PROGRAM BOOK MCC Annual Meeting. Celebrating 20 Years of Strong Connections in Cancer Prevention and Control

Transcription

1 2018 MCC Annual Meeting Celebrating 20 Years of Strong Connections in Cancer Prevention and Control November 7, 2018 The Kellogg Hotel & Conference Center East Lansing, MI PROGRAM BOOK

2 MCC Co-Chair Welcome Welcome to the 2018 Michigan Cancer Consortium Annual Meeting. As the conference theme notes, the MCC celebrates 20 Years of Comprehensive Cancer Control in Michigan. We have achieved much and are still strong and working toward the future. The Consortium has many accomplishments and much to be proud of. Please take a look at the infographic on the back cover to see a full picture of the MCC. This conference gives us a chance to build on the work we ve done; Learn about new Programs in Michigan, Focus our work to reduce health disparities and Engage in the work of the Consortium. Please enjoy this day of learning with national and state experts. Visit the Abstract and Poster session to learn about projects and research outcomes in Michigan. Leave renewed to continue your important work in Comprehensive Cancer Control. We are so glad you could join us and encourage you to take advantage of all that is offered. Enjoy your day, Dana Zakalik, MD MCC Co-Chair Thomas Rich, MPH MCC Co-Chair

3 Table of Contents Conference Agenda Page 1 Floorplans Page 2 MCC Inspiration Award Page 3 Keynote Speaker Page 4 Posters & Reviewed Abstracts Page 20 Concurrent Session A Room 103AB Page 23 Cancer Pain: A Deeper Look into the Experience Across the Continuum of Care Concurrent Session B Room 104AB Page 39 Your Role in Increasing HPV Vaccination Rates in Michigan Concurrent Session C Room 105AB Page 68 Using Virtual Care to Address Health Disparities Among Cancer Patients Carol Friedman Award Page 98 Spirit of Collaboration Awards Page 99 MCC Champion Award Page 108 Continuing Education Information Page 109 Attendee List Page 111

4 Conference Agenda 7:45am 7:45am 8:30am 8:45am 10:30am Registration Open Big Ten A Hallway Abstract, & Poster Setup Centennial Room Continental Breakfast Big Ten A Room Conference Opening Big Ten A Room Welcome MCC Inspiration Award Presentation Opening Keynote - Dr. Camara Jones Break and Poster Viewing Centennial Room C. Using Virtual Care to Address Health Disparities Among Cancer Patients. Room 105AB Becky Sanders, MBA; Upper Midwest Telehealth Resource Center Marie Lee, M.Ed., PMP; Henry Ford Health System Geralyn Roobol, LMSW, RN, BS, CMAC; Spectrum Health Cancer Program 12:15 pm Lunch Big Ten A Room 1:15 pm MCC Awards Presentation Big Ten A Room CDC Carol Friedman Award Spirit of Collaboration MCC Champion 11:00am Concurrent Sessions A. Cancer Pain: A Deeper Look into the Experience Across the Continuum of Care Room 103AB Sandy VanBrouwer, MSN; Pediatric Pain and Palliative Medicine Helen DeVos Children's Hospital Sean Smith, MD; Cancer Rehabilitation Medicine at Michigan Medicine Angela Chmielewski, MD; Hospice and Palliative Medicine at Beaumont Hospital Royal Oak B. Your Role in Increasing HPV Vaccination Rates in Michigan Room 104AB Stephanie Sanchez, Division of Immunization at Michigan Dept of Health and Human Services Marcus DeGraw, MD; St. John Hospital and Medical Center Cristiane Squarize, DDS, MS, PhD; Periodontics and Oral Medicine at University of Michigan Carolyn Johnston, MD; Gynecological Oncology at Michigan Medicine 1:45 pm MCC 20 Year Celebration & Accomplishments 2:00 pm Meeting Adjourned Board of Directors Meeting will begin immediately following the Annual Meeting in Room 105AB. Please join us. We need your feedback. Please complete the Annual Meeting online Evaluation. You may use this QR code or a link will be ed to you after the meeting. Page 1

5 Floorplan Concurrent Session Rooms Poster Session Room Conference Registration Parking Garage Entrance General Session Room Keynotes Meals Awards Kellogg Hotel & Conference Center Notes All Keynotes, Awards and Meals will be located in the Big Ten A Room The Abstract & Posters along with the AM Coffee Break will be In the Centennial Room, located across the hall from Big Ten A Concurrent Sessions will be in 103AB, 104AB & 105AB; located down the main hall, toward the Parking Garage entrance of facility Ladies restrooms are located outside of Big Ten Room B Men s restrooms are located downstairs, directly below the ladies room. There are additional restrooms down the main hallway, near the Concurrent Session Rooms Please make sure to get a paid Parking Pass from registration staff Enjoy your day! Page 2

6 MCC Inspiration Award 2018 Award Winner ERIKA LOJKO No one should face cancer alone. Courageous, determined, resolute, faithful; these are the faces of cancer survivors. Page 3

7 Opening Keynote 9:00-10:15am Big Ten A Camara Phyllis Jones, MD, MPH, PhD is a Past President of the American Public Health Association ( ) and a Senior Fellow at the Satcher Health Leadership Institute and the Cardiovascular Research Institute at the Morehouse School of Medicine. Dr. Jones is a family physician and epidemiologist whose work focuses on naming, measuring, and addressing the impacts of racism on the health and well-being of the nation. She seeks to broaden the national health debate to include not only universal access to high quality health care, but also attention to the social determinants of health (including poverty) and the social determinants of equity (including racism). As a methodologist, she has developed new methods for comparing full distributions of data, rather than simply comparing means or proportions, in order to investigate population-level risk factors and propose population-level interventions. As a social epidemiologist, her work on "race"-associated differences in health outcomes goes beyond simply documenting those differences to vigorously investigating the structural causes of the differences. As a teacher, her allegories on "race" and racism illuminate topics that are otherwise difficult for many Americans to understand or discuss. She aims through her work to catalyze a national conversation on racism that will mobilize and engage all Americans in a National Campaign Against Racism. Dr. Jones was an Assistant Professor at the Harvard School of Public Health (1994 to 2000) before being recruited to the Centers for Disease Control and Prevention (2000 to 2014), where she served as a Medical Officer and Research Director on Social Determinants of Health and Equity. Highly valued as a mentor and teacher, she is currently an Adjunct Professor at the Rollins School of Public Health at Emory University and an Adjunct Associate Professor at the Morehouse School of Medicine. She has been elected to service on many professional boards, including the Board of Directors of the American College of Epidemiology, the Executive Board of the American Public Health Association, the Board of Directors of the DeKalb County (Georgia) Board of Health, the Board of Directors of the National Black Women s Health Project, and the National Board of Public Health Examiners. She is also actively sought as a contributor to national efforts to define health equity, including her role as a Project Advisor and on-screen expert for the groundbreaking film series Unnatural Causes: Is Inequality Making Us Sick? Her awards include the David Satcher Award (ASTDHPPHE, 2003), Hildrus A. Poindexter Distinguished Service Award (APHA Black Caucus, 2009), John Snow Award (APHA Epidemiology, 2011), Paul Cornely Award (APHA Health Activists, 2016), Woman in Medicine Award (NMA Women Physicians, 2017), Louis Stokes Health Advocacy Award (NMA, 2018), Cato T. Laurencin Distinguished Research Award (Cobb Institute and NMA, 2018), and Wellesley Alumnae Achievement Award (Wellesley College, 2018), among many others. Lauded for her compelling clarity on issues of race and racism, she has also delivered seven Commencement Addresses in the past four years: University of Washington School of Public Health (2014), University of California San Francisco School of Medicine (2016), University of California Berkeley School of Public Health (2016), University of Minnesota School of Public Health (2017), Southern Illinois University School of Medicine (2017), City University of New York School of Medicine (2017), and University of North Carolina Gillings School of Global Public Health (2018). She was awarded an honorary Doctorate of Science by the Icahn School of Medicine at Mount Sinai (2016). Dr. Jones earned her BA in Molecular Biology from Wellesley College, her MD from the Stanford University School of Medicine, and both her Master of Public Health and her PhD in Epidemiology from the Johns Hopkins School of Hygiene and Public Health. She also completed residency training in General Preventive Medicine at Johns Hopkins and in Family Practice at the Residency Program in Social Medicine at Montefiore Medical Center. Page 4

8 Going Public A B S T R A C T Levels of Racism: A Theoretic Framework and a Gardener s Tale Camara Phyllis Jones, MD, MPH, PhD The author presents a theoretic framework for understanding racism on 3 levels: institutionalized, personally mediated, and internalized. This framework is useful for raising new hypotheses about the basis of race-associated differences in health outcomes, as well as for designing effective interventions to eliminate those differences. She then presents an allegory about a gardener with 2 flower boxes, rich and poor soil, and red and pink flowers. This allegory illustrates the relationship between the 3 levels of racism and may guide our thinking about how to intervene to mitigate the impacts of racism on health. It may also serve as a tool for starting a national conversation on racism. (Am J Public Health. 2000;90: ) Race-associated differences in health outcomes are routinely documented in this country, yet for the most part they remain poorly explained. Indeed, rather than vigorously exploring the basis of the differences, many scientists either adjust for race or restrict their studies to one racial group. 1 Ignoring the etiologic clues embedded in group differences impedes the advance of scientific knowledge, limits efforts at primary prevention, and perpetuates ideas of biologically determined differences between the races. The variable race is only a rough proxy for socioeconomic status, culture, and genes, but it precisely captures the social classification of people in a race-conscious society such as the United States. The race noted on a health form is the same race noted by a sales clerk, a police officer, or a judge, and this racial classification has a profound impact on daily life experience in this country. That is, the variable race is not a biological construct that reflects innate differences, 2 4 but a social construct that precisely captures the impacts of racism. For this reason, some investigators now hypothesize that race-associated differences in health outcomes are in fact due to the effects of racism. 5,6 In light of the Department of Health and Human Services Initiative to Eliminate Racial and Ethnic Disparities in Health by the Year 2010, 7,8 it is important to be able to examine the potential effects of racism in causing race-associated differences in health outcomes. Levels of Racism I have developed a framework for understanding racism on 3 levels: institutionalized, personally mediated, and internalized. This framework is useful for raising new hypotheses about the basis of race-associated differences in health outcomes, as well as for designing effective interventions to eliminate those differences. In this framework, institutionalized racism is defined as differential access to the goods, services, and opportunities of society by race. Institutionalized racism is normative, sometimes legalized, and often manifests as inherited disadvantage. It is structural, having been codified in our institutions of custom, practice, and law, so there need not be an identifiable perpetrator. Indeed, institutionalized racism is often evident as inaction in the face of need. Institutionalized racism manifests itself both in material conditions and in access to power. With regard to material conditions, examples include differential access to quality education, sound housing, gainful employment, appropriate medical facilities, and a clean environment. With regard to access to power, examples include differential access to information (including one s own history), resources (including wealth and organizational infrastructure), and voice (including voting rights, representation in government, and control of the media). It is important to note that the association between socioeconomic status and race in the United States has its origins in discrete historical events but persists because of contemporary structural factors that perpetuate those historical injustices. In other words, it is because of institutionalized racism that there is an association between socioeconomic status and race in this country. Personally mediated racism is defined as prejudice and discrimination, where prejudice means differential assumptions about the abilities, motives, and intentions of others accord- The author is currently with the Department of Health and Social Behavior, Department of Epidemiology, and the Division of Public Health Practice, Harvard School of Public Health, Boston, Mass. She will soon begin working with the Centers for Disease Control and Prevention, Atlanta, Ga. Requests for reprints should be sent to Camara Phyllis Jones, MD, MPH, PhD, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS K45, Atlanta, GA This article was accepted April 12, American Journal of Public Health August 2000, Vol. 90, No. 8 Page 5

9 ing to their race, and discrimination means differential actions toward others according to their race. This is what most people think of when they hear the word racism. Personally mediated racism can be intentional as well as unintentional, and it includes acts of commission as well as acts of omission. It manifests as lack of respect (poor or no service, failure to communicate options), suspicion (shopkeepers vigilance; everyday avoidance, including street crossing, purse clutching, and standing when there are empty seats on public transportation), devaluation (surprise at competence, stifling of aspirations), scapegoating (the Rosewood incident, 9,10 the Charles Stuart case, the Susan Smith case ), and dehumanization (police brutality, sterilization abuse, hate crimes). Internalized racism is defined as acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth. It is characterized by their not believing in others who look like them, and not believing in themselves. It involves accepting limitations to one s own full humanity, including one s spectrum of dreams, one s right to selfdetermination, and one s range of allowable selfexpression. It manifests as an embracing of whiteness (useofhairstraightenersandbleaching creams, stratification by skin tone within communities of color, and the white man s ice is colder syndrome); self-devaluation (racial slurs as nicknames, rejection of ancestral culture, andfratricide); andresignation, helplessness, and hopelessness (dropping out of school, failing to vote, and engaging in risky health practices). The following allegory is useful for illustrating the relationship between the 3 levels of racism (institutionalized, personally mediated, and internalized) and for guiding our thinking about how to intervene. I use this story in my teaching on race and racism at the Harvard School of Public Health as well as in my public lectures. Levels of Racism:A Gardener s Tale When my husband and I bought a house in Baltimore, there were 2 large flower boxes on the front porch. When spring came we decided to grow flowers in them. One of the boxes was empty, so we bought potting soil to fill it. We did nothing to the soil in the other box, assuming that it was fine. Then we planted seeds from a single seed packet in the 2 boxes. The seeds that were sown in the new potting soil quickly sprang up and flourished. All of the seeds sprouted, the most vital towering strong and tall, and even the weak seeds made it to a middling height. However, the seeds planted in the old soil did not fare so well. Far fewer seeds sprouted, with the strong among them only making it to a middling height, while the weak among them died. It turns out that the old soil was poor and rocky, in contrast to the new potting soil, which was rich and fertile. The difference in yield and appearance in the 2 flower boxes was a vivid, real-life illustration of the importance of environment. Those readers who are gardeners will probably have witnessed this phenomenon with their own eyes. Now I will use this image of the 2 flower boxes to illustrate the 3 levels of racism. Let s imagine a gardener who has 2 flower boxes, one that she knows to be filled with rich, fertile soil and another that she knows to be filled with poor, rocky soil. This gardener has 2 packets of seeds for the same type of flower. However, the plants grown from one packet of seeds will bear pink blossoms, while the plants grown from the other packet of seeds will bear red blossoms. The gardener prefers red over pink, so she plants the red seed in the rich fertile soil and the pink seed in the poor rocky soil. And sure enough, what I witnessed in my own garden comes to pass in this garden too. All of the red flowers grow up and flourish, with the fittest growing tall and strong and even the weakest making it to a middling height. But in the box with the poor rocky soil, things look different. The weak among the pink seeds don t even make it, and the strongest among them grow only to a middling height. In time the flowers in these 2 boxes go to seed, dropping their progeny into the same soil in which they were growing. The next year the same thing happens, with the red flowers in the rich soil growing full and vigorous and strong, while the pink flowers in the poor soil struggle to survive. And these flowers go to seed. Year after year, the same thing happens. Ten years later the gardener comes to survey her garden. Gazing at the 2 boxes, she says, I was right to prefer red over pink! Look how vibrant and beautiful the red flowers look, and see how pitiful and scrawny the pink ones are. August 2000, Vol. 90, No. 8 American Journal of Public Health 1213 Page 6

