Form 0920-1046 Annual National Breast and Cervical Early Detection Prog

Form Approved

OMB No. 0920-1046

Expiration Date: XX/XX/XXXX

Attachment 5: Annual National Breast and Cervical Early Detection Program (NBCCEDP) Survey

The Centers for Disease Control and Prevention (CDC), Division of Cancer Prevention and Control (DCPC) is assessing how DP22-2022 recipients implement the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). This survey asks about your program implementation during program year 1 (PY1), the time period July 1, 2022 through June 30, 2023.

The aims of this data collection are to better understand how you are implementing your BCCEDP; therefore, your feedback is extremely important. You should respond to this survey based upon the work conducted by your program in year 1 only.

If you have any questions about the survey content while completing it, please contact Stephanie Melillo at 770.488.4294 or bcu6@cdc.gov. If you have technical issues in completing the survey, please contact Information Management Services, Inc. at support@NBCCEDP.org.

The survey should take approximately 56 minutes to complete in one sitting.

Thank you for your participation.

Public reporting burden of this collection of information is estimated to average 56 minutes per response including the time for reviewing the instructions and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, NE, MS D-74, Atlanta, GA 30333. ATTN: PRA (0920-1046)

INSTRUCTIONS/DEFINITIONS

WHO SHOULD COMPLETE THIS DATA COLLECTION? The person responsible for the day-to-day management of the program and/or with the most program knowledge should complete this data collection.

WHAT TIME PERIOD IS BEING ASSESSED? We are collecting information about the implementation of your DP22-2022 NBCCEDP, program year 1 (PY1). All responses should reflect implementation of your NBCCEDP in PY1 ONLY, July 1, 2022 – June 30, 2023.

WHAT DO WE MEAN BY ‘YOUR BCCEDP’? The term ‘Your BCCEDP’ refers to all those involved in the implementation of your NBCCEDP program/program activities, including you, your consultants and/or contractors, and your partners, regardless of the source of program funds.

WHAT DO WE MEAN BY ‘HEALTH SYSTEM’? For purposes of this survey, when we use the term ‘health system’, we mean entities delivering clinical care to a defined patient population including, but not limited to, federally qualified health centers/community health centers (FQHCs/CHCs), other publicly funded entities providing primary care, academic health care centers, health plan clinic networks, other health care networks, and hospitals. Health systems often include multiple primary care clinic sites. Insurers/health care plans, Medicaid, and Medicare may also be considered health systems given they have an applicant-defined patient population and reimburse for clinical services rendered.

WHAT ARE THE STRATEGIES AND ACTIVITIES OF INTEREST?

The NBCCEDP implements a comprehensive and coordinated approach to increase access to breast and cervical cancer screening services for women in partner clinical settings. These strategies include using cancer data and surveillance to identify program-eligible population and inform screening projections, delivering breast and cervical screening and diagnostic services, implementing evidence-based interventions (EBIs) in partner clinics, and conducting program monitoring and evaluation. Detailed descriptions of each of these strategies can be found on the NBCCEDP website: [pop-up/link to NBCCEDP logic model]

WHAT ARE EVIDENCE-BASED INTERVENTIONS?

Our program considers evidence-based interventions (EBIs) to be those strategies that have been reviewed and recommended by the Community Guide to Preventive Services Task Force (Community Guide). Definition for these strategies (Provider Assessment and Feedback (PAF), Provider Reminders (PR), Reducing Structural Barriers (RSB), Patient (Client) Reminders (CR), Interventions that engage Community Health Workers (CHWs), Small Media (SM), Group Education (GE), One on One Education (OOE) and Reducing out of Pocket Costs (ROPC)) can be found on the Community Guide website: https://www.thecommunityguide.org/topic/cancer

WHAT IS PATIENT NAVIGATION?

Patient navigation is a strategy aimed at assisting women who receive screening or diagnostic services in overcoming barriers to complete screening and diagnostic services, and initiate cancer treatment. All women enrolled in the NBCCEDP for clinical services must be assessed to determine if patient navigation services are needed and provided with these services according to CDC guidance (e.g., assessment, education, barrier reduction, follow-up).

