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Mammograms After Sunday Service (MASS)

State: FL Type: Promising Practice Year: 2020

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Florida Department of Health in Broward County
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Mammograms After Sunday Service (MASS)

Overview: Provide a brief summary of the practice in this section

Broward County is in the southeastern portion of the State of Florida, with Miami-Dade County to the south, and Palm Beach County to the north. In 2017, Broward County is the second most populous county in Florida, and the seventeenth largest county in the nation. Broward County has a diverse population with residents representing more than 200 countries that speak over 130 languages as 31.4% of the residents are foreign-born. Broward County is a minority/majority county demonstrated by its 2017 population by race (Black 28.4%, Asian 3.6%, Hispanic 28.4%, more than one race 0.2%, and White 61.6%). Also, the county has a female population of 51.6 % of which 14.4% are below the federal poverty level (FPL), many of which do not have access to routine screening services. Mammogram After Sunday Service (MASS) is a program administered through the Florida Department of Health in Broward County (DOH-Broward) Florida Breast and Cervical Cancer Early Detection Program (FBCCEDP) as a community partnership project in coordination with the not for profit Beautiful Gate Cancer Support and Resources Center (TBG). Although no one has been excluded the program provides breast health education seminars with on-site mammograms and/or referrals to eligible women after Sunday religious services at predominantly black ministries.  Historically, the African American church has been the guardian and the perpetuator of the black culture, from which its defining values and norms have been generated. It is seen as the social institution that provides order and meaning to the black experience in the community., the target population currently being served are African American places of worship in underserved communities in Broward & Palm Beach County. One hundred eighty-six women & men were provided education on good breast health. 

The current population being served via FBCCEDP MASS collaboration includes women ages 50-64, residing in Broward, Palm Beach and Martin Counties who have little or no health insurance, with incomes at or below 200% of the FPL. Women who are under the age of 50 with a current breast condition or ages 40-49 with a 1st degree relative (parent, sibling, child) with a history of breast cancer can also receive free services. The services provided include breast and cervical cancer screenings, follow-up for abnormal results and referrals for treatment to women who are diagnosed with breast and cervical cancer.

The selection of the targeted and high-risk communities with late stage diagnosis are based on a University of Miami report titled Cancer Data for South Florida: A Tool for Identifying Communities in Need.  Many of the events in 2017/18 were held with audiences that were either Creole speaking, women from the Bahamas, Haiti and African-American According to a UM Study by Dr. Judith Hurley, breast cancer and cervical cancer are the leading cause of cancer death in Caribbean women. 86% of breast cancers are self-detected in Caribbean women, late stage breast cancer predominates and Bahamian women with breast cancer had a harmful mutation in brca1 or brca2.

Per the Centers for Disease Control and Prevention (CDC), breast cancer in the United States is the most common cancer in women, regardless of race or ethnicity and is the most common cause of death from cancer among Hispanic women, and the second most common cause of death from cancer among white, black, Asian/Pacific Islander, and American Indian/Alaska Native women. Black women are also more prone to aggressive forms of breast cancer as well as harder to treat forms, such as triple negative breast cancer.  Advances in treatment aid many women to live long, healthy lives after diagnosis but early detection is vital to long-term survival. Mammograms can detect breast cancer early, possibly before it has spread.

Several research studies have shown that women who are uninsured or underserved, are older, have lower socioeconomic status, are from racial or ethnic minorities groups, or lack a usual source of care are the least likely to be appropriately screened for breast cancer. Health equity is also a factor in receiving appropriate or advanced medical care. Further, low education levels, lack of knowledge about breast cancer and breast cancer screening; distorted perceptions of risk and susceptibility to cancer, cultural beliefs, language barriers, and, lack of transportation are some of the barriers that prevent women from obtaining breast cancer prevention services.

The latest CDC data reports (2016) the rate of female breast cancer as 124.2 per 100,000 (a slight decrease).  The breast cancer rate is higher among White (125.0) and Black (122.6) females than for other races/ethnicities. Also, the rate of new breast cancers is higher among the age group 70-74. By addressing these barriers through a health equity lens, DOH-Broward's goal is to reduce the incidence of breast cancer in the tri-county area and provide early screening services in the community.

The goal of the FBCCEDP MASS collaboration is to reduce breast cancer mortality in Broward, Palm Beach and Martin Counties through outreach, education, screening, care coordination and if needed-treatment. All the clients that were referred to the FBCCEDP were provided needed services within 60 days of initiation. The MASS objectives are: 1) provide education and resources to vulnerable communities of color affected by breast cancer; and, 2) provide breast health services to eligible women through FBCCEDP who are recruited through MASS.