10 This part of the story illustrates some important aspects of institutionalized racism. There is the initial historical insult of separating the seed into the 2 different types of soil; the contemporary structural factors of the flower boxes, which keep the soils separate; and the acts of omission in not addressing the differences between the soils over the years. The normative aspects of institutionalized racism are illustrated by the initial preference of the gardener for red over pink. Indeed, her assumption that red is intrinsically better than pink may contribute to a blindness about the difference between the soils. Where is personally mediated racism in this gardener s tale? That occurs when the gardener, disdaining the pink flowers because they look so poor and scraggly, plucks the pink blossoms off before they can even go to seed. Or when a seed from a pink flower has been blown into the rich soil, and she plucks it out before it can establish itself. And where is the internalized racism in this tale? That occurs when a bee comes along to pollinate the pink flowers and the pink flowers say, Stop! Don t bring me any of that pink pollen I prefer the red! The pink flowers have internalized the belief that red is better than pink, because they look across at the other flower box and see the red flowers strong and flourishing. What are we to do if we want to put things right in this garden? Well, we could start by addressing the internalized racism and telling the pink flowers, Pink is beautiful! That might make them feel a bit better, but it will do little to change the conditions in which they live. Or we could address the personally mediated racism by conducting workshops with the gardener to convince her to stop plucking the pink flowers before they have had a chance to go to seed. Maybe she ll stop, or maybe she won t. Yet, even if she is convinced to stop plucking the pink flowers, we have still done nothing to address the poor, rocky condition of the soil in which they live. What we really have to do to set things right in this garden is address the institutionalized racism. We have to break down the boxes and mix up the soil, or we can leave the 2 boxes separate but fertilize the poor soil until it is as rich as the fertile soil. When we do that, the pink flowers will grow at least as strong and vibrant as the red (and perhaps stronger, for they have been selected for survival).and when they do, the pink flowers will no longer think that red pollen is better than pink, because they will look over at the red flowers and see that they are equally strong and beautiful. And although the original gardener may have to go to her grave preferring red over pink, the gardener s children who grow up seeing that pink and red are equally beautiful will be unlikely to develop the same preferences. This story illustrates the relationship between the 3 levels of racism. It also highlights the fact that institutionalized racism is the most fundamental of the 3 levels and must be addressed for important change to occur. Finally, it provides the insight that once institutionalized racism is addressed, the other levels of racism may cure themselves over time. Perhaps the most important question raised by this story is Who is the gardener? After all, the gardener is the one with the power to decide, the power to act, and the control over the resources. In the United States, the gardener is our government. As the story illustrates, there is particular danger when this gardener is not concerned with equity. The current Initiative to Eliminate Racial and Ethnic Disparities in Health by the Year 2010 is to be lauded as the first explicit commitment by the government to achieve equity in health outcomes. Many other questions arise from this simple story. What is the role of public health researchers in vigorously exploring the basis of pink red disparities, including the differences in the soil and the structural factors and acts of omission that maintain those differences? How can we get the gardener to own the whole garden and not be satisfied when only the red flowers thrive? If the gardener will not invest in the whole garden, how can the pink flowers recruit or grow their own gardener? The reader is invited to share this story with family members, neighbors, colleagues, and communities. The questions we raise and the discussions we generate may be the start of a much-needed national conversation on racism. References 1. Jones CP, LaVeist TA, Lillie-Blanton M. Race in the epidemiologic literature: an examination of the American Journal of Epidemiology, 1214 American Journal of Public Health August 2000, Vol. 90, No. 8 Page 7

11 Am J Epidemiol. 1991;134: Cooper R, David R. The biological concept of race and its application to public health and epidemiology. J Health Polit Policy Law. 1986;11: Cavalli-Sforza LL, Menozzi P, Piazza A. The History and Geography of Human Genes. Princeton, NJ: Princeton University Press; 1994: Williams DR. Race and health: basic questions, emerging directions. Ann Epidemiol. 1997;7: Krieger N, Rowley DL, Herman AA, Avery B, Phillips MT. Racism, sexism, and social class: implications for studies of health, disease, and well-being. Am J Prev Med. 1993;9(6 suppl): Jones CP. Methods for Comparing Distributions: Development and Application Exploring Race -Associated Differences in Systolic Blood Pressure [dissertation]. Baltimore, Md: Johns Hopkins School of Hygiene and Public Health; President Clinton announces new racial and ethnic health disparities initiative [White House fact sheet]. Washington, DC: US Dept of Health and Human Services Press Office; February 21, US Dept of Health and Human Services. The Initiative to Eliminate Racial and Ethnic Disparities in Health. Available at: raceandhealth.hhs.gov/. Accessed May 29, Jones MD, Rivers LE, Colburn DR, Dye RT, Rogers WW. A documented history of the incident which occurred at Rosewood, Florida, in January Located at: State Library, Tallahassee, Fla. Also available at: com/klove01/rosehist.txt. Accessed May 29, Love K. Materials on the destruction of Rosewood Florida. Available at: com/klove01/rosedest.htm. Accessed May 29, Canellos PS, Sege I. Couple shot after leaving hospital: baby delivered. Boston Globe. October 24, 1989;Metro/Region section: Jacobs S. Stuart is said to pick out suspect. Boston Globe. December 29, 1989;Metro/Region section: Cullen K, Murphy S, Barnicle M, et al. Stuart dies in jump off Tobin Bridge after police are told he killed his wife: the Stuart murder case. Boston Globe. January 5,1990;Metro/Region section: Graham R. Hoax seen playing on fear, racism: the Stuart murder case. Boston Globe. January 11, 1990;Metro/Region section: Davis R. Prayers lifted up for abducted boys: tots whisked off in S.C. carjacking Tuesday. USA Today. October 27, 1994:10A. 16. Terry D. A woman s false accusation pains many blacks. New York Times. November 6, 1994;section 1: Harrison E. Accused child killer s family apologizes to blacks. Race relations: Susan Smith s brother says that his sister s false claim that an African American man kidnapped her sons was a terrible misfortune. Los Angeles Times. November 9, 1994:A Lewis C. The game is to blame the blacks. Philadelphia Inquirer. November 16, 1994:A15. August 2000, Vol. 90, No. 8 American Journal of Public Health 1215 Page 8

12 10/30/2018 Achieving Equity in cancer prevention and control tools for naming and addressing the impacts of racism on health Camara Phyllis Jones, MD, MPH, PhD Keynote Address 2018 MCC Annual Meeting Celebrating 20 Years of Strong Connections in Cancer Prevention and Control Michigan Cancer Consortium East Lansing, Michigan November 7, 2018 Dual Reality: A restaurant saga D O O R I looked up and noticed a sign... 1 Page 9

13 10/30/2018 Racism structures Open/Closed signs in our society. D O O R It is difficult to recognize a system of inequity that privileges us. Those on the outside are very aware of the two sided nature of the sign. 2 Page 10

14 10/30/2018 D O O R Is there really a two sided sign? Hard to know, when only see Open. A privilege not to HAVE to know. Once DO know, can choose to act. What is racism? A system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what we call race ), that Unfairly disadvantages some individuals and communities Unfairly advantages other individuals and communities Saps the strength of the whole society through the waste of human resources Jones CP. Confronting Institutionalized Racism. Phylon 2003;50(1-2):7-22. Addressing the social determinants of health Primary prevention Safety net programs and secondary prevention Jones CP et al. J Health Care Poor Underserved Acute medical care and tertiary prevention 3 Page 11

15 10/30/2018 But how do disparities arise? Differences in the quality of care received within the health care system Differences in access to health care, including preventive and curative services Differences in life opportunities, exposures, and stresses that result in differences in underlying health status Phelan JC, Link BG, Tehranifar P. Social Conditions as Fundamental Causes of Health Inequalities. J Health Soc Behav 2010;51(S):S28-S40. Byrd WM, Clayton LA. An American Health Dilemma: Race, Medicine, and Health Care in the United States, New York, NY: Routledge, Smedley BD, Stith AY, Nelson AR (editors). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press, Addressing the social determinants of equity: Why are there differences in resources along the cliff face? Why are there differences in who is found at different parts of the cliff? Jones CP et al. J Health Care Poor Underserved dimensions of health intervention Health services Addressing social determinants of health Addressing social determinants of equity Jones CP et al. J Health Care Poor Underserved Page 12

16 10/30/2018 Why do we spend so much money on ambulances at the bottom of the cliff? Jones CP et al. J Health Care Poor Underserved Why are the Greenies launching themselves over the edge of the cliff? Jones CP et al. J Health Care Poor Underserved This situation looks fine to me. What s the problem with a three-dimensional cliff? Jones CP et al. J Health Care Poor Underserved Page 13

17 10/30/2018 Institutionalized Personally-mediated Internalized Levels of Racism Jones CP. Levels of Racism: A Theoretic Framework and a Gardener s Tale. Am J Public Health 2000;90(8): Institutionalized racism Differential access to the goods, services, and opportunities of society, by race Examples Housing, education, employment, income Medical facilities Clean environment Information, resources, voice Explains the association between social class and race Jones CP. Levels of Racism: A Theoretic Framework and a Gardener s Tale. Am J Public Health 2000;90(8): Personally-mediated racism Differential assumptions about the abilities, motives, and intents of others, by race Differential actions based on those assumptions Prejudice and discrimination Examples Police brutality Physician disrespect Shopkeeper vigilance Waiter indifference Teacher devaluation Jones CP. Levels of Racism: A Theoretic Framework and a Gardener s Tale. Am J Public Health 2000;90(8): Page 14

18 10/30/2018 Internalized racism Acceptance by the stigmatized races of negative messages about our own abilities and intrinsic worth Examples Self-devaluation White man s ice is colder syndrome Resignation, helplessness, hopelessness Accepting limitations to our full humanity Jones CP. Levels of Racism: A Theoretic Framework and a Gardener s Tale. Am J Public Health 2000;90(8): Levels of Racism: A Gardener s Tale Jones CP. Levels of Racism: A Theoretic Framework and a Gardener s Tale. Am J Public Health 2000;90(8): Who is the gardener? Power to decide Power to act Control of resources Dangerous when Allied with one group Not concerned with equity Jones CP. Levels of Racism: A Theoretic Framework and a Gardener s Tale. Am J Public Health 2000;90(8): Page 15

19 10/30/2018 How is racism operating here? Identify mechanisms Structures: the who?, what?, when?, and where? of decision-making Policies: the written how? Practices and norms: the unwritten how? Values: the why? Jones CP. Confronting Institutionalized Racism. Phylon 2003;50(1-2):7-22. What is [inequity]? A system of structuring opportunity and assigning value based on [fill in the blank], that Unfairly disadvantages some individuals and communities Unfairly advantages other individuals and communities Saps the strength of the whole society through the waste of human resources Race Gender Many axes of inequity Ethnicity and indigenous status Labor roles and social class markers Nationality, language, and immigration status Sexual orientation and gender identity Disability status Geography Religion Incarceration history These are risk MARKERS 8 Page 16

20 10/30/2018 What is health equity? Health equity is assurance of the conditions for optimal health for all people Achieving health equity requires Valuing all individuals and populations equally Recognizing and rectifying historical injustices Providing resources according to need Health disparities will be eliminated when health equity is achieved Jones CP. Systems of Power, Axes of Inequity: Parallels, Intersections, Braiding the Strands. Medical Care 2014;52(10 Suppl 3):S71-S75. Barriers to achieving health equity Narrow focus on the individual Self-interest narrowly defined Limited sense of interdependence Limited sense of collective efficacy Systems and structures as invisible or irrelevant A-historical culture The present as disconnected from the past Current distribution of advantage/disadvantage as happenstance Systems and structures as givens and immutable Myth of meritocracy Role of hard work Denial of racism Two babies: Equal potential or equal opportunity? Using black holes Look for evidence of two-sided signs Shine the bright light of inquiry Are there differences in outcomes? Are there differences in opportunities, exposures, resources, risks? See the absence of Who is NOT at the table? What is NOT on the agenda? What policies do NOT YET exist? What are we NOT doing? Reveal inaction in the face of need 9 Page 17

21 10/30/2018 Life on a Conveyor Belt: Moving to action Racism is most often passive 1. Name racism 10 Page 18

22 10/30/ Ask How is racism operating here? 3. Organize and strategize to act Camara Phyllis Jones, MD, MPH, PhD Past President American Public Health Association Senior Fellow Satcher Health Leadership Institute and Cardiovascular Research Institute Adjunct Associate Professor Department of Community Health and Preventive Medicine Morehouse School of Medicine (404) (404) mobile 11 Page 19

23 Poster and Reviewed Abstracts 10:15 10:50am Centennial Room Page 20

24 2018 Poster Session ACCESS Hiam Hamade, BSN, MA, MPH, PTA; (2 Posters) 1. Knowledge Assessment and Screening Barriers for Breast Cancer in an Arab American Community in Dearborn, Michigan 2. Colon Cancer in Arab American Knowledge Levels & Screening Services Henry Ford Health System Amanda Holm, MPH; Tobacco Cessation Treatment in Patients Referred for Lung Cancer Screening, November 2015 June 2017 InheRET, Inc. Amanda Cook, BA; InheRET, empowering individuals to accurately identify their risk for hereditary conditions. Karmanos Cancer Institute Knoll Larkin, MPH; Using the Michigan Cancer HealthLink Model to Increase Cancer Survivor/Caregiver Engagement in Cancer Research Michigan Department of Environmental Quality Aaron Berndt, Michigan Indoor Radon Program Specialist; Percentage of Elevated Radon Test Results by County Michigan Department of Health and Human Services Audra Putt, MPH, CPH; Financial Navigation for People Undergoing Cancer Treatment: A White Paper Report Michigan Department of Health and Human Services Taylor Olsabeck, MS; seatont1@michigan.gov Utilizing Surveillance Data to Identify the Needs of Cancer Survivors National Kidney Foundation of Michigan Samantha Raad, LLMSW; sraad@nkfm.org Improving the Quality of Life for Cancer Survivors and Caregivers University of Detroit Mercy School of Dentistry Jill Loewen, RDA, MS; loewenjm@udmercy.edu Highlights of the Memorial Sloan Kettering Cancer Center s Assessment & Treatment of Tobacco Dependence in Cancer Care Training Program Page 21

