentiality will be maintained. I am/will make suggestions for you based on the information you give me. If, for some reason, that information is not correct or if your situation changes, that may affect what I told you. In that case, please call me and we will talk about this further. Document Yes in the Client Verbal Acknowledgement for Services on the Michigan Breast and Cervical Navigation Services Outreach Navigation Intake Form. Prior to ending the contact/call with the client obtain the next date that you will contact her and document it on the enrollment form.

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55 Outreach Navigation Services: Intake Form Completion

56 Outreach Navigation Services: Intake Form Completion

57 Outreach Navigation Services: Encounter Summary Completion Provision of Navigation Services: 2 nd Navigation Encounter 1. Implement strategies to address barriers. 2. Assist client in obtaining screening/diagnostic and/or treatment services 3. Arrange follow-up date to contact the client to determine if services received. 4. Document on Encounter Form and in MBCIS type of navigation provided (Screening, Diagnostic Follow-up, Treatment)

58 Outreach Navigation Encounter Summary: Documenting Services Received

59 Outreach Navigation Services: Termination of Services Navigation ENDS when the client completed her screening/ diagnostic services and/or begins cancer treatment. If Service/Diagnostic Results Normal (NO Cancer) Navigation Ends Enter Navigation END Date on form AND in MBCIS. Navigation END date = last date of contact with the client. Client added to recall/anniversary list to contact in one year to determine if navigation required in obtaining screening services.

60 Outreach Navigation Services: Termination of Services If Cancer Diagnosed: Determine if: Client s cancer treatment covered by insurance Client assisted with obtaining treatment through insurance. Navigation ends when cancer treatment begins. Navigation end date is date of cancer treatment Client s cancer treatment partially/not covered by insurance. Client given option to terminate insurance coverage/enroll in MTA. For Breast Cancer Clients: Contact BCCNS Navigation Consultant. Referral to ACS.

61 Special Situations: Clients lost to follow-up/refuse services If possible, try to determine why client did not receive service. Check Navigation Pending on Encounter form and enter date for next contact. If client no shows for scheduled services or decides to not obtain a scheduled service (refuses) contact Debbie Webster or E.J. Siegl

62 Navigation Services Questions Insured Clients Still hanging in there??

63 Can we provide navigation services to the same insured client the following year?

64 Outreach Navigation Services: HMP Clients Annual Re-Screening BCCCNP is collaborating with Medicaid to identify former BCCCP clients now enrolled in HMP and FFS Medicaid clients who have not received breast/cervical cancer screenings. BCCCNP will be able to obtain information on clients requiring screening services. Outreach Navigation services will be offered to those clients so they can obtain needed screening services. Project in Works Implementation Date Fall 2015

65 Outreach Navigation Services: Marketplace Insured Clients Annual Re-Screening Client placed on a recall list and contacted by the agency navigator at a specified date (yearly) to determine if the client has obtained insurance. If insurance obtained: Client assisted to obtain screening services (if needed) If uninsured: Client may be re-enrolled in BCCCNP (if eligible) to obtain needed services.

66 Navigation Services Questions Annual Re-Screening

67 Outreach Navigation Services: MTA Clients Effective July 1, 2015 ALL BCCCNP MTA Clients will become Outreach Navigation Clients 1. No change in procedure for verifying client eligibility or enrolling client in MTA. 2. MTA client contact information MUST be documented in the MBCIS OUTREACH NAVIGATION database.