Website http://broward.floridahealth.gov

Responsiveness and Innovation

The incidence of breast cancer is comparatively higher in the tri-county area of Broward, Palm Beach and Martin Counties than that of the entire state of Florida. Florida Health CHARTS (CHARTS) (http://www.floridahealthcharts.com/) is a web site providing comparative health indicator data at the community and statewide levels from the state of Florida's Bureau of Vital Statistics. CHARTS data indicate that not only is the incidence of breast cancer higher in Broward County when compared to Florida's rate, but the death rate is also higher. The 2016 data for Broward County indicates that only 62.3% of women who are 40 years and older received a mammogram in the past year and this is a downward trend when compared to 2010 data. In 2015, 36.4 percent of female breast cancer cases were at an advanced stage when diagnosed (CHARTS). In addition, 35.1% of individuals in Broward County are below 200% of the federal poverty level.

100% of eligible women referred to FBCCEDP received breast cancer screening services.  Additionally, any needed follow-up procedures were provided to all women.  It is the goal of FBCCEDP to arrange follow-up care within 60 days following the date of the abnormal result. Since 1994, FBCCEDP has provided breast and cervical cancer screenings plus care coordination services to underserved women in the tri-county area and have consistently provided final medical results to women within 60 days.  All providers of the program go through a training program conducted by the staff of FBCCEDP that provides technical advice and ongoing support to ensure that every woman enrolled in the program receives optimal medical care and navigation.

In 2017, the FBCCEDP program experienced a funding and staffing shortage for outreach and education.  In order to still provide these much-needed services to the underserved community, the TBG/MASS collaboration was initiated. At outreach events, the FBCCEDP outreach team and Health Educator educated individuals or groups on the importance of breast cancer screenings, the different screening tools available to women, and referred women for FBCCEDP services or to other organizations that provided free or low-cost breast related services. 

The mission of the FBCCEDP MASS project began with an idea in 2015 to provide resources, education and support services to vulnerable communities of color predominantly affected by late stage breast cancer. MASS brings together two entities; community resources for breast cancer screenings and places of worship that were mostly attended by women of color, although services are available and open to all races. Involving the places of worship was paramount since it was a well-known fact that pastors in the black community had a great influence on its congregants, further, that when pastors emphasized and encouraged breast cancer screenings, it was believed that an increase in screenings would occur within that congregation, potentially diagnosing a cancer before it reached an advanced stage. Tackling one congregation at a time, the MASS project provided three months of continuous contact with the target congregation assisting them in reaching out to their parishioners as well as to those that lived near their place of worship.   The result of the outreach culminated on a weekend with a large educational and mammogram screening event. 

The collaboration between FBCCEDP and MASS was a linkage of available resources to benefit these vulnerable, underserved communities.  The MASS project initiated and provided the congregation and surrounding community with outreach and education.  The FBCCEDP would arrive on the day of the event or thereafter, to provide the resources for the breast and cervical cancer screening procedures as well as patient navigation and follow-up procedures until a final diagnosis was reached.  If needed, cancer treatment through the FBCCEDP/state of Florida Medicaid would be available to eligible women.  Services provided would be at no cost to the patient.

After Sunday services, participants would hear a presentation from a breast cancer survivor that consisted of information on breast cancer, the risk factors, screening recommendations, and the availability of free or low-cost screening services through community partners, namely, the DOH-Broward FBCCEDP. The FBCCEDP contracted with a mobile mammography-unit to provide the screening 3D mammograms after the presentation.  A referral for a free mammogram was also provided to eligible women if they chose not to utilize the mobile mammogram unit.

FBCCEDP has contracted with several hospital districts and mobile mammography units to ensure accessible, high quality, and full-service breast imaging availability. This practice allows women to be served at their place of worship which is often near their residence. TBG coordinates with various community partners to schedule mobile mammography units at places of worship after Sunday service. Clients are referred to FBCCEDP for an eligibility screening.  Those ineligible for the program are referred to community or hospital district providers.

The FBCCEDP MASS collaboration created an important catalyst in the community to build relationships, especially since many minority communities are still not trusting of health-related services.  This partnership also created safe environments to seek medical care, to provide holistic support and linguistically appropriate health literacy resources and education.

The FBCCEDP MASS collaboration is a unique practice in the field of public health. It is a true illustration of collaboration of community partners working towards a common goal; to reduce the incidence of breast cancer, provide routine screenings, and access to care to targeted communities.  MASS has served as a liaison between health providers and vulnerable populations living with breast cancer. The program is funded by various organizations such as the Florida Breast Cancer Foundation, America Cancer Society, National Cancer Institute, Florida Association of Community Health Centers, Jessie Trice Community Health Center, Inc, Florida Health, South East Florida Cancer Control Collaborative and Susan G. Komen Foundation. These organizational collaborations depict the validity and community-wide acceptance of the program.   

In 2016, the FBCCEDP provided the initial educational expertise to MASS staff providing education current breast and cervical cancer issues, trends and updates.  Since 2017, MASS has educated over 800 residents across the state and referred 200 women to the FBCCEDP statewide.  305 of the 800 men and women of color receiving the education resided in the Broward Region.  52 of those were women who were referred to FBCCEDP.  Two of the 52 women were diagnosed with breast cancer and received cancer treatment at no cost.