25 2018 Peer Reviewed Abstracts Health Related Quality of Life among Detroit Lung Cancer Survivors: Findings from the Detroit ROCS studies Author(s): Julia Mantey, MPH, MUP (Wayne State University, Department of Oncology, Detroit, MI & Barbara Ann Karmanos Corresponding Author: Julia Mantey, Engaging in Physical Aactivity after a Cancer Diagnosis: A Detroit ROCS Study Author(s): Julie J. Ruterbusch,(1,2) Ann G. Schwartz,(1,2) Terrance Albrecht,(1,2) Tara Baird,(1,2) Dave Finlay,(2) Felicity Harper, (1,2) Stephanie Pandolfi,(1,2) Julia Mantey,(1,2) Andrew G. Rundle,(3) Jennifer L. Beebe Dimmer (1,2) Author Affiliations: 1. Wayne State University, Department of Oncology, Detroit, MI 2. Barbara Ann Karmanos Cancer Institute, Detroit, MI 3. Mailman School of Public Health, Columbia University, New York, NY Corresponding Author: Julie Ruterbusch, MPH, ruterbus@med.wayne.edu, Treatment of Prostate Cancer Using Cesium 131 Seed Implant: Dosimetric Comparison with Iodine 125 Author(s): Jacquelyn G. Booher DO1, Judith Boura PhD1, Kyle Verdechia, PhD1, Rachel Powell, CMD1, Kimberly Duke RN1, Renu Sharma MS2, Elaine Arterbery MD3, and Todd Campbell MD1, Paul J Chuba, MD, PhD, FACR1. 1Departments of Radiation Oncology and Urology, St John Macomb Oakland Hospital, Warren MI Department of Radiation Oncology, West Michigan Cancer Center, Kalamazoo, MI Department of Radiation Oncology, St Mary's of Michigan, Saginaw MI Corresponding Author: Jacquelyn Booher, greinerj7@gmail.com, Implementing a Clinical Decision Aid Tool, Personal Patient Profile Prostate (P3P), for localized prostate cancer patients across the state of Michigan Author(s): Stephanie Ferrante* Ann Arbor, MI, Susan Linsell, MHSA* Ann Arbor, MI ; Tae Kim* Ann Arbor, MI;, Donna Berry, PhD, RN, AOCN, FAAN** Boston, MA; Conrad Maitland, MD*** Detroit, MI; Arvin George, MD* Ann Arbor, MI; James Montie, MD* Ann Arbor, MI for the Michigan Urological Surgery Improvement Collaborative (MUSIC) *Michigan Medicine Department of Urology ** Dana Farber Cancer Center *** Sherwood Medical Center Corresponding Author: Stephanie Ferrante, sferrant@med.umich.edu, Page 22

26 Concurrent Session A Room 103AB Cancer Pain: A Deeper Look into the Experience Across the Continuum of Care Pain from cancer treatment can affect survivors throughout the treatment continuum. This session will address cancer pain during treatment by exploring the concept of earlier palliative care referrals, chronic pain in survivorship through describing the role of cancer rehabilitation in addressing pain and the importance of pain management in end of life care. Speakers Sandy VanBrouwer, MSN; Pediatric Pain and Palliative Medicine at Helen DeVos Children's Hospital Sean Smith, MD; Cancer Rehabilitation Medicine at Michigan Medicine Angela Chmielewski, MD; Hospice and Palliative Medicine at Beaumont Hospital Royal Oak Moderator: Deb Doherty, PT, PhD, CEAS; Michigan Physical Therapy Association. Page 23

27 10/29/2018 Acute pain in the midst of cancer therapy Sandy Van Brouwer, ACNP/PNP Pediatric Palliative Care Helen DeVos Children s Hospital sandra.vanbrouwer@helendevoschildrens.org Objectives Identify inciting factors Discuss aspects of management Pediatric highlights Framing the discussion Cancer pain and opioids Majority of persons (adults and children) suffer from pain Opioids play an inevitable role at some point in one s disease evolution and cancer therapy Opioid related relief is seldom all or nothing Need to balance analgesia versus toxicity when it tips towards toxicity Opioid poorly responsive pain 1 Page 24

28 10/29/2018 Possible differentials of poor responders Cancer related pain Progression Sequelae (i.e. neuropathy, skin ulceration, muscle pain) known to be less responsive to systemic opioids or opioid monotherapy Psychology/spiritual pain related to the cancer experience Opioid pharmacology/technical problems Non cancer pain Other psychological problems Management strategies bird s eye view Non Opioids Acetaminophen NSAIDS Integrative Therapies Massage Distraction Deep Breathing Biofeedback Aromatherapy Hypnosis Opioids Tramadol* Morphine 4 WHO Principles By the clockʺ Psychology CBT Rehabilitation Exercise Physical therapy Sleep Hygiene Occupational Therapy Child Life Invasive Approaches Palliative radiation Regional anesthesia Neuraxial anesthesia Epidural or intrathecal Nerve blocks Neurolytic blocks Adjuvants Alpha agonist Gabapentinoids TCA/Antidepress ants NMDA Antagonists Na channel blockers Management strategies Initial steps Non opioids Maximize single opioid until change is required Treat opioid toxicities aggressively and creatively Non Opioids Acetaminophen NSAIDS Opioids Tramadol* Morphine 4 WHO Principles ʺBy the clockʺ 2 Page 25

29 10/29/2018 Management strategies Next steps Non pharmacologic strategies Utilize adjuvant analgesics Integrative Therapies Massage Distraction Deep Breathing Biofeedback Aromatherapy Hypnosis Adjuvants Alpha agonist Gabapentinoids TCA/Antidepress ants NMDA Antagonists Na channel blockers Psychology CBT Rehabilitation Exercise Physical therapy Sleep Hygiene Occupational Therapy Child Life Special consideration Breakthrough pain Incidence: more than half for both children and adults Which route to pursue? PCA limited to patient location? Special consideration Procedural pain Benzodiazepine, opioid, Na channel blocker 4 must haves Nitrous oxide Creative palliative home infusions 3 Page 26

30 10/29/2018 Treating Chronic Pain in Cancer Survivors: Diagnose and Rehabilitate Sean Smith MD Assistant Professor, Michigan Medicine Medical Director, Cancer Rehabilitation Disclosures None Outline Impact of chronic pain in cancer survivors Opioid prescribing for chronic pain Diagnosing the problem Case example 1 Page 27

31 10/29/2018 Chronic Pain in Cancer Patients Chronic pain is due to treatment and/or direct tumor damage Chronic pain alters mechanics/function, leads to more pain Pain associated with fatigue, anxiety, sleep deficits, distress Huang, I Chan, et al. "Differential impact of symptom prevalence and chronic conditions on quality of life in cancer survivors and non cancer individuals: a population study. Cancer Epidemiology and Prevention Biomarkers (2017): cebp Risk Factors for Pain Pre cancer pain Poor coping mechanisms/social support Psychosocial distress Increased number of surgeries Poor sleep Radiation Surgery Pain Fatigue Depression 2 Page 28

32 10/29/2018 So What Can Treat Chronic Pain? Not one pill. Probably not one shot. Probably not one physical therapy Rx. Cure it first. Treat it second. Haig, Andrew J., and Martin Grabois. "Chronic pain: cure it first, treat it second." PM&R 7.11 (2015): S324 S325. Pain Comes From Something! RTC/etc Pec dysfunction Myofascial Breast Cancer Rib pain, notalgia paresthetica Edema, plexopathy, radic, etc Axillary web Synovitis Trigger finger 3 Page 29

33 10/29/2018 Aim at a Target Pain management requires setting expectations What are YOU treating? What are your options if the Plan A fails? What does the patient want? Are the patient s expectations reasonable? Opioid Prescribing Low risk of abuse with cancer pain High risk of dependence for non cancer pain Risk of overdose/death, constipation, fatigue, hypotension, immunosuppression, hyperalgesia, and more Not shown to reduce pain or improve function in chronic, non cancer pain Non Opioid Pharmacologic Analgesia What about other medications? What is your plan? What are their expectations? 4 Page 30

34 10/29/2018 Will a Pill Fix This? Rehabilitation Medicine Paradigm Multidisciplinary approach that: Thoroughly evaluates for cancer and non cancer related causes of pain Reduces symptom burden Focuses on function Uses a biopsychosocial model to diagnose/treat emotional contributors Rehabilitation Team Physiatrist (PM&R physician) PT OT (often treat lymphedema) Speech pathology (includes memory/cog) Neuropsych 5 Page 31

35 10/29/2018 When Do You Refer to PM&R? Unsure about diagnosis Need medical management, including procedures Coordinating multiple specialties Did not get better with PT (etc) referral Case Example 51 year old woman with a history of stage II breast cancer, ER positive, treated 2.5 years ago with: Mastectomy with ALND AC T Radiation, 66.5 Gy in 1.9 Gy fractions Has right shoulder, chest, arm pain. This began during treatment, has worsened over time Physical Exam Shoulder: positive Hawkins test, pain with overhead movements. Tight/tender upper trapezius, SCM. Sore rhomboids Chest: moving shoulder causes pain to radiate anteriorly into the chest. Tight pec. Tender along sixth rib, and Tinel s sign radiates around anteriorly Arm: Obvious stage II lymphedema, not wrapped. Skin is red. 6 Page 32

36 10/29/2018 RTC/etc Pec dysfunction Myofascial Example Rib pain Edema Diagnoses Shoulder: rotator cuff impingement, myofascial pain Chest: pec spasm, scapulothoracic bursitis, intercostal neuralgia Arm: lymphedema, probably cellulitis RTC/etc Pec dysfunction Myofascial Is a Pill Going to Fix This? Rib pain Edema 7 Page 33

37 10/29/2018 Pec Shortening Treatment Shoulder: Home exercise program, PT. If this fails, steroid injection PRN. Chest: Ultrasound guided scapulothoracic bursa or intercostal blocks; depends on results of PT. Arm: Antibiotics, OT for lymphedema treatment, garment. Education about skin care. 8 Page 34

38 10/29/2018 Summary Patients without evidence of disease do not have cancer related pain They often have several pain generators compounded by psychosocial distress Pain management should have an anatomic approach Multi modal rehabilitation is often needed to restore function and quality of life Thank you! 9 Page 35

39 10/29/2018 Pain Management As End of Life Nears Michigan Cancer Consortium Annual Meeting November 7 th, 2018 Angela Chmielewski, MD HMDC Chief, Palliative Care Clinical Services Beaumont Health Angela.chmielewski@Beaumont.edu Pain Assessment Patient s self report is the gold standard Use of standardized scales to rate pain severity is a best practice standard Scale will depend on patient Verbal Rating Scale (0 10) Wong Baker FACES pain rating scale FLACC (Faces; Legs; Activity; Cry; Consolability) Edmonton Symptom Assessment System (ESAS) Pain Assessment Continued Nonverbal indicators of pain Facial tension, grimace/brow furrow, wincing Bracing/tightening Vocalization, crying, moaning Restlessness Observe incident pain 10/29/ Page 36

40 10/29/2018 Pain Management WHO ladder Same approach may be used for life limiting illnesses Level and type of pain should guide intervention Non pharmacological strategies and adjuvants should be considered at each step Treatment Approach Identify source and mechanism Treat underlying disease if possible Select therapy based on mechanism/cause and severity Use short acting medications for acute paintitrate to relief Consider available routes* Anticipate side effects Sedation may be a side effect, or dying process 10/29/ Principles of Opioid Prescribing Choose the right drug for the level of pain, clinical situation, mechanism and available routes for administration Titrate up 25 50% per day for mild moderate pain, % per day for moderate severe pain No Ceiling dose Can use shorter time frame for titration inpatient and at end of life Schedule around the clock doses in addition to as needed doses for ongoing sources of pain Anticipate and prevent side effects Use appropriate (and dual purposed) adjuvant medication A simple regimen is best 10/29/ Page 37

41 10/29/2018 References Doyle D, et al. Oxford Textbook of Palliative Medicine, 3 rd edition American Academy of Hospice and Palliative Medicine, Essential Practices Unipac 3, 2017 American Academy of Hospice and Palliative Medicine, UNIPAC 3, 2008 Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care 1991; 7:6 9. Herr K, et al. Pain Assessment in the Patient Unable to Self Report: Position Statement with Clincial Practice Recommendations.Pain Manage Nurs,2011 Dec;12(4): Quill TE, et al. Primer of Palliative Care, 6 th edition. American Academy of Hospice and Palliative Medicine, Roth, SH, Shainhouse JZ. Efficacy and safely of topical dicolfenac solution (Pennsaid) in the treatment of primary osteoarthritis of the knee. Arch Intern Med. 2004; Heiskanen T, et al. Transdermal fentanyl in cachectic cancer patients. Pain. 2009; 144: /29/ Page 38

42 Concurrent Session B Room 104AB Your Role in Increasing HPV Vaccination Rates in Michigan According to the CDC, over 30,000 people in the US are affected by HPV associated Cancers each year. While the HPV vaccine provides safe, effective and lasting protection against HPV infections that most commonly cause cancer, vaccination rates for children in MI are slow to climb. This breakout session will shed light on ways to improve HPV vaccine uptake through policies and systems change at provider offices; examine current MI HPV vaccination rates and related data; and offer a better understanding of why the HPV vaccine is so important for cancer prevention. Speakers Stephanie Sanchez; Division of Immunization at MDHHS Marcus DeGraw, MD; St. John Hospital and Medical Center Cristiane Squarize, DDS, MS, PhD; Periodontics and Oral Medicine at University of Michigan Carolyn Johnston, MD; Gynecological Oncology at Michigan Medicine, Rogel Cancer Center Moderator: Thomas Rich, MPH; American Cancer Society, Inc. North Central Region Page 39

43 Top 10 Tips for HPV Vaccination Success Attain and Maintain High HPV Vaccination Rates 1 Appreciate 2 Acknowledge 3 Use 4 Motivate 5 Implement 6 Use 7 Know 8 Maintain 9 Learn 10 the significance of achieving high HPV vaccination rates. the importance your recommendation has when it comes to parents choosing to get their children vaccinated. an effective approach by bundling your vaccine recommendation. your team and encourage their immunization conversations with parents. systems to ensure you never miss an opportunity to vaccinate. your local health department s resources. your rates of vaccination and refusal. strong doctor-patient relationships to help with challenging immunization conversations. how to answer some of parents most common questions about HPV vaccine. Use personal examples of how you choose to vaccinate children in your family. By boosting HPV vaccination rates among your patients, you will be preventing cancer. Clinician recommendation is the number one reason parents decide to vaccinate. This is especially important for HPV vaccination. Recommend the HPV vaccine the same day and the same way you recommend all other vaccines. For example, Now that Danny is 11, he is due for vaccinations to help protect against meningitis, HPV cancers, and whooping cough. We ll give those shots during today s visit. Do you have any questions about these vaccines? Starting with your front office, ensure each team member is aware of HPV vaccine s importance and is educated on proper vaccination practices and recommendations, ready to answer parents questions, and/or regularly remind and recall parents. Be sure staff regularly check immunization records, place calls to remind families about getting vaccines, and let you know if parents have additional questions. Establish a policy to vaccinate at every visit. Create a system to check immunization status ahead of all visits. Before seeing the patient, staff should indicate if the patient is due for immunization, with special consideration to HPV vaccination. Use standing orders. Use the resources of the local health department to achieve your goals of protecting your patients. Deputize your staff to assist you with knowing your actual vaccination rates and learning more about why some patients are behind on their vaccines. They can also help you facilitate solutions on how to bring these patients in and get or keep immunization rates up. It is extremely gratifying when parents who initially questioned immunization agree to get their child vaccinated on time. It s always nice to hear: Okay, that makes sense and I trust you! Be prepared to answer parents questions succinctly, accurately, and empathetically by using terms that they understand. A parent will often accept your explanations if presented with their children s best interests in mind. Providing personal examples shows you believe in the importance of immunizations, especially HPV vaccine. These examples combined with an effective recommendation can help parents better understand the benefits of HPV vaccination for cancer prevention. Adapted with Permission from: Khatib, B. (2015) The 10 Immunization Success Factors: Practical Strategies for Providers. Unpublished manuscript. Page 40