SECTION 1: RESPONDENT INFORMATION

1. With which NBCCEDP program are you affiliated? [Dropdown list of all NBCCEDP recipients]

• Check appropriate RECIPIENT NAME

2. What is your current position with the BCCEDP program? (Check all that apply)

• Program director (the primary contact for the NBCCEDP cooperative agreement)

• Program manager/coordinator (the day-to-day manager for the BCCEDP)

• Other (please specify): __________________

3. Are you the person who responded to this survey last year? [PY2-5]

• Yes

• No

SECTION 2: PROGRAM MANAGEMENT

1. Using the following response options: “Did not use”, “Used, but not helpful”, “Helpful”, and “Very helpful,” how useful did you find the following technical assistance resources in PY1?

Technical Assistance Resources	Did not use	Used, but not helpful	Helpful	Very helpful
New recipient staff orientation materials
Measuring Breast, Cervical, and Colorectal Cancer Screening Rates in Health System Clinics: Guidance Document
Clinic Data Collection Forms
NBCCEDP Clinic Data Users’ Manual
CDC NBCCEDP website www.cdc.gov/cancer/nbccedp
Screen Out Cancer website www.cdc.gov/screenoutcancer
Clinic Data Reports in B&CBARS and Tableau
Clinic implementation readiness assessment (Clinic IRA) tool
Evaluation Planning Guidance Document [Program year 1 only]
MDE Data Users’ Manual (including MDE data dictionaries)
MDE Feedback Reports
CDC NBCCEDP DP22-2022 Program Manual Part 1
CDC NBCCEDP DP22-2022 Program Manual Part 2 (TBD)
Evidence Based Intervention Planning Guides (EPGs)
Quick Guide to Planning and Implementing Selected Activities to Increase Breast, Cervical, and Colorectal Cancer Screening
State Maps with county level screening rate estimates
NBCCEDP Evaluation Network
TA provided by CDC Program Consultants
TA provided by Evaluation Team and/or IMS
TA provided by OFR
Ask Dr. Miller Newsletter
Success story templates
Health Equity 1-pager
SMART objective 1-pager
Strategy 1-pagers
Other (please specify 1 resource): ___________

2. Please list the amount of Federal (do not include BCCEDP funds, which are displayed above the table), State, Tribal, non-profit, university and other funding that supported or supplemented your BCCEDP program in PY1. Please pro-rate funding if needed to associate with PY1, July 1, 2022 – June 30, 2023. Do not include in-kind resources.

BCCEDP 1701 award for PY1: [amount will be displayed here for recipient reference]

Funding Source	Amount Received in PY1
Non-BCCEDP Federal Funds	$
State	$
Tribal	$
Non-profit (e.g., American Cancer Society, LIVESTRONG)	$
University (e.g., other grant funds, internal university funds)	$
Other - please specify:	$

SECTION 3: PARTNERSHIPS

1. Please indicate which of the following CDC funded programs your BCCEDP partnered with during PY1. (check all that apply)

• Other NBCCEDP funded programs

• Colorectal Cancer Control Program (CRCCP)

• Comprehensive Cancer Control Program (CCC) (including State Cancer Coalition)

• National Program for Cancer Registries (NPCR)

• WISEWOMAN

• Million Hearts Program

• Diabetes Prevention Program

• National Tobacco Control Program

• State Physical Activity and Nutrition Program (SPAN)

• National Immunization Program (NIP)

• We did not partner with any of these programs

2. Have you partnered with any state or local COVID Vaccine efforts?

• Yes

• No

3. Please indicate the number of partners (up to ten) that helped support your program activities in PY1. Partners can include both those that you fund (e.g., contract) and those that collaborate with your program but are not funded by you to do so.

____________ partner(s)

[Ask questions 4-7 for each partner indicated in previous question]

4. What is the name of partner #N ? ____________________

5. Please list the amount of funding (if any) that you provided partner #N . _________

6. Did you have a Memorandum of Understanding (MOU) or contract in place with partner #N in PY1?

• Yes

• No

7. Which of the following activities did partner #N conduct in PY1? (Check all that apply)

• Conduct implementation readiness assessment

• Improve usability of EHRs

• Provide TA for clinic QI efforts

• Provide TA for EBI implementation

• Collect clinic data

• Evaluation

• CHW activities

• Conduct outreach to program-eligible women

• Conduct outreach to specific populations of focus

• Connect women to needed health (other than breast and cervical cancer screening services), community, and social services

• Other (please describe only if applicable, do not enter ‘N/A’ or ‘NONE’): ­­­­­____________

SECTION 4: HEALTH SYSTEMS CHANGE FOR SCREENING DELIVERY

a. Client eligibility criteria

Please describe who was eligible for screening and diagnostic services through your BCCEDP program, based on your program’s general eligibility requirements, including Federal Poverty Level, age, and insurance status.

