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Integrating Cancer Control into Chronic Disease Programs:  What Works and Why?


Coordinator: Welcome and thank you for standing by. At this time all lines are in a listen only mode. Today’s call features a question and answer session. If you would like to ask a question during the call please press star one on your touchtone phone and record your name clearly. Today’s conference is being recorded. If you have any objections you may disconnect at this time. Now I would like to turn the call over to our speaker today, Ms. Margaret Farrell. You may begin. Margaret Farrell: Good afternoon everyone. I am Margaret Farrell and on behalf of the National Cancer Institute I would like to welcome everyone to our April Research to Reality Cyber Seminar. This month we are highlighting a topic of interest to many in the public health and cancer control field. Over the last several years there has been increasing movement towards integrating comprehensive cancer control programs into broader chronic disease prevention and control strategies. In many cases comp cancer programs have benefited by collaborating around cost efficient evidence based methods to enhance cancer screening and prevention efforts. In other cases, however, unfortunately such integration has resulted in a lack of support for comp cancer programs and approaches. Our first speaker, (Nicky Hayes) will share an overview of CVC’s Coordinated Chronic Disease Prevention and Health Promotion Program and how this approach seeks to increase access to clinical preventive services to prioritize and promote effective synergies across conditions to improve efficiencies and outcomes. Next (Crystal Moorwood) of the Colorado Department of Public Health and Environment will speak. In her presentation (Crystal) provides specific examples of how the chronic disease (unintelligible) cancer plan and Colorado’s current cancer coalition action plans align and what Colorado has learned along the way. Each of our speakers will offer unique perspective on the opportunities and directions in comprehensive cancer control and how researchers and practitioners can collaborate with one another to improve the health of their communities to share resources, approaches and interventions. Full bios for each of today’s speakers are available on researchtoreality.cancer.gov where you also be able to engage in a discussion forum on todays’ topic and others as well to view the archive of previous cyber seminars. As is always the case for that cyber seminar the final part of this call will be devoted to your questions and comments. At any time during the presentation please press star one to be placed in the queue and ask your question live during the question and answer portion of the seminar or if you prefer you can also submit your question using the Q&A feature at the top of your screen. Just type in your question and then hit ask. We specifically and warmly welcome those of you who are joining us for the first time on R to R to engage in the discussion today both on the call and on line with the R to R community of practice. Thank you all for joining us today and we really look forward to this important and informative topic. And with that I will turn it over to you (Nicky Hayes) to start us off. Thank you. (Nicky Hayes): Thank you Margaret. I am delighted to be here today. I have the pleasure of providing an overview of our National Center for Chronic Disease Prevention and Health Promotion activities and during that overview I will review our priority domains and these are the domains that we use to facilitate a dramatic approach to prevention and control that encourages collaboration and support across the chronic disease programs regardless with the division within the center or the categorical disease. I will also talk about our cancer programs, particularly the National Comprehensive Cancer Control Program and discuss some of the ways that NCCCP activities contribute to coordinated chronic disease program activities in the four domain areas. I would like to begin just by addressing chronic diseases in general. We all know that seven of the ten leading causes of death in the United States are chronic diseases and almost 50% of Americans live with at least one chronic illness. People who suffer from chronic diseases experience limitations in functions, health, activity and work and this affects their quality of lives as well as the lives of their families. Underlying these diseases and these conditions are significant health risk factors such as tobacco use and exposure, physical inactivity, poor diet, alcohol consumption. Engaging in healthy behaviors greatly reduces the risk for illness and death due to these chronic diseases. And that is really how we define our existence in the National Center for Chronic Disease Prevention and Health Promotion. Our center has investments in cancer prevention and control, diabetes prevention and control, heart disease and stroke disease prevention and control, arthritis and oral health programs and in addition we also have significant investment in activities to reduce the risk of chronic diseases to include tobacco control, physical activity and nutrition, school health and community transformation. We also have significant investments in infrastructural support for Coordinated Chronic Disease Programs, as well as programs to reduce ethnic and racial disparities in health. Individual health depends on societal health and healthy people living in healthy communities. So in addition to strong medical care systems healthy communities have a range of policy systems and environmental support that promote and protect health across the lifespan. They put health in the people’s hands and they give the American people an even greater opportunity to take charge of their health. So transforming our nation’s health and providing our Americans with equitable opportunities to take charge of their health requires work within four key domain areas that I will describe next. In our opinion this is a much more efficient approach than focusing directly on individual behavior change because we all know that small impact strategies are often our resource high and impact low whereas large impact strategies tend to be resource low and impact high. So the first domain area is the policy and environmental interventions area and this domain focuses on evidence based practice and environmental approaches to promoting health in schools, work sites and communities and these approaches really make healthy behaviors easier and more convenient for people. Examples of activities in this domain area include expanding access to and availability of healthy foods and beverages through a variety of strategies, promoting increased physical activity, facility joint use