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MASS (Mammograms After Sunday Service)

State: FL Type: Promising Practice Year: 2019

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 was 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 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). 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. The current population being served via the MASS and FBCCEDP 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.

Per the CDC, not counting some kinds of skin cancer, breast cancer in the United States is: the most common cancer in women, no matter your race or ethnicity, 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. Breast cancer is one of the most commonly diagnosed cancers among women in the United States. 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 or groups, or lack a usual source of care are the least likely to be appropriately screened for breast cancer. 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. CDC 2015 data report the rate of female breast cancer as 124.8. The breast cancer rate is higher among White (125.6) and Black (123.3) 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 MASS and FBCCEDP collaboration is to reduce the breast cancer mortality in Broward, Palm Beach and Martin Counties through outreach, education, care coordination and treatment. The 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. All the clients that was referred to the FBCCEDP was provided needed services within 60 day of initiation.

Website http://broward.floridahealth.gov

http://broward.floridahealth.gov/programs-and-services/clinical-and-nutrition-services/florida-breast-cervical-cancer/index.html

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 the 2010 data. In 2015, 36.4 percent of female cancer cases were at an advanced stage when diagnosed (FLCHARTS). In addition, 35.1% of individuals in Broward County are below 200% of the federal poverty level.

100% of clients that were referred to FBCCEDP were provided needed service within 60 days of initiation of services. Since 1994, FBCCEDP has provided breast and cervical screenings and care coordination services to underserved women in the tri-county area. The outreach and education component of the program is carried out by a DOH-Broward Health Educator. At outreach events, the FBCCEDP Health Educator educates individuals or groups on the importance of breast cancer screenings, the different screening tools available to women, and refer women for FBCCEDP services or to other organizations that provided free or low cost breast related services. As the FBCCEPD program was grant funded, when grant funding was exhausted, the program initiated the TBG collaboration to sustain the activities performed by the health educator.

The mission of the MASS project is to provide resources, education and support services to vulnerable communities of color affected by breast cancer. Although the services are open to all, the targeted group is black communities as they have the highest breast cancer mortality rates. MASS reaches the community by partnering with religious organizations to provide education after the religious/spiritual/church services.  Many minority communities are not trusting of health-related services so the importance of building relationships, creating safe environments, holistic support and linguistically appropriate health literacy resources and education is important to reach this demographic. The workshop includes a presentation from a breast cancer survivor that includes information on breast cancer, the risk factors, screening recommendations, and the availability of free or low-cost screening services through community partners, including DOH-Broward FBCCEDP. A referral for a free mammogram is provided to women who are eligible for the FBCCEDP services. FBCCEDP has provider contracts 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 and/or near their residence. TBG coordinates with various community partners to make the mobile mammography units available at worship places after Sunday service. Clients are referred to FBCCEDP if they meet the eligibility criteria. Community partners/hospital districts with mobile mammography units and that have a provider contract with FBCCEDP, provide care coordination to women enrolled into the program. The program ensures women receive the results of their mammogram as well as care coordination for those who receive an abnormal result after the breast screenings. The care coordination process is continued until a final diagnosis has been reached. Should breast cancer be diagnosed, eligible women are referred into the FBCCEDP Medicaid program or to community providers. The MASS and FBCCEDP collaboration is unique practice in the field of public health. The program is a true illustration of collaboration of partners working towards the same 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 non-profit is funded and/or supported by various organizations such as the Florida Breast Cancer Foundation, United 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 numerous organizational collaborations depict the validity and community-wide acceptance of the program. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) as administered by the Centers for Disease Control and Prevention (CDC) funds the Florida Breast and Cervical Cancer Early Detection Program (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 central office and 16 lead County Health Department (CHD) regional coordinators 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 10 years.

The goal of the MASS and FBCCEDP collaboration is to reduce breast cancer mortality in 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.

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.  Agreement is 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 non-covered services, such as lab work for scheduled surgeries, may be the responsibility of the client, depending on 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 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 $164,000 with $60,000 allotted for mammogram services and $40,000 for care coordination. Since collaboration serves as the foundation of the program, there was no start-up cost associated with the program.



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 service available to them. Increasing awareness and educating women about breast cancer screening is equally important. MASS and DOH-Broward 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.

The breast cancer education and targeted outreach strategies are evidence-based, address community needs and are successful though collaboration with community partners. Provided services 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 FBCCEDP until the funding sources to execute outreach and education is exhausted.

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