44 THROUGH HPV VACCINATION AN ACTION GUIDE FOR PHYSICIANS, PHYSICIAN ASSISTANTS, AND NURSE PRACTITIONERS You have the power to reduce the incidence of human papillomavirus (HPV) cancers and pre-cancers among patients in your care. HPV cancer prevention starts with you. Make it your goal for every patient you care for to be vaccinated against HPV before the age of 13. Every member of a practice plays a critical role in advocating for HPV vaccination as cancer prevention and should work together as a team. TEAM APPROACH EVALUATE & SUSTAIN SUCCESS STRONG RECOMMENDATION HPV CANCER PREVENTION STARTS WITH YOU ANSWER QUESTIONS NO MISSED OPPORTUNITIES TAKE THESE ACTIONS TO INCREASE HPV VACCINATION WITHIN YOUR PRACTICE TODAY. Make a presumptive recommendation Your recommendation is the #1 reason parents choose to vaccinate their children. Answer parents questions Let parents know the vaccine is safe, effective and prevents cancers. Minimize missed opportunities Use every opportunity to vaccinate and keep patients up-to-date. Use EHR prompts to help. Take the team approach Empower every member of the team to be a HPV vaccination champion. Provide in-service training. Discuss vaccination status at huddles. Practice messaging HPV vaccination is cancer prevention. Evaluate and sustain success Implement quality improvement strategies to drive up HPV vaccination rates to be on par with your Tdap and MenACWY rates. DOWNLOAD the full Action Guide at hpvroundtable.org/action-guides. To review the entire guide and citations, visit hpvroundtable.org/wp-content/uploads/2018/04/providers-action-guide-web.pdf Page 41

45 Screening won t protect your patients from most HPV cancers. your preteen patients today with HPV vaccine. Cervical Cancer Just the tip of the iceberg. Cervical cancer is the only type of HPV cancer for which there is a recommended screening test. Even with screening, in the United States women are diagnosed with cervical cancer each year. 12,000 Source: CDC. Cancers associated with human papillomavirus, United States USCS data brief, no. 1. Atlanta, GA: Centers for Disease Control and Prevention ( Cervical Precancers While cervical precancers are routinely screened for, these precancers may require invasive testing and treatment. Sources: Joura EA. et al. Cancer Epidemiol Biomarkers Prev Oct;23(10): Guan P. et al. Int J Cancer Nov 15;131(10): Other HPV Cancers Cases Every Year ~216,000 High Grade Cervical Lesions Cases Every Year 800 Penile Cancer ~468,700 Low Grade Cervical Precancers 3,200 5,700 12,200 Vulvar & Vaginal Cancer Anal / Rectal Cancer Oropharyngeal Cancer Recommended cancer screening tests are not available yet for these cancers. These cancers may not be detected until they cause health problems. OVER 90% of HPV cancers are preventable through HPV vaccination. Source: CDC. Cancers associated with human papillomavirus, United States USCS data brief, no. 1. Atlanta, GA: Centers for Disease Control and Prevention ( Don t rely on screening to catch it later. Protect them now with HPV vaccination. Page 42

46 Want Best Practice Strategies for Increasing HPV Vaccination Rates? Get the go-to-guide for health care professionals and systems to increase HPV vaccination rates. The experts of the National HPV Vaccination Roundtable have assembled the most effective interventions and promising strategies into short, easy to implement guides. Each guide has tips and strategies that will impact your immunization rates. Each Clinician and System Action Guide has role-specific actions along with: best practice actions, interventions and promising strategies interactive links including links for Continuing Education rationale for prioritizing HPV vaccination detailed appendix of resources facts about HPV cancers and vaccination DOWNLOAD the FREE National HPV Roundtable s Clinician and System Action Guides Today! hpvroundtable.org/ action-guides Page 43

47 Physicians/ Physician Assistants/ Nurse Practitioners Nurses & Medical Assistants Dental Health Professionals All guides are available online for free download at hpvroundtable.org/ action-guides. Large Health System Leaders Office Administrative Teams Small Private Practice Leaders By using these guides to improve HPV vaccination, your practice or health system can lower costs associated with treatment, reduce future suffering, and ultimately help save patients lives. We hope clinicians and health systems across the county can use this information to raise HPV vaccination rates. The guides represent our best current knowledge to help promote the prevention of HPV cancers. There is so much potential in sharing this knowledge, said Margot Savoy, MD, chair of the National HPV Vaccination Roundtable Provider Training Task Group. Let us know what your system is doing to increase HPV vaccination rates through our We re In Story Collector at hpvroundtable.org/were-in. Questions about the guides? Reach us at Page 44

48 Michigan HPV Immunization Data Update November 2018 Stephanie Sanchez Immunization Quality Improvement Coordinator Bureau of Child & Family Services, Division of Immunization Together, we can prevent cancer We can prevent more than 30,000 cancers each year! 91 of cervical & anal cancers HPV is linked with: of penile cancers % % % of oropharyngeal cancers PROBLEM Low HPV vaccination rates ~31,500 cases of HPV cancers each year Causes 6 types of cancer and nearly ALL cases of cervical cancer Note: Presentation may include additional or updated slides and the order may be changed Page 45

49 The HPV vaccine is cancer prevention! Boys and Girls Boys and girls should get the HPV vaccine series by age 13, starting as early as age 9. It works! Since the release of the vaccine, infections that cause most HPV cancers and genital warts have dropped 71% among teen girls. Increase Rates Make it your goal for every age eligible patient you care for to be vaccinated against HPV NIS Teen Data, Adolescents 13 through 17 years of age National Data Coverage is 85% or higher for: 1 Tdap, 1 MenACWY, 2 MMR, and 2 Varicella 56% of adolescents have not received both doses of meningococcal conjugate vaccine. 51% of adolescents have not received all the recommended doses of HPV vaccine. HPV coverage is higher among adolescents living below the federal poverty level compared to those at or above the poverty level 1 HPV: 73.3% compared to 53.7% HPV UTD: 62.8% compared to 46.7% Michigan Data Compared to 2016 MI data, coverage estimates were similar Notable increase: HPV UTD from 44.8% (±7.0) to 54.3% (±6.4) Michigan has higher point estimates than the national average 1 Tdap: 93.4% vs. 88.7% 1 MenACWY: 93.5% vs. 85.1% 1 HPV: 67.3% vs. 65.5% HPV UTD: 54.3% vs. 48.6% Data source: Note: Presentation may include additional or updated slides and the order may be changed Page 46

50 Note: Presentation may include additional or updated slides and the order may be changed Page 47

51 Note: Presentation may include additional or updated slides and the order may be changed Page 48

52 Michigan Cervical Lesion Rates by HPV Vaccine Status MCIR 2 Data Linked to Michigan Cancer Surveillance Program 1 Data 250 Rate per 10,000 Women No HPV Vaccine Vaccine Incomplete HPV Complete HPV Vaccine Mei You, MS 1 ; Rachel Potter, DVM MS 2 ; Glenn Copeland, MBA 1 ; Georgetta Alverson, CTR 1 ; Robert Swanson, MPH 2 Best practices to increase HPV vaccination Action Guides Clinician Action Guides: MD, NP, PA RNs, MAs Office teams Dental professionals Systems Guides: Large Health Systems Small Private Practices hpvroundtable.org/action guides Note: Presentation may include additional or updated slides and the order may be changed Page 49

53 Speak with 1 Message to promote timely HPV vaccination Use your influence to encourage cancer prevention Speak with 1 Message to promote timely HPV vaccination Exemplify a proimmunization attitude HPV Cancer Prevention Starts With YOU! You have the power to reduce the incidence of human papillomavirus cancers and precancers among patients in your care. Note: Presentation may include additional or updated slides and the order may be changed Page 50

54 Michigan HPV Immunization Data Update November 2018 Stephanie Sanchez Immunization Quality Improvement Coordinator Bureau of Child & Family Services, Division of Immunization Note: Presentation may include additional or updated slides and the order may be changed Page 51

55 10/29/2018 THE GYNECOLOGIC CONSEQUENCES OF HPV INFECTION or WHY WE SHOULD ENCOURAGE VACCINATION Carolyn Johnston, MD, FGCPS Michigan Medicine November 2018 I HAVE NO CONFLICTS TO DISCLOSE DO YOU WANT YOURSELF, YOUR FAMILY OR ANYONE TO HAVE THESE DISEASES OR THEIR CONSEQUENCES?? *SOME OF THE FOLLOWING IMAGES MAY BE TOO GRAPHIC FOR YOU, SO IF YOU DO NOT WANT TO SEE THEM, THEN SKIP SLIDES Page 52

56 10/29/2018 VULVA HPV IN AN 18 Y/O WOMAN VULVA GENITAL WARTS AT 22 WK GESTATION IN A 15 YEAR OLD VULVA VIN3 2 Page 53

57 10/29/2018 VULVAR CANCER AGE DIFFERENCES YOUNG ELDERLY VAGINAL HPV IN A YOUNG WOMAN VULVO VAGINAL CANCER 3 Page 54

58 10/29/2018 ANUS EXTERNAL GENITAL WARTS ANUS AIN 3 ANAL CANCER 4 Page 55

59 10/29/2018 PENIS WARTS PENIS SIL CERVICAL CANCER IN AN 18 YEAR OLD WOMAN 5 Page 56

60 10/29/2018 INVASIVE CERVICAL CANCER LYMPHEDEMA AND CONSIDER THIS. That vaginal cancer is treated primarily with radiation and chemotherapy leading to vaginal stenosis in 33 to nearly 80% of women That vulvar cancer treatment reduces women to the 4th percentile of body image That cervical cancer is most often treated with either radical hysterectomy or radiation and chemotherapy leading to personal inability to bear children despite being young That treatment of the much more common precursor lesions of these diseases can lead to changes in sexuality, marked physical disfigurement and to preterm labor Lymphedema is under appreciated and a common consequence of lymph node dissections especially when combined with radiation treatment 6 Page 57

61 10/29/2018 Approximately 100 subtypes HPV SUBTYPES Divided by their ability to cause pre and malignant diseases Low risk 6, 11, 40, 42, 43, 44, 53, 54, 61, 72, 73 and 81 High risk 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68 HPV 16 is most commonly linked with the pre malignant lesions and is associated with the highest risk of progression to cancer HPV INFECTIONS ETIOLOGIC ROLE IN CANCERS HPV DNA is commonly present in cancers of the lower genital tract, anus and oropharyngeal sites The best epidemiologic etiologic data comes from cervical cancer which shows HPV to be the major risk factor Viral oncogenes, E6 and E7, are demonstrated in these lesions E6 and E7 oncoproteins are required to maintain cancer phenotype Due to the immortalizing and transforming properties of these, that target the p53 and prb tumor suppressor pathways, respectively, rendering infected cells susceptible to mutations and cancer formation HPV INFECTIONS ETIOLOGIC ROLE IN CANCERS Percentage of cancers attributed to HPV (CDC 2018) Cervix % Vulva 69% Vaginal 75% Anal >90% Penis >60% (3.6 84%) Oropharyngeal SCCA > 70% 7 Page 58

62 10/29/2018 PREVALENCE OF HPV RELATED CANCERS CDC 2018 REPORT Based on data from 2010 to 2014 ~41,000 HPV associated cancers occur in the USA each year ~23,700 among women ~17,300 among men Cervical cancer is the most common HPV associated cancer among women Oropharyngeal cancers (cancers of the back of the throat, including the base of the tongue and tonsils) are the most common among men GENITAL HPV PREVALENCE IN THE USA Any genital HPV prevalence among all adults aged % 45.2% among men 39.9% among women HR genital HPV prevalence in the total population 22.7% 25.1% among men 20.4% among women Non Hispanic Asian adults had the lowest prevalence of any and high risk genital HPV among the total population and among men and women Non Hispanic black adults had the highest prevalence of any and high risk genital HPV among the total population and among men and women Prevalence is higher among men than women for both any and HR genital HPV in the total population and among non Hispanic white adults CDC/National Center for Health Statistics 4/2017, GENITAL HPV PREVALENCE IN THE USA 80% of women by the time that they reach age 50 will have at an HPV infection Cumulative incidence, although does not equal persistence!!! 8 Page 59

63 10/29/2018 DEVELOPMENT OF HPV DNA POSITIVITY Women (%) % of the college students had been HPV-DNA positive by 2 years of follow-up and 80% became positive with increased follow-up Follow-up (mo) Winer RL et al. Am J Epidemiol. 2003;157: HR HPV INFECTION AND CERVIX CANCER The longer the HR HPV infection persists, the higher the risk of cervical cancer or its precursors ie dysplasia or CIN 65% of women with cervical HPV 16/18 infection that lasts > 6 months developed SIL and/or CIN HPV TRANSMISSION There are many ways to get HPV, although sexual transmission seems to be the most common HPV DNA has been found in female virgins, women who only have sex with women, and children with no evidence of sexual abuse HPV has also been reported to be transmitted from hands to genitals or genitals to hands among both sexes and heterosexual couples Studies also indicate that HPV has the potential to be transmitted via contaminated medical instruments and environments 9 Page 60

64 10/29/2018 COMMON FACTORS FOR ACQUIRING HPV INFECTIONS Sexual Activity Most consistent predictor of genital HPV infection Close skin to skin contact with an infected area Unprotected intercourse Need not be penetrative Digital/anal contact Digital/vagina contact Oral/LGT contact Fomites Primary and secondary immunodeficiencies HPV INFECTIONS Transmission is often asymptomatic Thus unaware of risk Type specific concordance between partners 25% More transmissible from females to males From cervix to penis than from penis to cervix At least in this study, transmission was linked to sexual activity and condom use Sub Saharan Africa has the most different types of pathogenic HPV subtypes and co infection varieties HPV INFECTIONS Mean duration of oncogenic HPV infection is ~ 8 months Mean duration of non oncogenic HPV infection is ~4.8 months Persistence varies with age, and many other factors Persistent infection with HPV is a prerequisite for the development of cervical cancer and its precursors. J Natl Cancer Inst Monogr. 2003;31: Page 61

65 10/29/2018 Cervical cancer and HPV acquisition share many risk factors Most ano genital and some oropharyngeal cancers do also There are likely co factors which encourage the development of cervical cancer in HPV infected women Smoking Immunosuppression Oral contraceptives High parity Others we do not know Same is true for other HPV related cancers VAGINAL CANCER EPIDEMIOLOGY Primary Vaginal Cancer is rare 2% of all Gynecologic Cancers An estimated 5170 cases and 1330 deaths (ACS Cancer Facts & Figures, 2018) HPV related is more common in Black women Mostly a disease of post menopausal and elderly women 85 90% are squamous cell carcinomas Most Vaginal Cancers are metastatic from cervix, endometrium, vulva Precursor lesion 75% related to HPV infection VAIN Less common than CIN and VIN Similar risk factors except lower association with smoking and poor nutrition Up to 30% of patients with primary vaginal carcinoma have a history of in situ or invasive cervical cancer treated at least 5 years earlier VULVAR CANCER EPIDEMIOLOGY Also rare 4.4% of all gynecologic cancers 0.5% of cancer in women 87% squamous cell cancers Incidence increasing since mid 1970s By 0.5% per year Buchanan et al. Morbidity and mortality of vulvar and vaginal cancers: Impact of 2, 4, and 9 valent HPV vaccines. HUMAN VACCINES & IMMUNOTHERAPEUTICS 2016, VOL. 12, NO. 6, An estimated 6190 new cases and 1200 deaths in the USA in 2018 More white women get HPV related vulvar ca than other races ACS Cancer Facts & Figures, 2018 Mean age 65 Precursor lesions VIN 86% are HPV related (Trimble CL, et al. Obstet Gynecol 1996; 87: 59 64) Younger women Risk factors same as for cervical cancer dvin Lichen sclerosus Postmenopausal women 11 Page 62