agreement to increase the number of safe accessible places for physical activity in communities, implementing strategies for the built environment that promote active transportation, reducing tobacco use, preventing youth initiation of tobacco, eliminating exposure to secondhand smoke and through a variety of evidence based strategies that include comprehensive smoke-free air policies in work places, public places, smoke-free policies in multi-unit housing and outdoor areas and tobacco free campuses for colleges, work places, health care settings, State Health Department buildings, State buildings, all of which can be accomplished through these collaborative efforts of the comprehensive – of the CDC’s funded Coordinated Disease Program such as cancer, heart disease and stroke prevention, physical activity and nutrition, tobacco and school health programs. And so we really are encouraging our grantees to really work collaboratively to identify where there are these synergies and work collaboratively to make these things happen in policy and environmental changes. The second domain area is the area that focuses on accessing – increasing access to preventive clinical services through health systems change. Health systems intervention improve the clinical environment to more effectively deliver quality preventive services and help people more effectively use and benefit from those services. The result is that some chronic diseases and conditions can be avoided completely while others can be detected early – managed better and avert complications and progression and even improve health outcomes. Health systems and quality improvement changes such as the use of electronic health records, the use of systems to prompt clinicians and deliver feedback on performance and requirements of reporting on outcome such as control of high blood pressure and of a portion of the population up to date on their chronic disease screenings to include their cancer screenings really encourages providers and health plans to focus on preventive services. We all know that many of the largest modifiable gaps in health really do depend on clinical services such as cancer screening, blood pressure screening, (unintelligible) and control. And so what we want to do is provide our grantees an opportunity to really increase the access to those services and work together synergistically to make that happen. The third domain area is the area of community clinical linkages to provide community level support. This area focuses on making sure that people with or at risk for high – or at high risk for chronic disease have the opportunity and the access within their community resources to either support or prevent the delay or the management of chronic conditions once they occur. These supports include intervention such as clinician referral, community delivery and third party payment for effective programs that increase the likelihood that people with diseases such as cancer and heart disease, diabetes or even pre-diabetes, arthritis – that they will be able to follow the doctor’s orders once they leave their doctor’s offices and return to their communities – that they can take charge of their health and this will help to improve their quality of life – help them to avert or delay the onset or the progression of disease, reduce the risk of recurrence for secondary cancers and avoid complications and reduce the need for additional health care. Examples of activities that we see in this domain area and we have seen it play itself out across our Chronic Disease Programs are activities like making available accessible cancer, arthritis, diabetes, chronic disease, self-management education programs and these programs include physical activity programs to reach at-risk populations and community settings such as work site for YMCA’s and schools, senior citizen centers and other local organizations, developing guidelines and systems within clinical care and community settings to address cancer survivorship and make sure that cancer survivors have the appropriate support that they need to promote lifestyle interventions to reduce risk of recurrence and then to really promote effective outreach to the population to increase the use of clinical and other preventive services where necessary to really promote coverage or reimbursement for self-management programs. These are all activities that we see and that we envision can happen through this domain area. And then the fourth domain is the domain area of surveillance and epidemiology and we all know that making the investment in epidemiology and surveillance infrastructures across the states provides them with the necessary resources to not only collect the data and the information but also to develop it and to deploy it into effective interventions – identify gaps and then create interventions within programs to address those gaps. It is important to make the data available and it is as important to make sure that the data is actually used appropriately. And activities that we envision are those that collect appropriate data to monitor risk factors and chronic disease conditions such as the behavioral risk factor survey, the National Program for Cancer Registries or the cancer screening data systems, vital statistics and even Medicare data (unintelligible). Conducting surveillance of behavioral risk factors and social determinants of health to monitor environmental change policies as they relate to healthful nutrition or physical activity, tobacco, community water fluoridation and other areas, collecting cancer surveillance data to assess cancer burden and the trends and identify risk of populations and guide planning and evaluation for Cancer Control Programs. These are some of the activities that we see going on within categorical programs and also can be accomplished by collaborative efforts as well. So what is CDC doing? We created or established a Chronic Disease Prevention Health Promotion Program in 2012 – in 2010 that builds on and strengthens State Health Department capacity and expertise to prevent chronic disease and promote health. This program requires each State to develop or update a State Chronic Disease Prevention Plan and the plan is not intended to replace those categorical disease program plans or categorical disease program activities but those plans really are intended to support. They are there to make sure that the State has the functions, the people, the capacity and the skill set that they need to really make those categorical chronic disease programs successful or to contribute to their success. We know in these times when resources are so difficult to come by that it really does make a lot of sense to combine forces where we need to so that we can leverage these resources and strengthen each other’s capacity and