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

Form Approved

OMB No. 0920-1046

Expiration Date: xx/xx/xxxx

Annual National Breast and Cervical Cancer Early Detection Program (NBCCEDP) Survey

The Centers for Disease Control and Prevention (CDC), Division of Cancer Prevention and Control (DCPC) is assessing how DP22-2202 recipients implement the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). This survey asks about your program implementation during program year # (PY#), the time period [START DATE] through [END DATE].

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 # 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 or Kristy Kenney at 770.488.0963 or hsl7@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 46 minutes to complete in one sitting.

Thank you for your participation.

Public reporting burden of this collection of information is estimated to average 46 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 DP22-2202 NBCCEDP, program year # (PY#). All responses should reflect implementation of your NBCCEDP in PY# ONLY, [START DATE – END DATE].

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

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 individuals in partner clinical settings. These strategies include using cancer data and surveillance to identify program-eligible populations and inform screening projections, supporting partnerships for cancer control and prevention, delivering breast and cervical screening, implementing evidence-based interventions (EBIs), and conducting program monitoring and evaluation. A logic model detailing how these strategies work together to achieve program outcomes can be found in Appendix B of the NBCCEDP DP22-2202 Program Manual Part I.

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), Patient Navigation (PN), 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 to assist individuals with barriers to cancer screening.  It helps to ensure that these individuals complete screening and diagnostic services and initiate cancer treatment when needed.

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

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

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

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

2. Are you the person who responded to this survey last year? [Program years 2-5 only]

• Yes

• No

SECTION 2: PROGRAM MANAGEMENT

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

Program Resources	Did not use	Used, but not helpful	Helpful
CDC NBCCEDP DP22-2202 Program Manual Part I (Program year 1 only)
CDC NBCCEDP DP22-2202 Program Manual Part II, Monitoring and Evaluation (Program year 1 only)
New recipient staff orientation materials (Program year 1 only)
NBCCEDP website for recipients (https://nbccedp.cdc.gov)
Evidence Based Intervention Planning Guides (EPGs) (https://www.cdc.gov/cancer/php/ebi-planning-guides/)
Health Equity 1-pager (https://www.cdc.gov/cancer/nbccedp/pdf/nbccedp-health-equity-strategies-508.pdf)
SMARTIE objective 1-pager (https://www.cdc.gov/cancer/nbccedp/pdf/smartie-objectives-508.pdf)
Strategy 1-pagers
Ask Dr. Miller Newsletter
DCPC Cancer Screening Change Packages (https://www.cdc.gov/cancer/php/change-packages/)
Clinic implementation readiness assessment (Clinic IRA) tool (Program year 1 only)
Quick Guide to Planning and Implementing Selected Activities to Increase Breast, Cervical, and Colorectal Cancer Screening (Program year 1 only)
NBCCEDP Clinic Data Users’ Manual (includes data dictionaries, data collection forms, guidance document on measuring screening rates, and guidance for using B&C-BARS) (Program year 1 only)
Evaluation Planning Guidance included in the NBCCEDP Program Manual, Part II, Monitoring and Evaluation (Program year 1 only)
MDE Data Users’ Manual (including MDE data dictionaries)
MDE Feedback Reports
Clinic data quality calls (Program years 3-5 only)
Clinic Data Reports in B&C-BARS
NBCCEDP Evaluation Network, (evaluation listserv)
CDC/NACDD Peer-to-Peer (P2P) Webinars
TA provided by CDC Program Consultants
TA provided by Evaluation Team and/or IMS
TA provided by Office of Financial Resources (OFR)
FY24 Annual Performance/Progress Report (APR) Debrief Webinar (Program year # only)
Other Resource (please specify one resource or select ‘did not use’ if you have no other resource to add): _____________________

2. Please list the amount of Federal (do not include CDC NBCCEDP funds, which are displayed in red above the table), State, Tribal, non-profit, university and other funding that supported or supplemented your BCCEDP in PY2. Please pro-rate funding if needed to associate with PY#, [START DATE] – [END DATE]. Do not include in-kind resources.

BCCEDP DP22-2202 award for PY#: [amount will be displayed here for recipient reference]

Funding Source	Amount Received in PY#
Non-BCCEDP Federal Funds	$
State	$
Tribal	$
Non-profit (e.g., American Cancer Society, LIVESTRONG)	$
University (e.g., other grant funds, internal university funds)	$
Other funding sources - please specify or enter 0 if no other funding sources:	$

SECTION 3: PARTNERSHIPS

1. Please indicate which of the following CDC funded programs your BCCEDP partnered with during PY#. (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. Please indicate the number of partners (up to ten) that provided support (e.g., quality improvement, practice facilitation or other technical assistance) to clinics implementing your program activities in PY#. 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 3-7 for each partner indicated in previous question] 

 

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

 

4. Is partner #N a new partner in PY#?

• Yes

• No

4. How much funding did you provide to partner #N?

Funding Source	Amount Provided to Partner
NBCCEDP	$
Other funding sources - please specify or enter 0 if no other funding sources:	$

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

• Yes

• No

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

• Conduct implementation readiness assessment

• Improve usability of EHRs

• Provide TA for clinic QI efforts

• Provide TA for EBI implementation

• Provide patient navigation services

• Collect CDC-required clinic data or MDE data

• Plan and/or conduct evaluation

• Conduct outreach to program-eligible individuals, including by CHWs, and connect them to screening services