66 10/29/2018 CERVICAL CANCER ACS ESTIMATES IN 2018 More common ~13,240 new cases diagnosed ~4,170 women will die Cervical pre cancers are diagnosed far more often than invasive cervical cancer Types SCCA 65 80% (decreasing) Adenocarcinoma 25% (rising) Median age at diagnosis is 48 50% of women are between the ages of Rarely occurs in women younger than 20 >15% of cases are found in women over 65 These rarely occur in women who have been getting regular screening tests before age American Cancer Society, Inc. CERVICAL CANCER AT AGE > 65 Sarah Dilley, MD, MPH, et al. SGO abstract 55. March % of cervical cancer cases were diagnosed in women age > 65 from Surveillance, Epidemiology and End Results (SEER 18) program database 18.9% of cervical cancer cases were diagnosed in women age > 65 from National Cancer Database When stratified by age 22.9% of African American women who are diagnosed with cervical cancer are age age > 65 vs 20.5% of non Hispanic white women. CERVICAL CANCER EPIDEMIOLOGY In the United States Hispanic women > African Americans > Asians and Pacific Islanders > whites American Indians and Alaskan natives have the lowest risk of cervical cancer in the US 2018 American Cancer Society, Inc. 12 Page 63

67 10/29/2018 AGE ADJUSTED INCIDENCE RATES FOR HPV ASSOCIATED CERVICAL CANCER IN THE USA CERVICAL CANCER EPIDEMIOLOGY 527,624 new cervical cancer cases diagnosed worldwide annually (2012, IARC Globocan) 265,672 cervical cancer deaths worldwide (2012) Cervical cancer is the third most common cancer in women aged years worldwide Universally an HPV caused disease Prevalence of HPV DNA in cervical cancer is 99.7% Wal boomers (1999) analyzed cervical cancers from in 22 countries and found HPV DNA in 99.7%. J Pathol. 1999;189:12 19 Very few HPV infections actually become cervical cancer HPV 16 and HPV 18 cause approximately 70% of cervical cancers worldwide HPV 31, 33, 45, 52 and 58 cause another 20% CERVICAL INTRAEPITHELIAL NEOPLASIA (CIN) PRE CANCER The precursor lesion to cervical cancer 4x more common than invasive cancer 1,259,000 cases of CIN per year in USA 65,000 case of CIN 3 per year The risk of progression overall is 1% and but closer to 40% for CIS but over many years Detectable and treatable in part due to the relatively long pre invasive time period 13 Page 64

68 10/29/2018 By detecting and treating pre cancers before they become cancer Regular screening By preventing the pre cancers HPV vaccine Use of condoms to reduce HPV infection Smoking avoidance Avoid behaviors such as: Having sex at an early age Having many sex partners Having a partner who has had many sex partners Gardisil HPV 6, 11, 16, 18 Cervarix HPV 16, 18 Gardisil 9 HPV 6, 11, 16, 18, 31, 33, 45, 52, and Page 65

69 10/29/2018 HPV VACCINE SUCCESS HPV vaccination rates are closely tied to the implementation of school based programs Those countries with the highest uptake of vaccination have done so USA is approximately 40% overall and not school based Administration should be based on AGE, not onset of sexual activity SEXUAL ACTIVITY IN MICHIGAN 2013 DATA 8% of 13 year olds have had sex 38% of Michigan high school students (ages 12 18) have had sexual intercourse at least once 13.5% of high school seniors have had at least four sexual partners HPV VACCINATION RATES BY COUNTY IN MICHIGAN _4911_4914_ ,00.html If you have questions on the report, please contact Cristi Bramer at or Page 66

70 10/29/ Page 67

71 Concurrent Session C Room 105AB Using Virtual Care to Address Health Disparities Among Cancer Patients Virtual care, also known as telemedicine, is described as the use of technology to overcome barriers that prevent patients from receiving optimal health care. Virtual care is becoming an increasingly popular tool in the care of oncology patients throughout their cancer treatment. This session will explore Michigan s rules and regulations related to virtual care, including how Medicaid and insurance companies reimburse for these services. A panel will address how health systems are implementing virtual care programs, discussing clinic-to-clinic and clinic-to-home programs which provide pre and post treatment access for hard to reach cancer patient populations. Speaker Becky Sanders, MBA; Upper Midwest Telehealth Resource Center Panelists Marie Lee, M.Ed, PMP; Henry Ford Health System Geralyn Roobol, LMSW, RN, BS, CMAC; Spectrum Health Cancer Program Moderator: Maria George, MPH; Cancer Communications Consultant at Michigan Department of Health and Human Services Page 68

72 10/30/2018 Michigan Cancer Consortium Annual Meeting November 7, 2018 Becky Sanders, Program Director Upper Midwest Telehealth Resource Center This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number G22RH30351 under the Telehealth Resource Center Grant Program for $325,000. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government. Reach UMTRC Benchmark Study January industrysurvey/ Reach UMTRC Benchmark Study January industrysurvey/ 1 Page 69

73 10/30/2018 National Consortium of Telehealth Resource Centers UMTRC Services Virtual Librarians Individual Consultation Technical Assistance Connections with other programs Presentations & Trainings Project assessments Updates on reimbursement policy and legislative developments 2 Page 70

74 10/30/2018 Definitions and Concepts Telehealth and Telemedicine Sometimes used interchangeably Two types of distinctions Telehealth = Broader field of distance health activities (CME, etc.) Clinical remote monitoring (usually at home) Telemedicine = billable interactive clinical services Types of Telemedicine Asynchronous Describes store and forward transmission of medical images or information because the transmission typically occurs in one direction in time. (Store and forward telemedicine) Synchronous Describes interactive video connections because the transmission of information in both directions is occurring at exactly the same period. (Live and Interactive Telemedicine) ADVANTAGES No scheduling constraints. Less burdensome technical requirements. Low connection and equipment costs. (POTS) Information stored centrally, more secure. Store and Forward DISADVANTAGES Limited Specialties. Delay in getting feedback. No patient provider interaction. Incomplete view of the case. Limited reimbursement. 3 Page 71

75 10/30/2018 What is Store and Forward Store and Forward: A Web based telemedicine application that allows for the secure transfer of; Patient medical records Vital Signs Pictures Blood Sugars Video footage ECGs EKGs EEGs Patient Doctor Firewall Secure Server Doctor PCP Telehealth Platform Specialist Encrypted Data What is Live and Interactive Telemedicine? Utilizing videoconferencing technology to provide real time medical consultation between provider and patient or provider and provider. Service vs. Delivery Mechanism TH is not a service, but a delivery mechanism for health care services Most TH services duplicate in person care Some are made better or possible with TH Reimbursement equal to in person care 4 Page 72

76 10/30/2018 Federal Telemedicine Law & Policy Professionals are regulated at the state level (doctors, nurses, counselors, etc.) Medicare: Pays for certain outpatient professional services (CPT codes) for patients accessing care in rural counties and HPSAs in rural census tracts. *No regs; only conditions of payment. Medicaid: Telemedicine is a cost effective alternative to the more traditional face to face way of providing medical care that states can choose to cover. Medicare Telehealth Reimbursement Requirements Patient Outside of a MSA Patient in Designated Originating site Services within CPT Code Range Services Delivered by Eligible Practitioners? HPSA Rural Designation Updated Annually: Otherwise eligible sites in health professional shortage areas (HPSAs) located in rural census tracts of MSA counties will be eligible originating sites. (RUCA codes 4 10, also 2 3 in counties over 400 sq. mi., <35/sq. mi. density) Eligibility Lookup Tool dvisor/telehealtheligibility.aspx 5 Page 73

77 10/30/2018 Medicare Reimbursement Published Annually Eligible Originating and Distant Sites Eligible Providers Telehealth Services by HCPCS/CPT Code Most basic services usually allowed Many screening and prevention services allowed and-education/medicare- Learning-Network- MLN/MLNProducts/downloads/Te lehealthsrvcsfctsht.pdf New 2018 Codes HCPCS code G0296 (counseling visit to discuss need for lung cancer screening eligibility) CPT code (Interactive Complexity Psychiatry Services and Procedures CPT codes an d96161 (Health Risk Assessment) HCPCS code G0506 (Care Planning for Chronic Care Management) CPT codes and (Psychotherapy for Crisis) Basic Billing Model Professional fee (CPT based) goes to Specialist ( remote site ) Facility fee goes to Clinic ( originating site ) Originating site facility fee (Q3014) is a separately billable Part B service NOT the same as facility fee in Part A Billed as Q3014 (revenue code 780) Around $25 per encounter 6 Page 74

78 10/30/2018 Telemedicine The Standard Model Rural originating site Specialist at distant site Facility Fee (Part B) Professional Fee (Part B) Chronic Care Management (CCM) Services furnished to patient with 2 or more chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline First introduced 1/1/2015 CPT minutes/month Effective 1/1/2017 CPT minutes/month CPT additional 30 minutes/month and Education/Medicare Learning Network MLN/MLNProducts/Downloads/ChronicCareManagement.pdf CCM Services and Billing CCM Service CCM Service 99487/89 Authorized Billing Providers 20 minutes of clinical staff time per month, directed by physician or other qualified professional. Comprehensive care plan established, implemented, revised, or monitored. Create structured, clinical summary record, care plan demographics, problems, allergies, medications National Average: $ minutes of clinical staff time per month, directed by a qualified professional. Comprehensive care plan established, implemented, revised, or monitored. Each additional 30 minutes of care delivered, additional billing Create structured, clinical summary record, care plan demographics, problems, allergies, medications National Average Rates: $ $47 Physicians Certified Nurse Midwives Clinical Nurse Specialists Nurse Practitioner Physician Assistant 7 Page 75

79 10/30/2018 CCM Eligibility Eligible Patients Multiple (2 or more) chronic conditions expected to last at least 12 months, or until the death of the patient Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline Primary coverage Medicare or other participating health plan Eligible Chronic Conditions Examples Alzheimer s disease and related dementia Arthritis (osteoarthritis and rheumatoid) Asthma Atrial fibrillation Autism Spectrum Disorder Cancer Chronic Obstructive Pulmonary Disease Depression Diabetes Heart Failure Hypertension Ischemic Heart Disease Osteoporosis CCM Care Plan Requirements Typical Clinical Content Patient centered based on physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources Comprehensive plan for all health issues. Patient provided with written or electronic copy. Provision documented in the medical record. Care plan should be shareable with outside entities electronically (fax counts). Problem list Expected outcome and prognosis Measurable treatment goals Symptom management Planned interventions and individuals responsible for each Medication management Community/social services ordered A description of services outside the practice and how they will be directed/coordinated Schedule for periodic plan review, and revision as appropriate Behavioral Health Integration Services Enhances usual primary care services by adding two key services; care management support for patients receiving behavioral health treatment; and regular psychiatric inter specialty consultation to the primary care team Effective 1/1/2018 Psychiatric Collaborative Care Model (CoCM) CPT first month of CoCM 70 minutes/month CPT subsequent months 60 minutes/month CPT each additional 30 minutes/month General Behavioral Health Integration (BHI) CPT minutes/month and Education/Medicare Learning Network MLN/MLNProducts/Downloads/BehavioralHealthIntegration.pdf 8 Page 76

80 10/30/2018 Implications of CCM and CoCM CPT Codes Not telehealth codes but will drive many telehealth services that meet its requirements Will be used to promote: Primary Care Redesign Expansion of ACOs Commercial payer reimbursement for same services MACRA/MIPS 2019 Physician Fee Schedule - Released 7/21/2018 Monumental, sea of change - Brief Communications Technology based Service virtual check in - Proposed CPT GCVI1 at $14; not a telehealth code (no telehealth restrictions) - RHC/FQHC to get own code - Asynchronous Remote Evaluation of Pre Recorded Patient Information - Proposed CPT GRAS1 around $12.24; not a telehealth code (no telehealth restrictions) - RHC/FQHC to get own code - Interprofessional Internet Consultation between providers via phone/internet - Proposed ; rates TBD; verbal patient consent required - Additional Proposals - Bipartisan Budget Act of 2018 changes; remote psych monitoring, new CCM codes 2019 Physician Fee Schedule - Center for Connected Health Policy Info Graphic - D%20TELEHEALTH%20CHANGES%20TO%20PFS%20CY% pdf - Center for Connected Health Policy Fact Sheet - %20FINAL.pdf 9 Page 77

81 10/30/2018 Upper Midwest Telehealth Resource Center State of the State Michigan Medicare is the same in all states. Michigan Yes Medicaid Certificate Distance Limitation Physician Medical Licensure Compact Prescribing via Telehealth live and interactive only No No Bill introduced Yes, subject to certain conditions for controlled substances Patient Consent Private / Commercial Insurance Parity Remote Patient Monitoring Rural Health Clinics can be: RHC can bill Q3014 RHC can bill provider fee School Based Services Telepharmacy No reference found Parity in coverage No Originating site and distant site Yes Yes Cannot bill Q3014 originating fee No reference found The National Telehealth Policy Center at the Center for Connected Health Policy, updates their comprehensive scan of the 50 states and District of Columbia state telehealth laws and Medicaid program policies each spring and fall. See: Michigan Pending Legislation HB /28/18: To House Committee on Communications and Technology Creates Michigan broadband investment act HB /15/18: Requires the Dept of Mental Health to establish a hotline to connect individuals experiencing a mental health crisis to a local mental health providers using telecommunications and digital communications methods commonly in use. SB /7/18: Introduced and referred to Committee on Insurance Updates the insurance code and adds telehealth definitions for live and interactive telemedicine and store and forward telemedicine MI Rule , 10107, 10109, 10117, 10901, 10902, 10904, 10913, , /15/18: Introduces a definition for telemedicine including limitations to providing telemedicine services (real time, interactive audio and video telecommunications system, introduces modifier 95, and place of service code 02) 10 Page 78

82 10/30/2018 Michigan Pending Legislation MI Rule , 10107, 10109, 10117, 10901, 10902, 10904, 10913, , /15/18: Introduces a definition for telemedicine including limitations to providing telemedicine services (real time, interactive audio and video telecommunications system, introduces modifier 95, and place of service code 02) MI Rule: Dept of Licensing and Regulatory Affairs Pharmacy Controlled Substances 5/15/18: Prohibits the prescribing of controlled substances prior to establishing a bona fide prescriber patient relationship in person or via telehealth Michigan Approved Legislation Sec. 7303a. A prescriber who holds a controlled substances license may administer or dispense a controlled substance listed in schedules 2 to 5 without a separate controlled substances license for those activities. Unless other rules are promulgated before 3/31/2019 Must have bona fide prescriber patient relationship Meaning a treatment or counseling relationship between a prescriber and a patient in which both of the following are present: The prescriber has reviewed the patient s relevant medical or clinical records and completed a full assessment of the patient s medical history and current medical condition, including a relevant medical evaluation of the patient conducted in person or through telehealth. The prescriber has created and maintained records of the patient s condition in accordance with medically accepted standards. See: /publicact/pdf/2018 PA 0101.pdf Becky Sanders (812) , ext. 232 or bsanders@indianarha.org 11 Page 79