capabilities. When we think of the impact that cancer has on our own communities, our families and our lives – when we think about the fact that it is the number one cause of early death in the United States, that it is the second leading cause of death, that more than 1.5 million people are diagnosed with cancer each year- when you look at it through the disparities lens that for all cancers combined the death rate is 20% higher for blacks than it is for whites and that it costs us an estimated $264 billion in medical costs and lost productivity a year. And then when you consider that, while some cancers are caused by exposure to viruses like HPV and HBV that more than half of all cancer deaths result from preventable exposures. They are caused by human behaviors that include alcohol abuse, excess calories, tobacco use – when you think that cigarette smoking increases the risk for many, many, many types of cancers and that one out of three cancer deaths can be prevented if we were – if we could stop smoking. And when you think about that two thirds of the – of adults and one third of children living in the United States today are overweight or obese and that excess weight contributes to the increased incidents of many cancers that include, pancreatic, kidney and esophageal and that 90,000 cancer deaths could be prevented if obesity and overweight were reduced in the United States then we can see where there are obvious opportunities to strengthen our categorical program efforts by encouraging and supporting coordinated chronic disease program efforts. So within the division of cancer prevention and control we fund a number of cancer prevention and control activities. Our investments represent approximately 95% of our annual budget in these program or initiatives and campaign areas that you see on the slide here. The largest investments are in our three flagship programs, that being the National Breast and Cervical Early Detection Program, the National Program for Cancer Registries and the Comprehensive Cancer Control Program. We also fund the Colorectal Cancer Control Program. We fund cancer survivorship activities and initiatives and we fund two major communications campaigns, the Screen for Life that focuses on colorectal cancer control and the Inside Knowledge Campaign that focuses on gynecological cancers. The National Comprehensive Cancer Control Program convenes statewide coalitions to develop, implement and evaluate data driven cancer control plans. We fund 65 programs with 69 cancer plans and 50 United States – States and the District of Columbia, seven US territories and seven tribes or tribal organizations. Our focus is on comprehensive work that expands the continuum from prevention through survivorship and our priorities are emphasize primary prevention of cancer where we coordinate with relative partners such as tobacco, physical activity, nutrition, obesities, vaccinations, diabetes, to implement evidence based primary prevention interventions. We develop and promote primary prevention messages that are consistent with chronic disease partner messages. We also support early detection and treatment activities. We work together collaboratively to coordinate cancer control programs, chronic disease programs, clinical and public health settings and other key community sectors. We are looking to implement and sustain programs that are intended to reduce disparities. Those programs include patient navigation programs and community health work programs and then we also address the public health needs of cancer survivors, implement policy systems and environmental changes to guide sustainable cancer control, promote health equity as it relates to cancer control and then demonstrate outcomes through evaluation. Cancer Control Programs and Cancer Control Coalitions across the country have the expertise the experience to increase access to clinical preventive services to prioritize and promote effective synergies across conditions to improve efficiencies and outcomes. Examples of these activities are preventing cancer, diabetes, hypertension and (CVD) with lifestyle interventions and we have seen that in our grantees – across our grantees. Using breast cancer, cervical cancer and colorectal cancer screening visits to screen for cardiovascular risk factors and then direct those patients to intervention. Using screening visits to direct smokers to quit lines and to cessation programs or using community health workers to facilitate preventive care, appropriate screening and promote healthy behaviors. Our programs and our coalitions also have the capacity, the expertise and the experience to implement policies and environmental interventions that work synergistically to reduce tobacco use. We have seen increases in tobacco taxes, implementation of smoke-free air laws. We have seen cigarette sales banned in pharmacies. We have seen cigarette – the sale of flavored tobacco products banned in stores. We have seen coverage for tobacco cessation programs as a result of what our Cancer Control and Tobacco Coalitions are doing together in communities. Our Programs and our Coalition have the capacity and the experience to improve nutrition standards in communities. We have seen them work collaboratively to increase community gardens in schools and communities to support taxes on sugar sweetened beverages, to increase healthy food and beverages in schools using comprehensive farm-to-school strategies. To establish food procurement and vending standards that are adopted by state agencies and within local governments and really to support healthy food availability in convenience stores. And the last example that I have of things that we have actually seen is we have seen coalitions and we have seen programs working together to improve physical activity behaviors within communities and these activities include developing complete streets to accommodate all types of transportation, implementing policies that encourage physical activity for school age children, increasing the percent of child care centers that report that they require daily physical activity and then local communities adopting bicycle and pedestrian master plans. So these are some of the activities that we have seen. And now that I have given you more than enough of the theoretical it is my pleasure to introduce (Crystal Moorwood) who is the Program Director for the Colorado Comprehensive Cancer Control Program and she will demonstrate how these coordination activities have actually been put into practice – (Crystal). (Crystal Moorwood): Thank you (Nicky). It is my pleasure to be on the call today and thank you for the opportunity to highlight Colorado’s work for this Research to Reality Webinar My presentation will align perfectly with (Nicky)’s. We couldn’t have coordinated better if we had spent