Partnering to Improve Cancer Prevention, Treatment, & Outcomes Lisa Piercey, MD, MBA, FAAP | February 28, 2020
TDH’s Strategic Plan PREVENTION – Engage county health councils to improve local health metrics – Decrease youth obesity – Decrease tobacco use – Decrease substance misuse in high impact areas – ACEs 3
TDH’s Strategic Plan ACCESS – Optimize internal primary care efficiency • Reducing wait times • Streamlining electronic processes • Enhancing patient satisfaction – Improve external primary care access – Increase innovation • Telehealth • Payment models – Expand partnerships 4
Our Reality = Complexity
So… How are We Doing?
Cancer Trends in Tennessee 7
TN Experiences Higher Cancer Rates than U.S. Cancer Incidence Rates, All Cancer Sites, Tennessee and the U.S., 2007 - 2016 500 490 Age-Adjusted Rate per 100,000 480 470 460 450 440 430 420 410 400 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 United States Tennessee Source: Tennessee Cancer Registry
TN Experiences Higher Cancer Mortality than U.S. Source: CDC Wonder
Specific Cancers of Concern Top Ten Cancers Diagnosed in TN Top Ten Cancers Leading to Death in TN Residents, 2012 – 2016 Residents, 2012 – 2016 Cancer type Number Cancer type Number of Cases of Deaths 1 Lung 29,788 1 Lung 21,740 2 Female breast 25,014 2 Colorectal 5,941 3 Prostate 21,109 3 Female Breast 4,629 4 Colorectal 15,493 4 Pancreatic 4,317 5 Urinary bladder 7,630 5 Prostate 2,916 6 Melanoma 7,577 6 Liver and Intrahepatic bile 2,728 duct 7 Kidney and renal pelvis 7,048 7 Leukemia 2,578 Non- Hodkin’s Lymphoma 8 6,718 8 Non-Hodgkin Lymphoma 2,318 9 Oropharyngeal 5,092 9 Brain and other nervous 1,776 10 Leukemia 5,063 system 10 Esophageal 1,624 Source: Tennessee Vital Statistics
General Findings from the Data • Men in Tennessee experience higher cancer incidence • Men and black people in Tennessee experience higher cancer mortality rates • Despite in- depth investigations, no cancer “hot spots” have been identified in Tennessee – (i.e., regions where cancer incidence rates are higher than what is statistically expected)
Disparities by Cancer Type, by Race, TN, 2012-2016 Note: These disparities highlight a few, but not all of the cancer disparities • by race in the state Lung and Bronchus cancer : Black Tennesseans were more likely to be • diagnosed with lung cancer in the late stages than white Tennesseans – Approximately 16.5% of black lung cancer patients and 19.5% of white lung cancer patients in TN survived 5 years or more after their initial diagnosis Prostate cancer : Black men were disproportionately affected by prostate • cancer compared to white men, experiencing: – An incidence rate over 1.5 times higher than that of white men – A mortality rate over 2.5 times higher than that of white men
Disparities by Cancer Type, by Race, TN, 2012- 2016 (cont’d) Female breast cancer : Black women were significantly more likely than • white women to be diagnosed in the late stages among all new female breast cancer cases in TN – Treatment is less successful in late stages – There were significantly higher breast cancer mortality rates of black women compared to white women in TN Colorectal Cancer : Compared to whites, blacks experienced significantly • greater incidence and mortality rates
Rural Areas Tend to Experience Higher Cancer Incidence and Mortality Cancer Incidence and Mortality Rates by County, Tennessee, 2012 - 2016 Source: Tennessee Cancer Registry Tennessee Vital Statistics
TDH Cancer Services 15
TDH’s Cancer Screening Offerings Available at TDH Primary Care Clinic Sites: • Breast : Mammogram and clinical breast exam • Cervical : Pap Smear and HPV testing • Colon : Hemoccult testing – Some relationships with providers for colonoscopy • Prostate : PSA testing with shared decision making 16
Breast & Cervical Screening Program Provides breast and cervical screening and • Urban/Rural Status of Resident County diagnostic tests to low income, uninsured TBCSP Patients, Fiscal Year 2019 Tennesseans (over 11,000 in FY2019) Large Central Metro 11% Large Fringe metro 23% Medium Metro – Most patients were in urban areas (purple) — Small Metro Micropolitan 19% opportunity for partnership with rural providers! Noncore In fiscal year 2019, Provides patient navigation along the • 13% appoximately one-third of TBCSP 10% continuum of care including assistance in patients (N=3.444) resided in non- metropolitan enrollment into TennCare for treatment of these counties. 24% cancers Provides community education and outreach • Assists health systems with the initiation of evidence-based • interventions to increase screening rates