• Conduct outreach to specific populations of focus, including by CHWs, and connect them to screening services

• Connect individuals 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: DELIVERING BREAST AND CERVICAL CANCER SCREENING

a. eligibility criteria

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

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

• 250% FPL

• 200% FPL

• Other (please specify): _____%

2. During PY#, at what age were average risk individuals eligible for screening in your program? (Do not report age exceptions for symptomatic or high risk; enter an integer between 18 and 99, if you do not provide the specific testing, enter ‘UNK’):

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 PY#, were under-insured individuals eligible to receive clinical services through your BCCEDP? (this includes those who cannot afford their insurance co-pay or deductible or whose insurance plan does not cover cancer screening)

• Yes

• No – skip to question 5

4. During PY#, what percentage of individuals receiving clinical services through your BCCEDP were under-insured? (enter ’UNK’ if unknown) __________

B. BCCEDP Clinic Service Reimbursement Model AND DATA USE

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

• 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 only if applicable, do not enter ‘N/A’ or ‘NONE’): _________________

6. Does your BCCEDP require program-eligible individuals to pay some amount of money toward screening services? (Check only one)

• Yes, using sliding scale

• Yes, using other process

• No

C. BCCEDP PROVIDER SITES

7. In the table below, please enter the number of individual primary care sites that delivered BCCEDP screening/diagnostic services in PY# 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 imaging centers, labs or primary care sites that only serve populations not eligible for the program (i.e., pediatric). 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 PY# 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 (FQHCs) or Community Health Centers (CHCs)
Primary care sites affiliated with tribal health organizations or Indian Health Service (any FQHC/CHC that are also IHS sites should be included here instead of FQHC category)
Hospitals, health care systems, or any primary care provider (PCP) sites or clinics, not including FQHCs
Other primary care sites (please specify below or enter 0 if no other sites): _______________

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

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

8. 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 (if selected, go to question 9 and skip question 10)

• No (if selected, skip to question 10)

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

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

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

• Any individual 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): __________

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

• Yes, please describe this process: __________

• No

E. OUTREACH AND ASSISTANCE TO PROGRAM-ELIGIBLE INDIVIDUALS

Outreach refers to activities that meet individuals where they are in the community, inform them about cancer screening, facilitate their access to clinical services with the goal of ensuring screening completion.

11. Did your program’s staff do any of the following as part of their outreach efforts in PY#? (check all that apply)

• Use state or local data to identify program eligible individuals and/or populations of focus

• Contact program eligible individuals in the community

• Refer and link individuals to breast and cervical cancer services

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

• Partner with organizations that serve populations of focus, including program-eligible individuals

• Partner with organizations that implemented efforts to link program eligible individuals to breast or cervical cancer services, or other health, community and social services

• No, we did none of these activities – skip to Section 5

12. 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 PY#?

• Yes

• No

13. In PY#, how many individuals were reached through these outreach activities by your BCCEDP? (please report the number of individuals reached, regardless of the number of times they were contacted. An individual contacted separately for both breast and cervical screening should only be counted once. Do not include individuals who were reached through “inreach”, that is, activities conducted within clinics or health systems to get individuals screened. Please enter an integer between 1 and 50,000; if you do not know the number of individuals, enter ‘UNK’) __________ women (If ‘UNK’, skip to Section 5)

14. Among those individuals reached through outreach activities, how many of them completed breast and/or cervical cancer screening? (Please enter an integer between 0 and 50,000; if you do not know the number of individuals, enter ‘UNK’) __________ women (If ‘UNK’, skip to Section 5)

15. In PY#, how did you confirm screening completion for individuals reached through these activities? (check all that apply)

• Based on medical records

• Based on self-report

• Billing system

• Linkage with MDEs

SECTION 5: IMPLEMENTATION SUPPORT

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

• BCCEDP staff members

• Partner organization(s)

• Did not provide (skip to Section 6)

2. What modes are used by you and/or your partners to deliver implementation support/TA for EBI-related activities to clinics? (check all that apply)

• Peer learning, including learning collaboratives with representatives from multiple clinics

• In person or virtual site visits

• Phone/conference calls

• Webinars

• Trainings, classes, seminars, professional conferences

• Guidance documents, publications or reports

• Other: ________

3. In PY#, did your program use a structured approach to implement the NBCCEDP with each of your partner clinics? For example, an approach that involves an assessment period for the clinic, followed by active TA while EBIs are enhanced or newly implemented, and then ending the partnership.

• Yes

• No (skip to Section 6)

4. On average, how long does your structured approach allow for active TA with each clinic? (Check only one)

• Less than 1 year

• 1 year

• 2 years

• More than 2 years

• Length of active TA is based on benchmarks rather than time

3. Based on your experience, please indicate which of the follow factors you consider critical to support program sustainability? (select all that apply)

• Using readiness assessment results to inform implementation

• Providing ongoing support for optimal electronic health record (EHR) use

• Engaging clinic leadership to support EBI implementation and sustainment

• Adopting a team-based approach among clinic staff and cross-training clinic staff

• Integrating EBI implementation into existing clinic workflows, policies, and standard operating procedures

• Identifying and supporting a clinic champion

• Establishing quality improvement (QI) practices

• Ongoing funding to support EBI implementation

• Ongoing training and technical assistance to support sustainment

• Other: __[free text]__________

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 or Kristy Kenney at 770.488.0963 or hsl7@cdc.gov.

END OF SURVEY

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