weeks doing this so it really was great to hear your presentation. So I would like to talk about what this presentation is. I would like to highlight how the Colorado Chronic Disease State Plan encompasses our cancer plan and provides specific examples of how the Chronic Disease State Plan, the Cancer Plan and Colorado’s current Cancer Coalition Action Plans align. I would like to touch base on our Department of Health Internal Cancer Program Management and the growth of the health systems project that originated in cancer but it has been integrated into other chronic disease initiatives and it really gives a good example of how coordinated chronic disease work can be successful. So I would like to share with you that this is just one example of obviously our State’s example of how this work can happen but I would like to acknowledge that there are many other strategies and multiple successful ways that will achieve this. So I would like to begin by going over the strategic direction statements of both the Cancer Plan and the State Plan. Because you all probably have them in your own states I will just do this very quickly. So the Colorado Cancer Plan is a plan to reduce incidence mortality in (unintelligible) cancer in Colorado as opposed to the Colorado Chronic Disease State Plan which is a roadmap for Colorado to reduce the burden of chronic disease in Colorado with the following goals – so developing a common vision and shared agenda, creating a plan for aligning state and local approaches to coordinated chronic disease prevention and then of course insuring efficient and effective use of public resources. So these plans are not meant to be action plans or work plans – they are very high level so I would just like to note that and then talk a little bit about the specifics of the State Plans before I get into the specific examples of how they are coordinated together. So the Colorado Cancer Plan – the ultimate goal is to reduce incidences of and mortality of cancer, to – the great thing about it is it is very aligned with the NCCCP cancer priorities that (Nicky) just spoke about in her previous presentation. The Chronic Disease State Plan’s ultimate goal is to reduce the presence – prevalence of cardio-vascular disease, stroke, diabetes and cancer and it is organized by the domain areas that (Nicky) was talking about also in her presentation so the one difference is that Colorado’s group, through a stakeholder engagement and feedback process chose to – I am sorry I missed my slide – chose to add an additional domain area of health education and communication. So the vision of the Chronic Disease State Plan – I keep clicking the wrong button – my apologies. The vision of the Colorado’s Chronic Disease State Plan encompasses all of the categorical plans together. So I (unintelligible) a challenge here – it was difficult for the State of Colorado to find the right level for the Chronic Disease State Plan and as (Nicky) mentioned before, the purpose of the Chronic Disease State Plan is not to replace these categorical programs but to really enhance and coordinate that work – so specifically for cancer because cancer has such a strong and passionate group of stakeholders. We definitely didn’t want to lose that there so I was – point of interest and conversation when we were putting together the Chronic Disease State Plan. So the following slides I am going to go through the specific examples domain area by domain area and talk about how we incorporated what was in the Chronic Disease State Plan and how it fits with the cancer plan. I am going to start with policy and environments. You will see here the overarching goal is to establish a system that supports coordinated chronic disease prevention policies, practices, programming and environmental change at the state and community level with the focus on health equity and all strategy and below that you will see a bunch of health outcomes. I am not going to go over all of them but point out the one that I am focusing on for today’s presentation. So the outcome that we are focusing on is providing local communities with policy and environmental strategies and best practices that focus on increased access to physical activity in an adult environment to support chronic disease prevention and control. So the objective underneath that outcome is to adopt and implement policies to increase physical activity in adult environments and of course then the next two are examples of how the cancer work has encompassed those outcomes and objectives and one is – one example is to promote the installation of shade structures in areas where people congregate outdoors for social and recreational purposes and as many reports, including the Institute of Medicine’s Report, include environment strategies for both skin cancer prevention and physical living – physically active living so that kind of hits two categorical areas there. So the Skin Cancer Task Force Action Plan which is a lower level or a more detailed plan over the one to two year period is to increase the number of shade structures and sun protection in local communities to 18. So the next domain I would like to talk about is health systems transformation. The Chronic Disease State Plan goal is built on existing effort to establish comprehensive health system of prevention, early detection treatment and management of chronic diseases and then you will see the outcomes listed there. And then the next slide will focus on one specific State Plan outcome, increased coordination of the public health and health care system through building an increased utilization of evidence-based services for chronic disease prevention, early detection and control and the specific objective under the State Chronic Disease State Plan is to work with community clinics to carry out systems change and deliver the latest and most appropriate chronic disease prevention, early detection, treatment and quality of life care for underserved and rural communities. So the cancer plan strategy encompassed is encourage practice changes at facility, increased screening and the specific cancer program activities that are happening in this realm or in this domain are with our colorectal screening program, or breast and cervical screening program and our CDC funded colorectal program are working on health systems activities to increase screening rates at community clinics for these cancers and this is the specific example I am going to use at the end of the presentation to talk about coordinated chronic disease. The next domain area is community clinical linkages and the goal here is to insure linkages between clinical and health care settings and effective evidence-based community resources for people with chronic disease and those at risk. So the outcome we will focus on is increased