83 10/30/2018 Michigan Cancer Consortium Virtual Care Offerings for Oncology Henry Ford Health System November 7, 2018 Henry Ford Health System Core Services: Five acute med/surg and Outpatient Dialysis Two behavioral health hospitals Home Health Care Henry Ford Medical Group Health Alliance Plan (HAP) 27 Medical Centers Insurance Provider 1200 physicians & scientists Henry Ford Cancer Institute The Henry Ford Cancer Institute is creating more hope for patients around the world. With one unified team of cancer specialists and innovations ranging from precision medicine to MRI guided radiation therapy, we deliver one of a kind cancer treatments. Our 900 highly skilled doctors, researchers, nurse navigators and other healthcare specialists provide world class cancer care to thousands of patients each year. With five hospital locations, six additional outpatient cancer centers and dozens of aligned doctor s offices, the Commission on Cancer designates us as an integrated network and recipient of the 2016 Outstanding Achievement Award. 1 Page 80

84 10/30/2018 Brigitte Harris Cancer Pavilion New 6 story, 187,000 square foot Detroit cancer facility Destination for comprehensive cancer care: ambulatory cancer treatment precision medicine clinical trials enhanced support services for cancer patients and caregivers "If you ask the customer he would have asked for a faster horse" Henry Ford Whether you think you can, or think you can t, you re right. ~Henry Ford Virtual Care Mission To improve the value of healthcare by leveraging virtual care to impact the customer experience, access, cost reduction, efficiency, and clinical quality. Technology + Doctor Virtual Care Experience * (Technology + Operations + Build + Engagement) = Virtual Care 2 Page 81

85 10/30/2018 Synchronous Asynchronous Virtual Care Capabilities MyChart Video Visit* MyChart Messaging Clinic to Clinic Telemedicine Visit* Remote Monitoring evisit* Virtual Post Op Visit *Some insurance payers will reimburse for these services MyChart Video Visits Video Call: Real time Audio and Video Scheduled appointment, patient can see their provider without going to the clinic. Video call using patient personal device MyChart mobile app from their smartphone or tablet MyChart website from laptop or desktop computer (with a web camera) Insurance Coverage Some payers cover Not covered by Medicaid or non ACO Medicare A&B MyChart Video Visit Programs Survivorship 2 providers servicing 3 clinic locations Available to any patient completing treatment OncoStat 10 providers servicing 5 clinic locations APPs available to patients during course of treatment Radiation Oncology 2 providers servicing 2 clinic locations Available for consults and post procedure visits 3 Page 82

86 10/30/2018 Clinic to Clinic Telemedicine Visit Video Call: Real time Audio and Video Similar to a regularly scheduled appointment, but patient will go to one clinic and be connected to a doctor at another distant clinic. Patient will check in and be shown to an exam room, and a Henry Ford team member will connect patient to the doctor in real time. Insurance Coverage Most payers cover Telemedicine Program Urology surgical consults referred from clinics outside tri county area Surgeon providing robotic kidney surgeries for patients diagnosed with kidney cancer Considerations Connectivity Technology/Equipment Space/Support Staff (tele presenter) at patient location Medical Licensure & Credentialing of HFHS provider Radiology Images & Medical Records Billing/Claims Telemedicine Program Urology surgical consults testimonial: This has to be one of the most fruitful and functional telemedicine arrangements. Thanks for your participation. Our staff and patients are very appreciative. 4 Page 83

87 10/30/2018 Consults performed 2017 = (through August) = 10 Miles saved 2017 = 3, (through August) = 4,330 Minutes of travel saved 2017 = 3, (through August) = 4,020 Telemedicine Program HFHS Virtual Care Specialties Allergy MVV Behavioral Health Services (Adult and Geriatric) C2C Cardiology ec Center for Autism and Developmental Disabilities MVV Dermatology C2C/MVV/eV/eC Dialysis MVV Endocrinology MVV ENT (Ear, Nose & Throat) C2C/MVV/VPO Functional Medicine MVV Gastroenterology (IBD) C2C Infectious Disease MVV International Travel Medicine C2C Nephrology C2C Neurology MVV/eC Neurosurgery VPO Oncology C2C/MVV Orthopedics C2C/VPO ev = evisit ec = econsult MVV = MyChart Video Visits C2C = Clinic to Clinic Telemedicine VPO = Virtual Post Op Pharmacy (Medication Therapy Mgmt) MVV Preventive Cardiology (Cardiac Rehab) MVV Primary Care MVV/eV Radiation Oncology MVV Reproductive Medicine (IVF) C2C Rheumatology C2C/MVV Sleep C2C Speech Therapy MVV Sports Medicine C2C Structural Heart Disease C2C Thoracic Surgery C2C/MVV Tobacco Treatment MVV Transplant (Liver & Kidney) C2C Urology C2C/MVV Vascular Surgery C2C/MVV Women s Health/OB MVV Virtual Care Enables Us To: Increase/improve access and reach Offer alternate access to healthcare Track with patient experience and expectations Reduce costs (time, travel, convenience, etc.) Increase clinician productivity/efficiency Connecting with customers where, when, and how they want to be reached All For You! 5 Page 84

88 10/30/2018 Contact Information Marie Lee Program Coordinator, Virtual Care care 6 Page 85

89 10/30/2018 Advanced Technology in Caring for Cancer Patients Remotely Geralyn Roobol, LMSW, RN, CMAC Director Cancer Services, Spectrum Health Cancer Center Michigan Cancer Consortium Annual Meeting November 7, Objectives Spectrum Health MedNow Overview Spectrum Health TeleOncology 2 Overview of Spectrum Health Spectrum Health is a not-for-profit health system, based in West Michigan and West Michigan's largest employer with over 29,000+ employees 3 PPT Demonstration_CA_ Page 86

90 10/30/2018 Overview of Spectrum Health Health Plan: Priority Health Spectrum Health Medical Group: Spectrum Health Hospitals ~790,000 members >1500 physicians & APPS 12 hospitals ~3400 physicians & APPs Inpatient and outpatient rehabilitation Hospice Home Care (VNA, medical home) Ambulatory Services, Surgery Centers and Urgent Care ~200 sites 4 The Spectrum Health Cancer Center Provides comprehensive services and a robust clinical research program; only BMT program in West Michigan Affiliated with MSU School of Medicine and Van Andel Research Institute Leading edge programs & technology ~ 4000 analytic cases ~ 30% of patients on trials >15 sites of service Leader in Tele Oncology 5 Telehealth comes in many forms Two-way video Smart phones Wireless tools 6 PPT Demonstration_CA_ Page 87

91 10/30/ What is MedNowSM? Telehealth program at Spectrum Health that is a fast, convenient and affordable way for patients to receive care using technology to bridge the distance between patient and providers. Three areas of focus Direct to Consumer (Direct to Patient) Specialty Care Remote Patient Monitoring Two core tools Video visits E visits 8 Why? Why? Consumer Demand Technological Advancements & Competition Value Based Care Cost Savings PPT Demonstration_CA_ Page 88

92 10/30/2018 Consumer Demand - What Matters Most? Convenience On Demand Access Local Low Cost High Quality Remove Geographical Barriers to Care Requires a New Care Model Traditional Access Points Primary Care Office Low Acuity High Acuity Emergency Department Consumer- Oriented Access Points Source: Mehrota A et al, "Visits To Retail Clinics Grew Fourfold From 2007 To 2009, Although Their Share Of Overall Outpatient Visits Remains Low," Health Affairs, August 2012; Health Care Advisory Board interviews and analysis. PPT Demonstration_CA_ Page 89

93 10/30/2018 What is MedNowSM? Direct to Consumer MedNow Care is available for low acuity primary care conditions using video visits or evisits. The patient and clinician are in different physical locations Specialty MedNow Allows patients with more serious conditions to have a consultation with a Grand Rapids-based Spectrum Health specialist via a secure video connection from remote clinics and hospitals. Remote Patient Monitoring Remote monitoring of chronic conditions by way of technology 13 Spectrum Health MedNowSM Direct to Consumer MedNowSM MedNow at Home MedNow at Work MedNow in Retail MedNow at School MedNow in Community Specialty MedNowSM Behavioral Health Cardiology Infectious disease Oncology Pediatrics Wound Vascular Remote Patient Monitoring Congestive Heart Failure Diabetes COPD Remote Patient Monitoring CHF COPD Diabetes Goals: Reduce hospital readmissions Improve QOL PPT Demonstration_CA_ Page 90

94 10/30/2018 Specialty MedNowSM Allows patients with more serious conditions to have a consultation with a Spectrum Health specialist via a secure video connection from remote Spectrum Health clinics and hospitals. Specialty MedNowSM Oncology Bariatrics Behavioral Health Cardiology Diabetes Infectious Disease Ob/Gyn/NICU Orthopedics Pediatrics/PICU Pulmonary/Sleep Vascular Wound Care Over 24 specialties and 90+ Use Cases Care Settings ED Inpatient Outpatient Home Let s Talk Tele Oncology Why Open up Access Physician Satisfaction Patient Satisfaction Decrease the Overall Cost of Care 18 PPT Demonstration_CA_ Page 91

95 10/30/2018 Access ASCO published its report The State of Cancer Care in America: 2016, which detailed a potential workforce shortage of oncologists over the next decade just as the demand for oncology services will be surging. Telemedicine or tele-oncology will definitely help mitigate the problem of a physician workforce shortage. In addition, the technology allows other populations of physicians, such as retired, disabled, or stay-at-home moms and dads, to continue to use their medical expertise by practicing medicine as virtual consultants as long as they maintain their board certification and keep current through CME courses 19 Increase Rural Access 2012 report by the Institute of Medicine for the National Academies, entitled The Role of Telehealth in an Evolving Health Care Environment (DOI: /13466), found that telehealth drives volume, increases quality of care, and reduces costs by reducing readmissions and unnecessary emergency department visits for rural communities. Through telemedicine, rural hospitals can serve rural patients at better costs and help cut down on the time it takes rural patients to receive care, particularly specialty care. 20 Tele Oncology Current Outcomes 35, 81 and now 176 YTD Slow but now steady growth Patient satisfaction top box currently 91% Provider satisfaction top box currently 91% No difference for either group by age or indication In Oncology, physicians are now actively searching for opportunities After exposure to the technology, believe in the potential Physical exam remains a barrier despite available tools 21 PPT Demonstration_CA_ Page 92

96 10/30/2018 Tele Oncology at Spectrum Health Areas of focus determined by: Alignment with strategic plan and areas of growth Potential market Community need Financial feasibility Physician interest/ readiness 22 Tele Oncology - Model Specialty based pre visit reviews are performed by the program coordinator Eligibility for the program Results of imaging Originating site is the regional cancer center Schedule patient for a tele oncology visit at both originating and central locations Patient registered and roomed at originating site Originating site bills the technical (facility) fee 23 Tele Oncology - Model Visit begun by physician after the patient is in the room Visit performed Follow up appointments are made based on physician recommendations Physician bills the professional component 24 PPT Demonstration_CA_ Page 93

97 10/30/2018 Tele Oncology Areas of Focus Psych Oncology Consult to onco-psychiatrist triggered when distress 7-10 Tele oncology used for non suicidal high distress regional patients Lung Program Lung Nodule follow up appointments Lung Cancer Screening counseling and follow up New patient evaluation for lung nodules Routine follow up from the Lung Cancer multispecialty clinic 25 Tele Oncology Areas of Focus Heme/ BMT Routine follow up with normal testing Low risk BMT patients at this point Benign Heme General Cancer Center Initiatives Medical Genetics consultations - Two studies in 2014 reported in Journal of Clinical Oncology indicate that telephone-based education or counseling initiatives can be successful in educating individuals at familial or genetic risk of cancer and in inducing these atrisk individuals to undergo recommended screening (J Clin Oncol 2014; DOI: /JCO , J Clin Oncol 2014; DOI: /JCO ). Survivorship Cancer Smoking Cessation counseling and follow up 26 Innovation - Knock Out Cancer Partnering with our community resources to provide cancer prevention and education to our underserved areas. The main topics discussed included: Exercise/Physical activity Diet/Nutrition Family cancer history Smoking cessation Cancer screening recommendations based on age and gender Guests knowing what is normal for their bodies and the need to report changes The nurse at Mel Trotter follows up with guests after each visit to ensure they have a plan to follow through on recommendations or to help make appointments as needed. 27 PPT Demonstration_CA_ Page 94

98 10/30/2018 Tele Oncology Opportunities Melanoma Skin Lesion screening: Dermatology is not yet a believer in the technology, despite the high resolution tools, and are worried about risk Melanoma multispecialty team: Dermatologist participation in MST conference from their office 28 Patient Impact BMT 10 Minutes- Patient Leaves Office and Returns to Vehicle 15 Minutes- Patient Meets with Specialist 6H Hours &34 Minutes-Patient Travels to Ludington (if traffic, construction, or weather allow) 15 Minutes- Patient Waits in Exam Room Total Time: 14.5 Hours Patient Lives in Marquette, MI Traditional Model Patient Costs Food Expense: $16.00 Total Gas Expense: $ Wages Lost: $ Total Patient Costs Excluding Any Medical Expenses: $ Patient's Household Income is $37,355 Patient's Appointment is with Specialist in Grand Rapids, MI Patient Must Take Time Off of Work to Attend Appointment 6 Hours & 34 Minutes-Patient travels to Grand Rapids (if traffic, construction, or weather allow) 20 Minutes- Patient Waits in Waiting Room 10 Minutes- Patient Walks to Specialist's Office 10 Minutes- Patient Parks and Locates Building Elevator Patient Locates Correct Parking Ramp of Specialist's Facility Patient Impact BMT Total Time: 0.7 Hours Patient Lives in Marquette, MI Patient's Household Income is $37,355 5 Minutes- Patient Travels Home 5 Minutes- Patient Leaves Office and Returns to Vehicle 15 Minutes- Specialist Meets with Patient via Telehealth 2 Minutes- Patient Waits in Exam Room Tele Oncology Patient Costs Food Expense: N/A Total Gas Expense: $1.43 Wages Lost: $12.57 Total Patient Costs Excluding Any Medical Expenses: $ Minutes- Patient Waits in Waiting Room 5 Minutes- Patient Parks and Locates Specialist's Office IRS Mileage Rate of.54 a Mile Patient's Appointment in Marquette Patient Must Take Time Off Work to Attend Appointment 5 Minutes- Patient Travels to Marquette Location PPT Demonstration_CA_ Page 95