1. During PY1, what Federal Poverty Level (FPL) was used to determine eligibility for clients receiving NBCCEDP-funded clinical (screening/diagnostic) services? (Check only one)

• 250% FPL

• 200% FPL

• Other (please specify): _____%

2. During PY1, at what age were average risk women eligible for screening in your program? (Do not report exceptions for special circumstances, e.g., younger women if symptomatic or higher risk; enter 99 if you do not provide the specific testing):

Minimum age for mammography screening: _____

Minimum age for Pap testing: _____

Minimum age for Pap with HPV co-testing: _____

Minimum age for primary HPV testing: ______

3. During PY1, were under-insured clients eligible to receive clinical services through your BCCEDP? (i.e., under-insured are clients who are insured but cannot afford their insurance co-pay or deductible or whose insurance plan does not cover cancer screening)

• Yes

• No – skip to 5.5

4. During PY1, what percentage of clients receiving screening and/or navigation services through your BCCEDP program were under-insured? (enter ’UNK’ if unknown) __________

B. BCCEDP Clinic Service Reimbursement Model AND DATA USE

5. During PY1, which payment reimbursement model best describes how your BCCEDP program paid for screening and diagnostic clinical services? (Check all that apply) [Program year 1]

• Our organization provides clinical services directly

• Fee for service (Provider bills and is reimbursed for services/procedures performed; may be managed internally by the recipient or externally by contractor, third party payer, etc.)

• Capitated payment (A uniform reimbursement rate per person served is established for a specified group of screening and/or diagnostic services.)

• Bundled payment (Reimbursement model where rates are established according to tiered case outcomes and are reimbursed retrospectively)

• Employed/Contracted Service Provider (Recipient uses NBCCEDP funds to employ or contract with service providers for screening and/or diagnostic services; uses other vendor for cytology, radiology, etc.)

• Other payment model (please specify): _________________

C. BCCEDP PROVIDER SITES

6. In the table below, please enter the number of individual primary care sites that delivered BCCEDP screening/diagnostic services in PY1 according to the type of provider setting. Primary care sites are where patients go to receive day-to-day health care, including cancer screening, from a health care provider. Please provide the total number of individual sites or clinics, not the number of contracts. Do not include specialty clinics. A site/clinic should be categorized in one of the four groups below, do not include a single clinic in more than one category

	Number of individual BCCEDP primary care clinic sites that delivered NBCCEDP screening services (including referring for mammography) in PY1 If no sites of this type participated, enter ‘0’.   If this type of site participated, but you do not know the number of sites, enter ‘UNK’.
Federally Qualified Health Centers or Community Health Centers
Indian Health Service (IHS) or other tribal health organization sites or clinics (IHS sites that are also FQHC/CHCs should be classified in this category)
Hospitals, health care systems, or any primary care provider (PCP) sites or clinics, not including FQHCs
Other: _______________

D. Breast and Cervical Cancer Prevention and Treatment Act of 2000 (Medicaid Treatment Act)

(This section should only be shown to state awardees -Tribes, Tribal Associations and Territories etc will not be shown this section)

1. Congress passed the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (Medicaid Treatment Act) and we would like to assess its current status in each state. Is the Medicaid Treatment Act currently in place in your state?

   • Yes

   • No

2. Who is eligible in your state to receive this special Medicaid coverage for breast or cervical cancer treatment in your state?

• Only women enrolled in your BCCEDP who are diagnosed with cancer or a precancerous condition

• Any woman diagnosed with cancer or a precancerous condition at a screening site that provides BCCEDP screening services

• Any woman diagnosed with cancer or a precancerous condition who would be eligible for the BCCEDP but may not have been screened with Federal funds

• Other: (please describe)______________

3. Do you have a process to ensure women diagnosed with cancer through your BCCEDP have access to cancer treatment if your state/jurisdiction does not offer coverage through Medicaid Treatment Act?