organization and coordination between health care systems, school districts, public health, low income housing authorities and the list goes on as you can read and the objective is insure low socio-economic groups have access to disease management and self-management care plans. So the cancer plan objective is increase the number of cancer survivors in Colorado who receive treatment summaries and care plans post treatment. Similarly to the skin cancer task force action plan the quality of life task force within our cancer coalition has an action plan and one of their goals is to assess the statewide status of treatment and survivorship care plan implementation and one very specific example was that we did a survey of oncology and primary care providers on who was providing that type of care within Colorado. Health education and communication – this is the domain area that was in addition to the CDC’s domain areas but our goal here is to promote awareness and knowledge of chronic disease prevention, early detection, treatment and management among diverse key audiences with an emphasis on health disparities and their root causes, including social and economic obstacles to health and limited English proficiency and the outcome that we are focusing on with this one is to expand access to tools and information that support all Coloradoans in making health choices related to chronic diseases and one of our objectives is to maintain online material fulfillment – is to maintain our online material fulfilment center to provide chronic disease related outreach materials. The cancer plan related strategy is to create a centralized resource directory and clearing house of cancer survivor programs that can be accessed by the diverse populations of cancer survivors in Colorado. And again, specific to the Colorado Cancer Coalition Action Plans both the breast cancer task force and the quality of life task force have an action plan item that discusses reviewing and updating current content listings in the 2013 breast cancer directory to have potential resources ready for inclusion in the all cancer directory and support production of a publicly available all cancer directory. So I am not sure if that one makes sense but what we are trying to do there is – we currently have a breast cancer directory which we are moving to be an all cancer directory in the mind of coordination and collaboration so that folks with cancer can go to one place to access all sorts of information. The last domain area I am going to talk about is data and evaluation. The goal here is to develop enhanced coordinated chronic disease surveillance and evaluation efforts that inform planning for chronic disease prevention and control and then the outcome that I am focusing on for this presentation is resources and technical assistance are available for public partners to use evidence-based public health approach for planning. The objective related to this Chronic Disease State Plan is to create and disseminate an online evidence based public health resource inventory that includes chronic disease data and evaluation resources. So the specific cancer plan strategy that correlates with the Chronic Disease State Plan is to use cancer related data for monitoring and surveillance of cancer risk factors, excuse me, preventive behavior incidents, stated diagnosis, treatment, survival, rehabilitation (unintelligible), socio-economic status, insurance status and mortality. And again, the Task Force Action Plan through the surveillance and evaluation task force is increased awareness among coalition members regarding available data sources and educate on the pros and cons of each resource – of each source and what that looks like here in Colorado is the state has developed a cancer data resource Website that we are rolling out this spring which has all of the cancer data resources listed in one place. We found that was one of our partner’s request was they had to go through two different Websites and weren’t sure what was available to them as far as all that data goes. So we didn’t reinvent the wheel – it doesn’t have the data on it but it directs you in the right place for whether it is surveillance data, (unintelligible) data and the like – American Cancer Society etc. So one of the ways we are meeting the goal of coordinated chronic disease programming within the Chronic Disease State Plan and the Cancer Plan comes from the health system’s domain area. The Chronic C-State Plan outcome which is increased coordination of public health and health care systems resulting in increased utilization of evidence-based services for chronic disease prevention, early detection and control. So to us, to internally operationalize this for cancer we created a cancer community of practice team and a challenge for us in this state was it was difficult to cross communicate and coordinate because our cancer related programs are not in the same unit or branches or even divisions within the State Health Department and I am sure other State Health Department partners can feel that challenge as well. So we developed a community of practice group that meets on a monthly basis to identify strategies to be able to coordinate our work. Well one of the great things that came out of this was we were able to share the success of a health systems project through the – that was implemented through the colorectal cancer screening program and it started with the breast and cervical program and then just used to our Wise Woman Program included tobacco strategies and is also assisting with the deliverables of our chronic disease and school health grant. So as you can see above on the slide if you look at the Chronic Disease State Plan objective – to work with community clinics to carry out health system change and deliver the latest and most appropriate chronic disease prevention and then the cancer plan strategy to encourage practice change at that facility, increase screening we have here colorectal cancer control program, health systems change project and as I mentioned before it has expanded to several different categorical programs and this particular health systems change project is in process or completed at least two – or sorry, 32 community clinics and the next slide I will show you the results from our pilot agencies and – oh first I am going to share with you our process on the health systems change objective and then I will share with you the success of our two pilot groups. So basically the health system change success was to identify potential clinics. Many of our federally qualified health centers or safety nets and we did a lot of that identification by linking with our breast and cervical screening program, as well as our state funded colorectal cancer screening program. We talked about doing a baseline assessment of