Assessing local capacity to expand rural breast cancer screening and patient navigation: An iterative mixed-method tool

Abstract

Background Despite federal funding for breast cancer screening, fragmented infrastructure and limited organizational capacity hinder access to the full continuum of breast cancer screening and clinical follow-up procedures among rural-residing women. We proposed a regional hub-and-spoke model, partnering with local providers to expand access across North Texas. We describe development and application of an iterative, mixed-method tool to assess county capacity to conduct community outreach and/or patient navigation in a partnership model. Methods Our tool combined publicly-available quantitative data with qualitative assessments during site visits and semi-structured interviews. Results Application of our tool resulted in shifts in capacity designation in 10 of 17 county partners: 8 implemented local outreach with hub navigation; 9 relied on the hub for both outreach and navigation. Key factors influencing capacity: (1) formal linkages between partner organizations; (2) inter-organizational relationships; (3) existing clinical service protocols; (4) underserved populations. Qualitative data elucidate how our tool captured these capacity changes. Conclusions Our capacity assessment tool enabled the hub to establish partnerships with county organizations by tailoring support to local capacity and needs. Absent a vertically integrated provider network for preventive services in these rural counties, our tool facilitated a virtually integrated regional network to extend access to breast cancer screening to underserved women.

County-level outcomes of a rural breast cancer screening outreach strategy: a decentralized hub-and-spoke model (BSPAN2)

“…We found that Spanish-speaking communities, in particular, leveraged communication about service access through social networks that crossed county boundaries [16,24,25]. Indeed, the availability of Spanish-language provider staff was commonly shared among women, resulting, as reported, in a large volume of women who preferred Spanish-language careseeking services in county 15.…”

“…Three qualitative scientists (RH, SI, SL) conducted thematic analysis in NVivo (9.0 QSR Australia). We began with [3,19,20], building on our capacity assessment tool [16] and conceptual model of the screening process [21]. In biweekly meetings, we undertook inductive analysis to identify and interpret emergent themes.…”

“…To expand access to the BSPAN program across 17 rural counties, the hub conducted a multilevel, multistep assessment process in each county and determined whether any organization in that county had the capacity to conduct outreach or patient navigation (details about the capacity assessment process reported elsewhere [16]). The process integrated publicly available county data (Table 1), hub staff's assessment of potential spoke organizations, and self-assessments by potential spoke organizations.…”

Effects of program scale-up on time to resolution for patients with abnormal screening mammography results

“…(27) As the hub, Moncrief anchors a contracted network of participating primary care and radiology facilities across these counties, delivers bilingual telephone-based, oncology nurse-driven navigation for patient intake and scheduling, and reimburses participating providers using a combination of funding mechanisms, per individual eligibility. (25) The NBCCEDP’s Texas state affiliate was the primary source followed by Medicaid, Komen for the Cure regional charities, Cancer Prevention Research Institute of Texas (CPRIT), and local philanthropies. A small number of patients used self-pay, Medicare, and occasionally some form of commercial insurance.. Local primary care and radiology providers serve as network spokes to deliver the full continuum of breast cancer screening services and document service delivery for reimbursement by Moncrief.…”

“…Previously, we tested a tool to assess county capacity (25) and demonstrated effectiveness of a decentralized rural breast cancer screening delivery model to maintain equivalent numbers of women served during program expansion from the original seven counties to 19 counties. (26) In this paper, we evaluate a key quality metric: time to resolution (TTR), to demonstrate effectiveness of that geographic scale-up.…”