• Yes

• No

If yes, briefly describe this process: _______

SECTION 5: EBI IMPLEMENTATION FOR HEALTH SYSTEMS CHANGE

A. EBI IMPLEMENTATION

1. During PY1, who provided implementation support (i.e., technical assistance) for EBI-related activities to your partner health systems and/or clinics? (Check all that apply)

• Did not provide

• BCCEDP staff members

• Partner organization(s)

2. How did you deliver implementation support/TA for EBI-related activities to clinics? (check all that apply)

• Practice facilitation

• Peer learning (e.g., project ECHO)

• In person or virtual site visits

• Phone/conference calls

• Webinars

• Trainings, classes, seminars, professional conferences

• Infographics, publications or reports

• Other: ________

B. REACHING AND ASSISTING PROGRAM-ELIGIBLE WOMEN

1. Did you implement any of the following activities to identify, reach out to or connect program-eligible women to needed health, community and social services in PY1? If so, please describe.

• Identify program-eligible women using state or local data

• Reach out to program-eligible women in need of breast or cervical cancer screening and follow-up services

• Partner with organizations to link program-eligible women to needed health (other than breast and cervical cancer screening services), community, and social services

• Connect program-eligible women to needed health (other than breast and cervical cancer screening services), community and social services

• No – skip to Section 6

2. If yes, Free text – description of activities

3. Did you implement any of the following activities to identify, reach out to or connect women in your population(s) of focus to needed health, community and social services in PY1? If so, please describe. (check all that apply)

• Identify population(s) of focus using state or local data

• Partner with organizations that show expertise in or have access to population(s) of focus

• Reach out to women in your population(s) of focus in need of breast or cervical cancer screening and follow-up services

• Partner with organizations to link population(s) of focus to needed health (other than breast and cervical cancer screening services), community, and social services

• Connect population of focus to needed health (other than breast and cervical cancer screening services), community and social services

• None of these

3. Were community-based patient navigators or other community-based workers (e.g. health educator, community health worker, community nurse, promotora) used to identify, reach out to or connect your population(s) of focus to needed health, community, and social services during PY1?

• Yes

• No

4. In PY1, did you track women reached through these activities through screening completion?

• Yes

• No

5. In PY1, how many women were reached through these activities by your BCCEDP? (please report the number of women reached, regardless of the number of times they were contacted. A woman contacted separately for both breast and cervical screening should only be counted once) (enter ’UNK’ if unknown)

How many women were reached through these activities?)________ women

Among those women reached through these activities, how many of them completed breast and/or cervical cancer screening? ________ women

6. In PY1, how did you confirm screening completion for women reached through these activities?

• Based on medical records

• Based on woman’s self-report

• Billing system

• Linkage with MDEs

• We did not confirm screening completion

SECTION 6: COVID-19 IMPACT

1. Please indicate the number BCCEDP-funded staff (up to ten) deployed to assist on the COVID-19 response during PY1.

____________ staff members

Complete this table for each person deployed:

 

Staff person position	Percent FTE time deployed (e.g., 50%, 100%)	Length of time deployed in weeks
Example: Data manager	50%	8

43. Did your BCCEDP program experience staffing shortages due to COVID-19 related reasons (other than deployment) during PY1?

• Yes

• No

43. How many of your provider sites that deliver BCCEDP screening and diagnostic services experienced staffing shortages that limited their capacity to provide screening services for some amount of time due to COVID-19 during PY1?

• Some

• All

• Do not know

•  None

44. Approximately what percent of your provider sites that deliver BCCEDP screening and diagnostic services suspended (i.e., temporarily stopped) or reduced breast and/or cervical cancer screening for some amount of time due to COVID-19 during PY1 although the clinic or provider practice remained open?

• __________%

• Do not know

45. Approximately what percent of your partner clinics that implement evidence-based interventions (EBIs) did your BCCEDP program temporarily stop working with during PY1 (e.g., temporarily stopped providing TA to these clinics) due to COVID-19? 

PY1

• __________%

• Do not know

 

46. During PY1, did your BCCEDP provide assistance to clinics to screen women who had missed their appointments and/or delayed routine clinical care due to COVID-19?

• Yes

• No

If yes, please describe: ______________________

46. Are there other ways that your BCCEDP program was affected by COVID-19 in PY1? 

• Yes

• No

If yes, please describe: ______________________

Thank you VERY MUCH for your time in completing this survey. The data provide a systematic assessment of NBCCEDP recipient program details. If you have any questions, please contact Stephanie Melillo at 770.488.4294 or bcu6@cdc.gov.

END OF SURVEY

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