preventive screening so of course originally it was just colorectal cancer screening compliance at those clinics and which increased to include the other disease areas. And then what we did from that baseline assessment was we shared results back with the clinics and it really provided an opportunity to educate and to put together sort of a plan. What we found it also did was it motivated clinics to want to change. For example with the initial clinic we started working with we did the baseline screening assessment and they found A, that it was very hard for them to figure out how to check to see where their compliance rates were so that was one of the challenges they identified. Additionally, after we figured out how to do that together we found that their screening compliance rate specifically for colorectal in this case, were very low. Sometimes with these clinics it is in the 20’s and the 30 percentages. And that was very motivating to the clinics. It – we didn’t really even have to say anything they just said, “Okay, now what do we do about that?” And so then we were ready with action plan development based on evidence-based strategies within the community guide and one of the tools that has been especially helpful has been the National Colorectal Cancer Roundtable Toolkit which is available on line which includes evidence-based strategy such as including office policy, flows, standing orders, electronic medical record updates – the use of the registries within these systems patient provider reminders and patient navigation use and then also included within this project is an annual follow-up and screening compliance assessment. So this strategy has worked for us on, not just cancer and has moved to – has grown to the other chronic disease areas and we are very excited about the potential use and really the difference we are going to be able to make. And the next slide illustrates our true pilot program. So if you look at the first period and it is – they are assessed at the baseline and then a year later so with one of our clinics they were at a 16.3 colorectal cancer screening from compliance rate and the other clinic was at 9.6 so one clinic went from 16.3 to 29.2% and the other clinic went from 9.6 to 47.5% so we are excited and energized by those results and are continuing to work with the breast and cervical program and the wise women program to recreate the wheel – not recreate – use the wheel that has already been created and move forward to see those kinds of similar successes. So with that I will turn it back to Margaret and would be happy to answer questions or talk about challenges. So thank you very much for your time today. Margaret Farrell: Great – thank you both so much for the whirlwind of activity and such a breath of experience and activities and insights. Thank you both so very, very, much for such an informative presentation. We now would like to open up for questions and for the discussion and just as a reminder if you would like to please press star one to be placed in queue to ask your question live we will put you over the phone and – or if you would like to just type your question we will be taking off the live meeting platform as well. If you just want to type it in to the Q&A box at the top of your screen and then press “ask” and that will put you in the queue there as well. For those of you who would like to request a copy of today’s slides please use the contact us link on researchtoreality.cancer.gov and so we just have a couple of questions already on line if we could start there (Nicky) and (Crystal). One question and I will say this for both of you (Crystal) it was originally directed to you but (Nicky) perhaps you have some insights also. (Ann Helprin) asked are some of the resources the presenter mentioned available online and (Crystal) they are specifically interested in the Survey of Oncologists and primary care providers regarding the provision of care for cancer survivors and the breast cancer survivor resource directory and (Nicky) perhaps a related question is do you have resources also for states that are looking to move into an integrated approach – so (Crystal) I will start with you. (Crystal Moorwood): Sure thank you. So the specific survey that I spoke about the oncology providers it was a key informant interview that we actually funded through our comprehensive cancer program funding for a contractor to actually do these key informant interviews and analyze the results throughout the state. We would be happy to share with you the specific questions that were asked but what we learned was that very few people in our state – very few oncology providers and hospitals were actually using survivorship care and treatment plans either A, appropriately or B, at all so that was definitely a highlighted outcome of that so that one is not on line. But the breast cancer resource directory is on line and the conversation – when it is converted to the full cancer resource directory it will also be on line but right now you could google Colorado Breast Resource Directory and you would be able to download a PDF of it. (Nicky Hayes): Thank you (Crystal) and thank you again for that awesome presentation and we really appreciate the demonstration and some of the activities that you have given us. We do have several resources on line. They are mostly available through our Chronic Disease Coordination Program and what we will do is we will just make sure that we send those resources or links to those resources out to our comprehensive cancer control program directors and then that way they can be made available to all the coalition members and/or planners in each community that is looking for them. Margaret Farrell: Great and thanks and we will be posting all of these also to Research to Reality, as well as part of the ongoing discussion so thanks to you both. A question here from (Melissa Baker) who asks, “Is compliance anonymous with completing screening? You know, certainly something that comes up a lot with HPD. (Crystal Moorwood): Sure, this is (Crystal) and by compliance what I meant and how we use that here is whether the screening guidelines are being followed and whether the patient has met or is following those screening guidelines so for colorectal obviously it would completion of SOBT within a year, sigmoidoscopy plus SOBT or the colonoscopy and the majority of the data we gathered was on average risk folks so those were the, you know, used the United States, USPSTS recommendations to sort of assess whether or not people were complying with screening services. (Nicky Hayes): And this is (Nicky) and if I might add – one of the things that we are looking to do now within the division of cancer prevention and control is as a result of some of the information, the recommendations that came out of the President’s