99 10/30/2018 Patient Impact Lung Total Time: 2.97 Hours Patient Lives in Lakeview, MI Patient's Household Income is $25, Minutes Patient Leaves Office and Returns to Vehicle 15 Minute Patient Meets with Specialist 49 Minutes Patient Travels to Hastings (if traffic, construction, or weather allow) 15 Minutes Patient Waits in Exam Room 20 Minutes Patient Waits in Waiting Room Traditional Model Patient Costs Food Expense: $9.00 Total Auto Expense: 10 Minutes Patient Walks to Specialist's Office $53.76 Wages Lost: $36.51 Total Patient Costs Excluding Any Medical Expenses: $ Minutes Patient Parks and Locates Building Elevator IRS Mileage Rate of.56 a mile Patient's t' Appointment is with Specialist in Grand Rapids, MI Patient Must Take Time Off of Work to Attend Appointment 49 Minutes Patient t Travels to Grand Rapids (if traffic, construction, or weather allow) Patient t Locates Correct Parking Ramp of Specialist's Facility Patient Impact Lung Total Time: 0.7 Hours Patient Lives in Lakeview, MI Patient's Household Income is $25, Minutes Patient Travels Home 5 Minute Patient Leaves Office and Returns to Vehicle 15 Minutes Specialist Meets with Patient via Telehealth 2 Minutes Patient Waits in Exam Room Tele Oncology Patient Costs Food Expense: N/A Total Auto Expense: $3.35 Wages Lost: $8.59 Total Patient Costs Excluding Any Medical Expenses: $ Minutes Patient Waits in Waiting Room 5 Minutes Patient Parks and Locates Specialist's Office IRS mileage rate of.56 a mile 5 Minutes Patient Travels to Spectrum Health Reed City Hospital Patient's t' Appointment with Specialist at Spectrum Health Kelsey Hospital via Telehealth ee eat Patient Must Take Time Off Work to Attend Appointment Summary Feasible Patient and physician satisfaction high Financially sustainable to date Broad number of indications in addition to traditional remote monitoring & primary care uses Tele Oncology Can expand market and exposure of subspecialists across broad geography and into rural areas Optimizes patient time and resources Potential not fully realized at this time PPT Demonstration_CA_ Page 96

100 10/30/2018 Lung Cancer Telehealth 34 PPT Demonstration_CA_ Page 97

101 Carol Friedman Award Excellence in Addressing Cancer Disparities 2018 Award Winner Hiam Hamade, BSN, MA, MPH Page 98

102 MCC Spirit of Collaboration 2018 Honorable Mention Projects Colorectal Cancer Awareness Network of Southeastern Michigan HPV Vaccine as Cancer Prevention Michigan HPV Cancer Summit: The Road to Prevention Page 99

103 The Colorectal Cancer Awareness Network of Southeastern Michigan Collaborating Partners: Henry Ford Health System, Beaumont Health, Ascension, Karmanos Cancer Institute, University of Michigan, Wayne State University, Oakland University, University of Detroit Mercy, Macomb County Health Department, Oakland County Health Department, The Tri-County Breast and Cervical Cancer Control Program, Detroit Area Agency on Aging, American Cancer Society, Community Health and Social Services, ACCESS and Detroit Community Health Connection Project description and outcomes The Colorectal Awareness Network (CRAN) is a community-based coalition of individuals and representatives of health system organizations, universities, community agencies and survivors who share a common mission to raise awareness to and prevention of colorectal cancer. The long-range goal of the CRAN is to raise awareness through education and increase colorectal screening rates, therefore preventing colorectal cancer. Initially formed to raise awareness about the need for colorectal cancer screenings in Macomb County, this group has expanded to include: the American Cancer Society, four hospital systems (Henry Ford Health System, Ascension, Beaumont Health and Michigan Medicine), four universities (Wayne State, Oakland, University of Detroit Mercy and University of Michigan), three county-level health departments (Macomb, Oakland, Wayne), Federally-Qualified Health Centers and other community agencies, such as the Detroit Area Agency on Aging and the Breast and Cervical Cancer Control Program (BCCCP). Past coalition activities include educational forums, annual colon health awareness events and the development and coordination of regional screening initiatives, such as the FluFIT program, which entails a partnership between health departments and health systems for the provision, processing and tracking of FIT tests to improve access to screening services for those who may not otherwise receive CRC screenings. The FluFit program received an honorable mention at the 2017 MCC Annual Meeting for collaboration. Current projects include expanding the FluFIT program to include faith-based initiatives and corporate /employee wellness partnerships, and the consideration of new innovations to combine FIT testing with the provision of other health services, such as Hepatitis A vaccinations, for example. CRAN has also established a small steering committee of sub-committee leads to further guide initiatives that will lead to increased survivor engagement and educational outreach. Also serving as an advocacy or action coalition, CRAN has worked alongside the American Cancer Society s Cancer Action Network (ACS CAN) to advocate for oral chemo parity, increased funding for the Michigan Tobacco Quit line and other tobacco prevention initiatives. CRAN also feverishly advocates for the closing of the Medicare loophole that permits additional cost sharing for patients, when polyps are removed during colonoscopies (Bill HR 1017). Although colonoscopies are provided at no cost-sharing to Medicare patients, the removal of polyps, however, is not a covered benefit, resulting in undue economic hardship for patients who often face significant barriers to care and prevention services. Page 100

104 CRAN exemplifies public health in action: through the collaboration of private, public and nonprofit sectors, public health concerns are being addressed in our community. This creative collaboration brings agencies together to promote health and well-being within their community, with an unwavering commitment to work together to achieve a world without cancer. Key outcomes of this collaboration include: Colorectal Cancer Awareness Month events, Regional FluFIT screening program (2016-current), and Colorectal Cancer Awareness Month in a Box toolkit for clinical, corporate and community partners. Page 101

105 HPV Vaccine as Cancer Prevention Collaborating Partners: Ascension Michigan, Michigan Department of Health and Human Services, American Cancer Society Project description and outcomes The HPV Vaccine as Cancer Prevention is an initiative supported by Ascension Michigan leadership. For this initiative, and HPV working committee was formed in the summer of 2017 to include vaccination champions within Ascension Michigan (including family medicine, internal medicine and infectious disease physicians, pediatricians, and hospital staff from the departments of Quality, Marketing, and Oncology, along with representation from the Michigan Department Health and Human Services Immunization Division and the American Cancer Society. The HPV Vaccine as Cancer Prevention initiative is a collaborative effort, led by Vilma Drelichman, MD and Joanne Shamoun, RPh, with a common goal of raising HPV Vaccination rates throughout the Ascension Michigan. Ascension Michigan serves individuals in multiple counties, but our focus was on Oakland, Macomb, and Wayne counties. The HPV working committee originated in the summer of 2017, following an educational meeting with Dr. Melinda Wharton, Director of Immunization Services Division at the Centers for Disease Control and Prevention. Following the 2017 meeting with Dr. Wharton, Dr. Drelichman and Ms. Shamoun, along with Megan Landry from the American Cancer Society and Stephanie Sanchez from the MDHHS Immunizations, received support from Ascension Michigan s leadership to form a working committee and to take this on as a system wide priority. The HPV Vaccine as Cancer Prevention initiative is carried out by the HPV working committee of Ascension Michigan which includes family medicine, internal medicine and infectious disease physicians, pediatricians, and hospital staff from the departments of Quality, Marketing, and Oncology. Megan Landry, Health Systems Manager, American Cancer Society and Stephanie Sanchez, AFIX QI Coordinator, Michigan Department of Health & Human Services, Immunization Division are also active members of the committee. The HPV working committee members were identified as HPV vaccination champions within Ascension Michigan, and all were invited and accepted to participate. This committee was tasked with creating and rolling out a strategic plan to help increase HPV Vaccination rates across the system, with the end goal of reducing HPV cancers. To begin the process, the committee members studied the current data trends related to HPV vaccinations and vaccination rates. In June of 2017, the HPV series completion for 13-year-olds at Ascension Michigan was 24.62%. Two main goals were developed by the committee: A. To educate all staff at physician offices on how to make a strong recommendation for the HPV vaccine to patients and parents. Members of the committee volunteered to Page 102

106 lead the effort in providing the education. B. To increase community outreach efforts to inform community members and parents about the importance of preventing HPV related cancers through timely HPV vaccination. Since the June 2017 initiation of the HPV working committee, there has been a 6% increase in the completion of the HPV Vaccination rate for 13-year-olds within the Ascension Michigan Health System, with the current June 2018 rate being 30.72%. Page 103

107 Michigan HPV Cancer Summit: The Road to Prevention Collaborating Partners: American Cancer Society, Michigan Department of Health and Human Services, Division of Immunization, Rogel Cancer Center Michigan Medicine, Karmanos Cancer Institute, Michigan Association of Physicians of Indian Heritage. Full Description of Collaborative Project: Human papillomavirus (HPV) is a recognized cause of cancer. Although most HPV infections are asymptomatic and clear spontaneously, persistent infections can progress to precancer or cancer. HPV causes most cervical cancers, as well as some cancers of the vagina, vulva, penis, anus, and oropharynx (cancers of the back of the throat, including the base of the tongue and tonsils). Cancer registries do not routinely collect information about HPV status, so in this report, HPV-associated cancers are defined as those that occur in parts of the body where HPV is often found. In the United States, 31,500 men and women get HPV related cancers each year. The HPV vaccine has a 97% effectiveness at preventing infection, yet the series completion rate of Michiganders getting the vaccine is below 50%. To change this, the collaborating partners planned and developed a summit to increase rates. Learning objectives included: Current ACIP HPV vaccine recommendations, HPV coverage rates for Michigan and the U.S., HPV Cancer occurrence for Michigan and the U.S., reasons to vaccinate 11 & 12-year-olds with HPV vaccine, communication approaches for making a string HPV vaccine recommendation, and evidence-based preventative strategies to reduce HPV cancers. Aimed primarily at providers, the summit featured presentations from national, state, and local champions. These include: Dr. Belinda Wharton, Director, Immunization Services Division, Center for Disease Control and Prevention; Dr. Basel Khatib, Pediatrician in Dearborn; Dr. Shelly Seward, Gynecologic Oncology at Karmanos Cancer Institute; Dr. Marcus DeGraw, St. John Hospital and Medical Center; Dr. Melissa Gilkey, Assistant Professor, University of North Carolina; Bob Swanson, Director of Immunization, Michigan Department of Health and Human Services; as well as a cervical cancer survivor. There were 81 attendees at the summit including doctors, nurses, social workers, health plan staff, researchers, and others. While it is too early to determine empirical results, i.e., HPV vaccination rates improved, the interest generated by the presenters was overwhelming. Attendees heard firsthand the methods physicians in the state of Michigan used to raise their HPV vaccination completion rates; that it could be done in their practice demonstrated that like results could be achieved elsewhere. The feedback from the attendees was excellent; the participant evaluations showed quite favorable impressions and interest in future summits. Page 104

108 2018 MCC Spirit of Collaboration Award Winner Karmanos Cancer Institute Michigan Cancer Healthlink for Equity in Cancer Care Cancer Action Councils A Collaboration of Community Member Cancer Action Councils Karmanos Cancer Institute Patient Centered Outcomes Research Institute Page 105

109 Michigan Cancer Healthlink for Equity in Cancer Care Cancer Action Councils Collaborating Partners: Karmanos Cancer Institute/Wayne State University, Detroit HealthLink Voices of Detroit Initiative/Conner Creek, Western Wayne Family Health Center/Inkster, and Cancer Action Council Members: Geneva Archie, Vera Bailey, Madeline Bialecki, Clare Carlisle, Veronica Dobine, Victoria Griffin, Victoria Gunn, Anita Orr, Moriah Peoples, Lanita Pickett, Elaine Stanley, Deborah Stewart-Anderson, Deborah Hill, Brenda Boyd, Megan Landry, Brenda Chambers-Threatt, Kayla Clermont, Eddie Conners, Greta Delabbio, Angelina Delabbio, Linda Huff, Shoma Pal, Meghan Wyse, Christina Zuniga, Tristan Amis, Bernice Bankhead, Diane Brown, Mitzi Cordona, Denise Franklin, Robert Johnson, Maria Jones, Gaylotta Murray, Ekanem Obong, Jean Overman, Gennifer Williams Project description and outcomes The Karmanos Cancer Institute (KCI) Michigan Cancer Healthlink for Equity in Cancer Care initiative is a region-wide coalition that addresses cancer related needs in the Metropolitan Detroit area. Several cancer action councils (including Western Wayne, Conner Creek, KCI, ACCESS of Dearborn, and LGBT Detroit) have been developed to empower cancer patients, caregivers, survivors and community members to address cancer issues in their communities through increased engagement in cancer research. Cancer Action Councils are groups made up of community members and representatives from community-based organizations who apply their knowledge about local cancer issues to improve the lives of cancer patients, survivors, and caregivers within their communities. The council members represent the various ethnic and social groups living in their neighborhoods. The project aims for KCI Michigan Cancer Healthlink for Equity in Cancer Care are: Increase capacity among community stakeholders Build trusting and collaborative relationships between community stakeholders and cancer researchers Identify cancer specific Patient Centered Outcome Research priorities based on the Cancer Action Councils input In order to recruit members, nominations were solicited through Karmanos Cancer Institutes partnering community-based organizations along with self-nominations. A Detroit HealthLink website was also created ( through which interested individuals could apply online. Individuals were formally invited to become a CAC member based on their expressed interest in advancing cancer research, demonstration of prior community participation or activism, understanding of the role of CAC member, and willingness/ability to attend CAC meetings over the course of 18 months. There were two types of CAC members. Core members were expected to be fully involved in all meetings and activities over an 18-month period. This type of member was eligible for a $1000 Page 106

110 stipend. Associate members were individuals willing and interested in playing a role in setting cancer care and research priorities in their community but may not be able to attend all activities and meetings. They could also be employees of non-profit agencies with goals aligned with HealthLink goals, such as the American Cancer Society. The CACs participated in a process of evidence prioritization in which they identified and prioritized research topics. This process began with the identification of critical needs along the cancer care continuum that they observed in their communities and was consistent with the steps in the Tufts Clinical and Translational Service Institutes Engaging Stakeholders in Comparative Effectiveness Research program, specifically, the identification of the mission, vision, and objectives for research. This step was followed by the identification and prioritization of research topics and research questions. A key strategy in this process was concept mapping. Steps in concept mapping included the following: 1) starting with a main topic or idea in the center of the map; 2) adding an idea that connects to the main topic; 3) taking these ideas to branch off even more; 4) using one branch of inquiry on the map to help form a question. CAC members worked in small groups to collaboratively generate concept maps. The program started with three Cancer Action Council locations: Karmanos Cancer Institute, Conner Creek (hosted by Voices of Detroit Initiative) and Inkster (hosted by Western Wayne Family Health Centers). The KCI CAC identified 7 research domains; Conner Creek CAC identified 10 research domains and Inkster CAC identified 11 research domains. Each then selected 4 research domains that were identified as the leading priorities for their group and in turn, developed specific patient-centered outcome research questions relative to these domains. The efforts of Detroit HealthLink are housed within KCI s newly established Office of Cancer Health Equity & Community Engagement. Detroit HealthLink for Equity in Cancer Care is now a part of Michigan Cancer HealthLink which covers KCI s 46-county catchment area in the state of Michigan. New CAC members are currently being recruited for the next phase. Learn More: Knoll Larkin Phone: larkink@karmanos.org Funded by: Patient Centered Outcomes Research Institute Engagement Award, Contracts# 2971 & 6252, Detroit Medical Center (DMC) Foundation Page 107