68 Outreach Navigation Services: New MTA Clients NEW MTA Clients: On Outreach Navigation Intake Form: Check YES in the BCCCNP MTA Client Section and complete Client Contact Information ONLY Section

69 Outreach Navigation Services: New MTA Clients On the Outreach Navigation Encounter Summary Complete MTA Client Information Check Enrollment Box Enrollment Date = Date MTA app. signed = First Encounter Date (Enter in MBCIS) Navigation Begins

70 Outreach Navigation Services: New MTA Clients CIN 2/CIN 3-CIS Clients MTA END DATE MTA End Date entered as SECOND ENCOUNTER Date in MBCIS. $60.00/MTA client will be paid to the agency when SECOND ENCOUNTER date is entered in MBCIS. Verify client has completed treatment PRIOR to entering SECOND Encounter Date in MBCIS. Navigation Ends

71 Outreach Navigation Services: New MTA Clients Invasive Breast/Cervical Cancer, DCIS, LCIS MTA Follow-up Date Contact client 3-4 months post treatment to verify client receiving treatment and/or if additional resources needed Follow-up Date entered as SECOND ENCOUNTER Date in MBCIS. $60.00/MTA client will be paid to the agency when SECOND ENCOUNTER date is entered in MBCIS. Navigation Ends

72 Outreach Navigation Services: Renewing MTA Clients Check Re-Enrollment Box Re-Enrollment Date = Date MTA app. signed = First Encounter Date (Enter in MBCIS) Navigation Begins Contact client 3-6 months after re-enrollment to verify client receiving treatment and/or if additional resources needed Follow-up Date entered as SECOND ENCOUNTER Date in MBCIS. $60.00/MTA client will be paid to the agency when SECOND ENCOUNTER date is entered in MBCIS. Navigation Ends

73 When in doubt, give a shout! Call EJ with questions when renewing MTA clients after July 1.

74 Outreach Navigation QI Improvement/Evaluation Data collected, analyzed, and evaluated on: # of clients navigated agency/statewide (Goal = 4000 clients for FY 2016) # of days (time period) for navigation services to be completed (Time from begin to End date) Types of barriers encountered by clients Types of services received: screening, diagnostic, and/or treatment Reasons for not completing services Review of Encounter Forms: KEEP ALL FORMS for the first year

75 Navigation Services Questions Enrolling MTA Clients

76 So are we there yet?

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78 Healthcare Watch 2015 On the National Level: USPSTF: Possible change in mammography recommendations for women < 50 Average risk women: mammography benefits will result from biennial screening during ages Screening mammography may reduce the risk of dying from breast cancer but number of deaths averted in much smaller than women < age 50 AND Increased number of false positive tests and biopsies in clients ACA Implications? Insurance Implications? Impact on BCCCNP?

79 Healthcare Watch 2015 On the Federal Level: Supreme Court Decision on Granting Subsidies to people who purchased insurance in states run by Federal Exchanges ACA Implications? Insurance Implications? Impact on BCCCNP?

80 On the State Level: Healthcare Watch 2015 June 1, 2015 Michigan Implements Breast Density Law Law mandates specific language that may be confusing for clients Additional imaging tests (MRI, US, Tomosynthesis) may be ordered but not reimbursed Uncertainty by providers in ordering imaging tests Insurance Implications? Impact on BCCCNP?

81 Moving Forward despite bumps, twists, turns etc. NEW FOCUS: Population Health Screening Women need to receive screening/diagnostic/treatment services. It doesn t matter if BCCCNP or another insurer pays. It matters that the woman GETS the services. Focus for 2016: Market ourselves AND BCCCNP Services (both caseload for diagnostic follow-up and navigation) to providers; insured clients, mammography facilities, Health Systems, FQHC s Increase Partnerships: MPCA, Medicaid (to start)

82 Moving Forward cont. We need to continually?? ourselves Why are we doing this way? Is there a better way to do this? This is just not working, can we change it? Can it be changed now?

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85 Caseload Changes Effective Immediately NEW change in agency caseload requirement: 100% coordination awarded if 40% caseload attained BCCCNP Team working on FY 2016 caseload allocation For planning purposes: projected agency caseload for 2016 will be 50%* of FY 2015 caseload (total 10,000 women/caseload services) *may be less Projected Outreach Navigation Services: 4000 clients All service allocations (caseload and navigation) contingent on available CDC funding for 2016

86 Contacts Ann Garvin, BCCCNP Lead Nurse Consultant E.J. Siegl, BCCCN Program Director/Nurse Consultant Debbie Webster, BCCNS Navigation Consultant