cancer counsel, the recommendations this year around HPV coverage and how do we make sure that there is appropriate coverage there. One of the things that we have made priority in collaboration with our CDC immunization program is really using the cancer prevention message to cancer prevention approach to making sure that HPV coverage is complete and so in the coming year I expect that you will see a lot more activity – a lot more resources that we will be making available to US programs to really help increase coverage in your communities for that vaccination. Margaret Farrell: Great, thanks to you both and again, just a reminder if you would like to ask a question live to press star one to be placed in queue or you can type your question at the top of the live meeting screen. We got a question early on from (Lisa Bradicks) who asked, “Do you all consider trauma informed care approach when designing programs?” and she adds that oftentimes people who smoke or use alcohol excessively are victims of trauma either early in their lives or more recently and just if you wouldn’t mind speaking to that, maybe (Nicky)? (Nicky Hayes): Well what we do – we ask our programs and encourage our programs to use evidence-based approaches to prevention and/or control and we do know that there are, you know, there are a lot of instances where there are mental health issues and/or concerns that do contribute to the health behavior and what we are doing is we are funding specifically to look at tobacco prevention and control and cancer control and looking at disparities within populations. We have recently funded the National Council on mental health to really help us make sure that we can provide our grantees, coalitions and partners in communities there looking at – when I am looking at how do I control cancer and/or how do I prevent tobacco use – what are the mental health issues and how can I make sure that the resources are available to address those issues. And so we have just recently funded the National Council for Mental Health to help us to make those resources available to our Comprehensive Cancer Control Programs and our Tobacco Control Programs and so that is something that you can look for more of in the coming months. Margaret Farrell: Great, thanks to you both. And a question for both of you from (Michelle Carvalo) who says, “Have you had any success stories evaluating PSC changes and demonstrating initial signs of sustainability? And then as a follow on, “Where can we find examples of those top case studies from Comprehensive Cancer Control Programs? (Nicky Hayes): Thank you (Michelle) for that for that question. We actually fund a demonstration program. It is what we affectionately call here as our DP10-1017 Program but that is a program that within Comprehensive Cancer Control we funded a few comp cancer programs to really look at what is it that we need to actually plan, implement and sustain PSC change interventions and so we are just completing a series of case studies from grantee surveys and evaluation activities that we will be making available to the Comprehensive Cancer Control grantees in general at our August program director’s meeting and so we will have the ability then to really share with you some very concrete examples. And they are examples around really first sitting down and developing these policy agendas and making sure that you have a task force that have – that has the right folks at the table that can really drive the issues and then once we do that making sure that there is an established media plan so that we have a very, very succinct plan of action for how we communicate, what the issues are, what needs to be elevated when we are looking at the types of policies and environmental change interventions that we need to be considering and we will be able to share a lot of those examples with the broader program so that we can begin to see them implemented more broadly but we are looking forward to doing that. We are just in the finishing stages of kind of look – evaluating and looking at – or analyzing the data that we have been able to collect and we are excited about being able to share that. (Crystal Moorwood): So this is (Crystal) and I will just add, you know, kind of from the program perspective – we, Colorado was actually funded under the 10-17 that (Nicky) was speaking of and two of the – I guess the most real and sustainable examples I can think of are through our patient navigation strategies, as well as our environment strategies so we have been very successful in getting communities and doing sort of a train the trainer approach on getting communities to promulgate bill environment and shade structure. Well they are both bill environment but shade structure and active living policies within to their – sorry, within their master plans and their community plans and then the patient navigation work we have found that is getting covered by – here they are called regional care collaborative through the Affordable Care Act – it is one of the ways Colorado has organized itself so this type of work is being funded and completed through those ways and some of our private funded health plans have also begun using patient navigation as a way to increase quality of care, as well as decrease health (asparities). Margaret Farrell: Great, thank you both so much – I mean there is such important interventions then, you know, really such an important opportunity to be able to work across platforms, you know, particularly with an integrated approach. A question on the line from (Jason) who asked, “What types of initiatives are you working on with regard to e-cigarettes?” Is that something that is coming up both in Colorado and (Nicky) what you are seeing in your programs? (Nicky Hayes): Sure – I don’t think (unintelligible) – this is (Nicky). We are working very, very closely with our office in smoking and health to really look at the research that needs to be done behind e-cigarettes and what the messages are that we want to – that we need to convey. We still are talking about the prevention and the nicotine issues and we are talking about how do we stop smoking. It is a difficult game at this point because we are behind the ball because industry has taken off but we really are looking at, well how can we get the evidence out there that says these are the things that we really need to be concerned about so that 50 years from now when we are releasing the next surgeon general’s report the next big issue that we don’t have, you know, that we are able to say these are the things that we know and this is how we were able to prevent these things. Unfortunately at this point we don’t have a lot of research available now that we can use to support our prevention messages. (Crystal Moorwood): And this is (Crystal) and I think – I don’t