Ways to Engage Preventing Cancer Risk Factors 18
Room for Improvement on TN’s Cancer Risk Factors Tennessee is consistently higher than the U.S. on: • Adult Cigarette Smoking • Adult and Youth Obesity • Lack of Physical Activity
TDH Cancer Initiatives • Tennessee Comprehensive Cancer Control Program • Tobacco control programs • Physical activity programs • County Health Council Assessments and Actions
Tennessee Comprehensive Cancer Control Program (TCCCP) • Cooperative agreement with CDC to support evidence-based interventions from prevention to palliative care. Covers areas such as: – Tobacco prevention – HPV vaccination – Exposure to UV light – Radon gas – Excess weight • Supports the Tennessee Cancer Coalition (TC2), a group of over 100 cancer stakeholders. • 2018-2022 Tennessee State Cancer Plan – Developed by TC2 – Information blueprint for: • Policy, systems, and environmental changes • Provider training and professional development • Patient access, education, and programming
TDH Tobacco Control Programs • QuitLine ▫ Free counseling & two-weeks of nicotine- replacement therapy for Tennessee residents ▫ Approximately 30% quit rate at 7-month follow-up • Baby & Me Tobacco Free Free counseling and incentive program for pregnant ▫ women who use tobacco products ▫ Reduction in low-birthweight births, prenatal complications, and postpartum exposure to secondhand smoke • Youth Engagement & TNSTRONG ▫ Training youth on peer-to-peer interventions with an emphasis on tobacco products and electronic nicotine delivery systems
TDH Physical Activity Programs • Built Environment Grants – Small grants for every county – Larger competitive grants ($1.8 M to 35 counties in 2018) • Project Diabetes – 35 currently funded projects in 30 counties – Focus on supporting positive policies and environments • Gold Sneaker – Recognition program for licensed childcare providers – Providers elect to adopt 7 policies related to physical activity, healthy eating, and tobacco • Whole Child Initiatives – Partnership with the Tennessee Department of Education to incorporate evidence on physical activity and nutrition into schools
Tennessee’s County Health Councils • Established in the 1990’s • Exist in all 95 TN counties • Top resource for improving • Representative of multiple population health at the local sectors within a community level
Tennessee’s Community Health Assessments • 16 counties completed a pilot CHA process in 2019 • 27 Counties will complete a CHA in 2020 Identify & Engage • Results feed into the TDH Stakeholders strategic planning process County • Results will drive community Health action Councils Implement Action Review Quantitative & • By 2022 all 89 TDH “rural” Plan Primary Data counties will complete a CHA • Opportunities for partnership Select Priorities & exist at every step Interventions
Ways to Engage Promoting Access to Care 26
TN State Loan Repayment Program (TSLRP) Placements by County • Provides educational loan repayment to qualified primary care practitioners in exchange for an initial 2-year service obligation to practice primary care in a designated Health Professional Shortage Area (HPSA) • 65% of practitioners continue practicing in shortage areas for one or more years after completing their initial service obligation • As of 2019, mental health providers can apply
J1 Visa Waiver Program 2010-2018 J1 Visa Placements (2010-2018) • Provides a Foreign Resident physician with a waiver of the 2-year requirement to return to their home county to practice medicine. • Physician practices in a federally designated shortage area for at least 3 years. • Up to 30 slots/year (17 currently filled)
National Health Service Corps Placements • 100% federally funded program • The TDH State Office of Rural Health assists applicants and provider organizations to apply
All Provider Placements
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