In 2018, the MASS staff expanded their reach to include not only South Florida but Central and North Florida as well. In January 2019, the FBCCEDP received $60,000 in grant funds over a two-year period from the Florida Breast Cancer Foundation to initiate a MASS replica in the Broward Region as the MASS founder was hired by the Florida Breast Cancer Foundation to expand the MASS project statewide.  The FBCCEDP MASS replica is still in its infancy stage and as such the FBCCEDP is still heavily reliant on the TBG/MASS. 

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) as administered by the Centers for Disease Control and Prevention (CDC) funds the FBCCEDP. The NBCCEDP was created in response to the Breast and Cervical Cancer Mortality Act of 1990; Public Law 101-354. The grant is administered through the DOH central office and the 17 lead regional coordinators with the Florida Department of Health (DOH) manage service provision in the counties across the state to assure statewide access.

DOH-Broward FBCCEDP has provided breast and cervical screenings and care coordination services to underserved women in the tri-county service area (Broward, Palm Beach and Martin) since 1994. The program's care coordination services have consistently achieved 100% of CDC's 12 quality indicators over the past 11 years.

LHD and Community Collaboration 

The goal of the MASS and FBCCEDP collaboration is to reduce breast cancer mortality in the tri-county area through outreach, education, care coordination and treatment. The objectives of the program are: 1) provide education and resources to vulnerable communities of color affected by breast cancer; and, 2) provide breast health services to eligible women through FBCCEDP, who are recruited through MASS.


To achieve these goals, an agreement was formed by DOH-Broward for The Beautiful Gate Cancer Support & Resource Center, Inc. (TBG) to be a participating service site for the Florida Breast and Cervical Early Detection Program. As part of the agreement, TBG is required to provide breast cancer education and/or outreach to residents of the FBCCEDP Broward region (Broward, Palm Beach and Martin Counties). The agreement is reviewed annually. Agreements are obtained from participating clients which permits TBG to share protected health information (PHI) and electronic protected health information (ePHI) with DOH-Broward. Every woman who is eligible for the service, receives a mammogram, follow-up breast procedures and care coordination through the program's Case Manager. The cost for noncovered services, such as lab work for scheduled surgeries, may be the responsibility of the client, depending on the situation. Care coordination is provided to women enrolled in FBCCEDP. All women who have been diagnosed with breast cancer and are U.S residents for five years or more will be enrolled with the FBCCEDP Medicaid program. Other women enrolled in the program are navigated by TBG through its contracted and non-contracted partners to ensure that every woman receives breast cancer treatment. The FBCCEDP program's annual budget is $560,000 with $357,500 allotted for breast and cervical cancer screening services and $202,500 for billing and care coordination.  Since collaboration serves as the foundation of the program, there was no start-up cost associated with the program.

Evaluation 

The objectives of the program are to: 1) provide education and resources to vulnerable communities of color affected by breast cancer; and, 2) provide breast health service to eligible women through FBCCEDP, who are recruited through MASS. The removal of financial and access barriers to screening alone may not be adequate to motivate women to utilize the free/low cost breast health services available to them. Increasing awareness and educating women about breast cancer screening is equally important. MASS and DOH-Broward's collaboration not only serve to get women screened through the program, but also educate and raise awareness throughout the community. Additionally, collaboration with community organizations facilitated in leveraging expertise and resources, subsequently expanding the capabilities and reach of the program. It also assisted in building a stronger infrastructure for outreach, education and recruitment activities.


To ensure data accuracy, a tracking database was created in 2017 to monitor all FBCCEDP activities.  In Fiscal Year (FY) 2015-2016, 93 outreach and educational events were attended within 52 weeks.  By FY 2017-2018 that number was cut by 47% to 44 events and in FY 2018-19 outreach had declined to 28 events within a 52-week period due a funding reduction.  Although outreach was cut by 47% in FY 2017-2018 the customer base increased by 9.4%.  This is due in part to residual marketing of the program, but also by the addition of the new partnership and collaboration with MASS. In FY 2017-2018 MASS conducted 17 events educating 306 participants on breast cancer awareness, providing 21 mammograms, and promoting the services of the FBCCEDP.

Sustainability

The breast cancer education and targeted outreach strategies are evidence-based, address community needs and are successful though collaboration with community partners. services provided are culturally appropriate, combine education and access to service, and increase the likelihood of utilization of breast health services. The FBCCEDP is funded through CDC, and the services are available to the community as funding allows. The agreement between the Beautiful Gate Cancer Support & Resources Center and DOH-Broward is renewed on a yearly basis. As per the agreement, TBG will provide referrals to FBCCEDP until the funding sources to execute outreach and education is exhausted.

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