know if this is an issue for all the states but here it has been helpful that our legislation included all kinds of tobacco products when it – in the ban to those under 18 so that was helpful and then of course we are working on media strategies to make sure and using the evidence that we get from CDC and other partners in order to better inform our work moving forward and I don’t work specifically for the tobacco program but I know they are doing a lot of work with that sort of e-cigarette hat on. I would be happy to talk to you offline and point you in the right direction if you were interested in talking to folks from Colorado. Margaret Farrell: Great and thank you (Crystal) and thanks (Nicky) it is, you know, these are ongoing issues that, you know, are so important to be addressed nationally and locally and at the state level as well. (Crystal) I did have to laugh. I am here with my colleagues and talking about how where – even though we are working on similar projects we are not in the same offices and divisions and so I was pleased to hear about (unintelligible) practice that you are able to kind of gather people together and I was wondering what else was surprising or what tool did you find kind of came out of your integration that – now that you see in hindsight has been really valuable? (Crystal Moorwood): You know, I think Colorado was also one of the national – the CDC pilot for integrate for Chronic Disease Integration Program and so we have been attempting to do this for quite a while and we have some struggles that we have gone though and some things that have worked really well and I think one of the things that did work really well was that we – all of our epidemiology planning and evaluation team is sort of a unit in itself. I think traditionally in Colorado we would have an evaluator and an (unintelligible) just assigned that worked directly for our program and really being able to use that group as a whole in their shared knowledge. We do – what we have been used to sort of held that gap as far as content knowledge was have a specific, sorry a specific liaison with that person from the (unintelligible) group and so that has kind of helped us get the data we need in order to make programmatic decisions but then they also get support from other like-minded folks and are able to use examples and successes from other programs in order to move – work in different categories forward. So that is one thing that sort of comes to mind initially. In fact it worked so well within our division – so the evaluation group was within our division which is pretty much the prevention services division – lots of chronic disease – all of the programs that I spoke about in my presentation. Now the (EPI) Group has gone department-wide so I am sure that will present a new challenge to us but it has been helpful to have that. (Nicky Hayes): (Crystal) this is (Nicky) – if I could just ask you one other question. I know one of the – we really are pleased with what we are seeing, you know, going on with your collaboration and your coordination and that is exactly what we intended when we created this coordinated program. We do know that some categorical or cancer coalition specifically, you know, when programs are looking to create these chronic disease plans it is sometimes or has at times been challenging to kind of not lose the cancer identity and it is important that our stakeholders see themselves and what we are doing. Can you talk a little bit about how – a little bit more about how you kind of faced that challenge and made sure that the coordinator coalition really did have, you know, your interest in mind or included? (Crystal Moorwood): Absolutely, that is a really good question. So one of the strategies that Colorado used was to develop a statewide what they called a chronic disease leadership team and all of the internal and external partners kind of came together to make sure all of the disease areas – health equity was addressed, (unintelligible) sources that everybody had a seat at the table and then every time we of course identified maybe more people or a different person that needed to be at that group but that is where a lot of those decision making processes happened so along with the department staff such as myself who were – obviously one of my focuses was to make sure cancer was covered and one of the things we did specifically was look through – once there was a draft of the chronic disease state plan I looked through the chronic disease state plan and really focused on will our cancer plan strategies fit within these evidence-based I guess directions and the roadmap of the chronic disease state plan and actually did a crosswalk of each of them and, you know, one of the things that came from that is the presentation today of how everything fits together. So it was important for us to make sure that the chronic disease state plan was at a high enough level that it didn’t water down or make the different coalitions that are so powerful lose their passion and so it – and we actually had presentations at the Colorado cancer coalition on what the chronic disease state plan was – what the goal was to really communicate that message that it wasn’t meant to replace the plan but it was meant to help coordinate the work that is happening within the plan. Does that help? (Nicky Hayes): Yes. Margaret Farrell: This is Margaret. I think and that is an ideal way to just maybe wrap up the discussion today and to continue and open this discussion on line at Research to Reality where we hope that many of you are colleagues from different comp cancer coalitions and chronic disease programs will join in and share some of their experiences there and some of their best practices and lessons learned so I think that is the ideal (unintelligible). Both of you were so wonderful that – to work with and really did provide such a wonderful back and forth. So, you know, thanks to both of you so very, very much and just want to thank the 200 plus people who were able to join us today online and I know there are even more of you on the phone and your feedback is very important to us and we will be sending an online evaluation link out momentarily and we would like to invite everyone back in May – on May 13th for our next (unintelligible) seminar on nutrition, environment, physical activity and obesity prevention. So thank you all very much for joining us today but particularly for (Nicky) and (Crystal) for being so generous with your time – with your thoughts and with your presentations and again, thank you both so very much for the presentations and thank you everyone for joining us today. (Nicky Hayes): Thank you it is our pleasure. (Crystal Moorwood): Thank you. Coordinator: That concludes today’s call. 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