111 MCC Champion Award 2018 Award Winner CAROLYN JOHNSTON, MD The MCC Champion has demonstrated leadership, excellence, success and impact on the fight against cancer. Page 108

112 2018 Michigan Cancer Consortium Annual Meeting Continuing Education Statements and Requirements CONFLICT OF INTEREST There is no conflict of interest for anyone with the ability to control content for this activity CRITERIA FOR SUCCESSFUL COMPLETION Criteria for successful completion includes attendance at the event, sign in at registration desk and submission of a completed evaluation form. Nursing: This continuing nursing education activity was approved by The Ohio Nurses Association an accredited approver of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. (OBN ) Activity Number: Approval valid through 11/07/2020 Social Work: This course is approved by the Michigan Social Work Continuing Education Collaborative Course Approval # The Collaborative is the approving body for the Michigan Board of Social Work. Conference Evaluation If you are requesting CE, you MUST complete the online evaluation Page 109

113 Certificate of Attendance Name: This certificate confirms that: Has successfully completed the 2018 Michigan Cancer Consortium Annual Meeting Activity Provider: Michigan Public Health Institute Provider Address: 2390 Woodlake Drive, Suite 360, Okemos, MI Date: November 7, 2018 Time: 8:30am-2:00pm (5.5 hours total, 3.0 hours CE) Location: The Kellogg Hotel & Conference Center 219 S Harrison Road, East Lansing, MI Debbie Webster, MSW, BSN, BA MCC Annual Meeting Program Committee Amy Stagg, CMP Education and Membership Coordinator Page 110

114 Anas Al Janadi Spectrum Health Cancer Center anas.al Georgetta (Jetty) Alverson Michigan Cancer Surveillance Program Ghada Aziz ACCESS Community Health & Research Center Jaclyn Badger Central Michigan District Health Department Louise Bedard MOQC Aaron Berndt Michigan Department of Environmental Quality / Indoor Radon Program berndta@michigan.gov Nancy Bierema City on a Hill Health Clinic Erica Bills Susan G. Komen Michigan ebills@komenmichigan.org Chris Bissell Henry Ford Cancer Institute cbissel1@hfhs.org Jacquelyn Booher St. John greinerj7@gmail.com Julie Brabbs University of Michigan Rogel Cancer Center erichris@med.umich.edu Lisa Braddix Greater Detroit Area Health Council lbraddix@gdahc.org Patty Brookover MCC Alumni brookoverp@gmail.com Nicole Brown, Rn Oakland Community Health Network brownn@oaklandchn.org Voncile Brown Miller Karmanos Cancer Institute millerv@karmanos.org Carolyn Bruzdzinski American Cancer Society, Inc. carolyn.bruzdzinski@cancer.org Sarah Bryant Ingham County Health Department/BCCCNP sbryant@ingham.org Sam Burke MPHI Cancer Prevention & Control burkes5@michigan.gov Helen Burns Saint Joseph Mercy Health System helen.burns@stjoeshealth.org Sharde' Burton MDHHS Cancer Prevention & Control burtons4@michigan.gov Jane Caplinger American Cancer Society jane.capliner@cancer.org Lisa Carlton Grand River Gastroenterology lcarlton@grgastro.com Mike Carr MDHHS Cancer Prevention & Control carrm7@michigan.gov Angela Chmielewski Beaumont Health angela.chmielewski@beaumont.edu Lauren Cibor Barry Eaton District Health Department lcibor@bedhd.org Marc Cohen Blue Cross Blue Shield of Michigan mcohen@bcbsm.com Courtney Cole MDHHS Cancer Prevention & Control colec13@michigan.gov Amanda Cook InheRET acook@inheret.com Sally Cory Kent County Health Department sally.cory@kentcountymi.gov Jessica Daniel American Cancer Society jessica.daniel@cancer.org Page 111

115 May Darwish Yassine Michigan Public Health Institute Lumbé Davis Centers for Disease Control and Prevention Susan Deming MDHHS Oral Health Elise DeYoung MPRO Deb Dillingham American Cancer Society Bonnie Dockham Cancer Support Community of Greater Ann Arbor Deborah Doherty Michigan Physical Therapy Association Tory Doney MPHI Cancer Prevention & Control Cathy Edgerly Inter Tribal Council of MI Dave Eggli American Cancer Society Suzanne Elder American Cancer Society Stephanie Ferrante Michigan Urological Surgery Improvement Collaborative (MUSIC) Carie Francis Karmanos Cancer Institute / Wayne State University francisc@karmanos.org Valerie Fraser IBC International Consortium valeriefraser@gmail.com Josie Garnoc Beaumont Health josephine.garnoc@beaumont.org Ann Garvin MCC Alumni agarvin224@aol.com Maria George MDHHS Cancer Prevention & Control georgem3@michigan.gov Kelsy Gibson Centers for Disease Control and Prevention (CDC) nkp9@cdc.gov Polly Hager MDHHS Cancer Prevention & Control hagerp@michigan.gov Heather Hall The Physician Alliance heather.hall@thephysicianalliance.org Hiam Hamade ACCESS Community Health & Research Center hhamade@accesscommunity.org Mayssoun Hamade ACCESS Community Health & Research Center mayhamade@aol.com Lauren Hamel Karmanos Cancer Institute hamell@karmanos.org Dawn Harris Heron Therapeutics dharris@herontx.com Heidi Haynes Heron Therapeutics heidijhaynes@yahoo.com Patricia Heiler MDHHS Tobacco Section heilerp@michigan.gov Denise Hill Karmanos Cancer Institute/BCCCNP hilld@karmanos.org Sarah Hockin Susan G Komen Michigan shockin@komenmichigan.org Bethany Hollender MPHI Cancer Prevention & Control hollenderb@michigan.gov Amanda Holm Henry Ford Health System aholm1@hfhs.org Page 112

116 Rosie Ingebritson Cancer Support Community of Greater Ann Arbor Denise Jacob Astrazeneca Kris Johns University of Michigan Flint Latasha Johnson Merck Oncology Sandra Johnson Covenant HealthCare mi.com Carolyn Johnston University of Michigan Rogel Cancer Center Camara Jones Keynote Speaker Josh Kellems American Cancer Society Patrice Kemp Centers for Disease Control and Prevention (CDC) Mohamad Khraizat ACCESS Community Health & Research Center Sara Kim Karmanos Cancer Institute / Wayne State University kimsa@karmanos.org Joy Klooster Health Department of Northwest Michigan j.klooster@nwhealth.org April Kuehn Integrated Health Partners kuehna@integratedhealthpartners.net Katherine Lacy Michigan State University Health and Risk Communication MA Program lacyk@msu.edu Megan Landry American Cancer Society megan.landry@cancer.org Thomas Lanni, Jr Beaumont Health thomas.lanni@beaumont.org Marie Lee Henry Ford Health System mlee4@hfhs.org Knoll Larkin Karmanos Cancer Institute, Office of Cancer Health Equity & Community Engagement larkink@karmanos.org Jill Loewen University of Detroit Mercy School of Dentistry loewenjm@udmercy.edu Nina Lavi Hoke Michigan Primary Care Association nlavi@mpca.net Erika Lojko Macomb County Health Department erika.lojko@macombgov.org Viki Lorraine MDHHS lorrainev@michigan.gov Bob Louwers Pfizer bob.louwers@pfizer.com Cassie Lynch Michigan Public Health Institute clynch@mphi.org Maria Lyzen Michigan Breast Cancer Coalition mlyzen@msn.com Maricar Macalincag MDHHS Lifecourse Epidemiology & Genomics macalincagm@michigan.gov Mary Kay Makarewicz MSHO mmakarewicz@msho.org Mona Makki ACCESS Community Health & Research Center mmakki@accesscommunity.org Sarah Manson Centers of Disease Control and Prevention (CDC) smanson@cdc.gov Julia Mantey Karmanos Cancer Institute / Wayne State University manteyj@karmanos.org Page 113

117 Angela McFall MDHHS Cancer Prevention & Control Mike Megyesi American Cancer Society Jan Miller Gilda's Club Metro Detroit Kara Milliron Michigan Cancer Genetics Alliance Abby Moler American Cancer Society Gwendolyn Murphy MDHHS Cancer Prevention & Control Dilhara Muthukuda MDHHS Cancer Prevention & Control Jennifer Nagy American Cancer Society Mike Neller MDEQ Radiological Protection Section Alyssa Nowak MDHHS Division of Immunization Mindi Odom American Cancer Society Sarah Oleniczak District Health Department #10 Taylor Olsabeck DHHS Lifecourse Epidemiology & Genomics Jill Onesti Mercy Health Physican Partners Melissa Ottinger Merck Gwendolyn Parker BCBSM Marcia Patton Family Medical Center of MI Leigh Pearce University of Michigan Lori Pearl Kraus LPK Healthcare Research, Policy, & Consulting Services, LLC Daniel Phillips Sparrow Hospital Herbert Herman Cancer Center Noel Pingatore Inter Tribal Council of Michigan Christine Plummer City on a Hill Health Clinic hc.christine@coahm.org Rachel Potter MDHHS Division of Immunization potterr1@michigan.gov Anita Powell MDHHS Cancer Prevention & Control powella5@michigan.gov Audra Putt MDHHS Cancer Prevention & Control putta@michigan.gov Samantha Raad National Kidney Foundation of Michigan sraad@nkfm.org Victoria Rakowski MCC Alumni vrakowskirn@gmail.com Tom Rich American Cancer Society thomas.rich@cancer.org Robin Roberts MDHHS Cancer Prevention & Control robertsr6@michigan.gov Linda Robinson Karmanos Cancer Institute at Mclaren Lapeer linda.robinson@mclaren.org Page 114

118 Geralyn Roobol Spectrum Health Cancer Center Gina Rosendall Saucedo Tobacco Free Michigan Julie Ruterbusch Wayne State University Stephanie Sanchez MDHHS Division of Immunization Becky Sanders Upper Midwest Telehealth Resource Center Mayada Saroki ACCESS Community Health & Research Center Andrew Schepers American Cancer Society Cancer Action Network Mary Lou Searls MPHI Cancer Prevention & Control E. J. Siegl MDHHS Cancer Prevention & Control Beth Sieloff Inter Tribal Council of Michigan Sean Smith Michigan Medicine Tracy Solis MDHHS Cancer Prevention & Control Cristiane Squarize University of Michigan Amy Stagg MPHI Cancer Prevention & Control JoAnne Steele Merck Susan Stevens Oakland Community Health Network Cindy Straight MOQC Connie Szczepanek Cancer Research Consortium of West Michigan Madiha Tarek ACCESS Community Health & Research Center Alexis Travis MDHHS Bureau of Health and Wellness Beth Trierweiler MPHI Cancer Prevention & Control Sandy Van Brouwer Helen DeVos Children's Hospital ens.org Tammy Vander Horst Kalamazoo Health and Community Services Angela Vanker Alliance Health Mary Jo Voelpel Michigan Osteopathic Association Robert Wahl MDHHS Lifecourse Epidemiology & Genomics Christen Walters Integrated Health Partners Debbie Webster MDHHS Cancer Prevention & Control Joan Westendorp West Michigan Cancer Center Dana Zakalik Beaumont Health Page 115

119 Callie Zampetis Budman Merck Page 116

120 MCC Financial Contributors We appreciate the MCC Financial Contributors which help support the Annual & Business Meetings of the Consortium. These contributions help us keep a modest registration fee, support needed scholarships and offer program support throughout the year. Thank you! Michigan Department of Health and Human Services Michigan Public Health Institute

121 MCC Pillars Implement policy, systems, and environmental changes Promote health equity Develop and maintain active partnerships in cancer prevention and control efforts Demonstrate outcomes through evaluation Cancer Control Improvements in Michigan Overall Cancer Incidence in Michigan has decreased by 16% since 1999 New cases of lung cancer have decreased by 17% Awards and Acknowledgements New cases of colorectal cancer have decreased by 34% Overall Cancer Mortality in Michigan has decreased by 18% since 1999 Deaths from breast cancer have decreased by 27% Deaths from lung cancer have decreased by 22% Females who are up to date for HPV vaccination have improved from 19% in 2010 to 40% in 2017 Males who are up to date for HPV vaccination have improved from 7% in 2010 to 34% in 2017 Adult tobacco use has declined 15% since 1995 Youth tobacco use has declined 73% since 1997 An estimated 526,000 cancer survivors reside in Michigan When established in 1998 the consortium had 31 founding member organizations. Today the MCC has 100 active member organizations. MCC Resources Cancer Fact Sheets/ Tool Kits Webinars Research Papers Cancer Plan for Michigan Infographics Patient Resources Health Care Provider Resources MCC Update Calendar of Events The Consortium's membership represents the following organizational categories: Trade/Professional/Advocacy Organizations Community Based Health Care Public Health Organizations Public Health Organizations Organizations representing hard to reach and /or Special Populations Health Education, Research and Evaluation Health Care Insurance Plans University Based Health Care Members/Partners Number reflects member organizations and active partners MCC Priorities Achieved Youth Tobacco priority achieved (2003) - Proportion of Michigan youth in grades 9-12 who report having smoked within the past 30 days reduced to 22% Colorectal Cancer priority achieved (2004) - Proportion of average-risk people with a life expectancy of at least five years who have received appropriate colorectal cancer screening increased to 50% Prostate Cancer priority achieved (2005) - Resource "Making the Choice: Deciding What to Do About Early Stage Prostate Cancer" was developed for newly diagnosed prostate cancer patients Basic Lexicon priority achieved (2006) - Developed standardized formats and lexicons for use by surgeons, pathologists, and radiologists that include data important in making breast, cervical, colorectal, lung, and prostate cancer treatment and prognostic decisions Provider Education priority achieved (2011) - The number of health care providers and allied health care professionals who received training on the tobacco use assessment and treatment methods increased Cervical Cancer priority achieved (2011) - The number of incidence rates for cervical cancer in situ (CIS) among women aged years decreased by 10% Survivorship priority achieved (2017) - The number of Michigan adults diagnosed with cancer who report they received instructions about where to return or who to see for routine cancer check-ups after completing treatment for cancer increased from 46.6% to 57.1% Clinical Trials priority achieved (2017) - Percentage of Michigan adults participating in cancer treatment clinical trials increased from 4.4% to 4.8% Cancer Plan for Michigan A guide to reducing the human and economic burden of cancer in the state. The plan addresses all parts of the cancer journey including: Prevention, Early Detection, Diagnosis and Treatment, and Quality of Life Awards and Acknowledgements C-Change National Award for Exemplary CCC Implementation Karmanos Cancer Institutes Heroes of Breast Cancer Leadership Award MCC Challenge receives first prize in I'm Your Community Guide Contest C-Change National Award for Coalition Impact Looking Ahead... The MCC will be interested in better understanding emerging cancer trends. Deaths and new cases of liver cancer have both increased by 22% since 1999 Several other cancers have increased in the rate of new diagnoses since 1999: oropharyngeal (24%), pancreatic(13%), Melanoma (9%) For more information about Michigan Cancer Consortium priorities, partners, and resources, visit