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Miriam Hernandez, Program Manager in Community Outreach at Cleveland Clinic Cancer Center, joins the Cancer Advances podcast to talk about our approach to community outreach and how we’re helping to educate and provide cancer screenings for the underserved population. Listen as Miriam highlights how the community outreach program initially started, what initiatives they are actively doing within the community, and how they are making a difference.

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Our Approach to Community Outreach

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals, exploring the latest innovative research and clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig Phase I and Sarcoma Programs. Today I'm happy to be joined by Miriam Hernandez, a program manager in community outreach here at Cleveland Clinic. She's here today to talk to us about community outreach. So welcome, Miriam.

Miriam Hernandez: Thank you so much for having me, Dr. Shepard.

Dale Shepard, MD, PhD: Absolutely. So we're going to talk a little bit about outreach and the things you're doing in that, but maybe start off by telling us a little bit about what your role is here at Cleveland Clinic.

Miriam Hernandez: Absolutely. So my role with the team is to decrease late stage cancer diagnosis by identifying health disparities and inequalities in our underserved populations. So essentially we establish partnerships in the community and we are able to work together to decrease some of the barriers that are found within those communities to ensure access for those who need it.

Dale Shepard, MD, PhD: Nice. So that's certainly something that's much needed. Tell us a little bit about how our community outreach program started. And you talked a little bit about the mission, but how did this all get started?

Miriam Hernandez: So our Taussig Cancer Institute Community Outreach Patient Navigation Program actually started in 2008 in June. And it was based off of a three-year grant from Pfizer that follow the mission of Dr. Harold P. Freeman from the Patient Navigation Institute. He's a physician from Harlem, from Harlem Hospital, who developed a program to ensure that traditionally underserved people would receive timely assistance necessary to help guide them through the complexities of the medical system. And so through the program and the mission, our goal was to affect cancer disparities within the targeted market and identifying and resolving barriers to care within our area.

Dale Shepard, MD, PhD: That's really important because as you think about where we sit here in the community, we're oftentimes much more likely to get patients from the suburbs than right down the street. So tell me a little bit about the things that we do to reach out to patients and bring them here to the Cleveland Clinic.

Miriam Hernandez: So we pretty much partner with anyone from local churches to Hispanic community partners, our local Federally Qualified Health Centers, homeless shelters, local government entities, barber shops, beauty shops, anyone that can help us reach those community members that are in those underserved populations. So anyone that is able to provide a platform for us or a partnership for us that will allow us to collaborate with them, those individuals that they are already aware of that are already familiar and have that confidence in going into their establishments.

Dale Shepard, MD, PhD: So what kind of activities sort of describe what that looks like? Like our barbershop interventions and churches, are these activities or are these ongoing efforts over the course of time? Tell me a little bit about how we partner with those groups to engage patients.

Miriam Hernandez: For our churches, we actually have a program called SCIT, Stop Cancer In Its Tracks program. And it actually is based on the partnership with our faith-based community. And so we seek out churches that may be interested in doing some of the events, education sessions, that we're able to provide. And we asked that they in turn, allow us to have a little bit of space in their churches or synagogues or mosques or whatever their faith-based location may be. And so to give us a bit of a platform and encourage not only their parishioners, but their local community members, going out into that community, like you said earlier. Just because someone attends that church doesn't mean that they live in that surrounding area. And so our goal is to ensure that we reach those that are in that surrounding area, as well as the parishioners that attend. And so our faith-based community is a large part in how we reach people and how we spread the word and allow for referrals to come to us in that manner as well.

Dale Shepard, MD, PhD: What do you think are some of the biggest barriers that you see when you go out and you talk to people who may not be coming to see us for their care? Is it primarily concern about the care they received, their ability to pay for the care, to get to the clinic? What are the sort of barriers that you're trying to overcome when patients are really not being seen and should be?

Miriam Hernandez: Absolutely. So it actually is all of the above. So we see everything from financial barriers where people are either uninsured or under-insured, because we often see that although an individual may have insurance, the deductibles that are being asked to be met before they can receive services are too high, and so they're not able to receive the services. So we help to eliminate some of that. We also help with transportation barriers.

One big issue that we found was that individuals who were looking to come to us to receive, let's say a colonoscopy, for example, who were in homeless shelters, they may not necessarily have access to a family member or close friend or someone that actually has a vehicle as is required when you have that type of procedure, to come sit with you, then take you home in a private vehicle. So we found that by partnering with an entity that allows us to provide that type of service for them, it allowed for us to see a larger number of patients who were receiving colonoscopies. Another big thing that we've seen as well is the language barriers. So our team, my team in particular, in my area, we focus on the Latinx community. And so being able to provide that service from beginning to end in their language has definitely made a big impact on the number of people that we're seeing.

Dale Shepard, MD, PhD: Tell me about the role of navigators and specifically with this group. What does it look like? I mean, from a programmatic standpoint, someone we finally... someone says, "Look, I need to come in and I need to be seen, I really want to start engaging with the healthcare system." How do we practically help them do that? What have we been able to do?

Miriam Hernandez: So I always say that our patient navigators are VIPs. They are our superstars, rock stars, because although we as program managers are able to create these opportunities for individuals to come and be screened, our patient navigators are really the ones that take the lead on being able to follow them through the entire process. So our patient navigators are able to establish rapport with them. They're able to communicate with them when and where the patient wants to be seen. They schedule the appointments. They're able to have reminder appointments and help them navigate the financial process by steering them over to our financial navigators that they need to see. They really do at all. And so they are able to follow them through and have the ability to connect with them, almost to the point that they consider them friends. A lot of the patients that I've seen and a lot of the patient navigators, great patient navigators that I've had the honor of working with, so many patients when they come to their visits, ask if they're going to meet them, if they're going to be able to see them.

And then there's that connection that would then allow them to alleviate some of the fears for some of the other services that they may need. So for example, we may have a woman that's coming in for a mammogram, which is pretty typical, but definitely would be not willing to come in for a colonoscopy, let's say, because that's a little bit more interfering with their lives. And so by having these conversations with patient navigators, we've seen so many people that have been able to transition from just one service that they're receiving to them receiving more than one because of that contact that they know that they will not be left just kind of out there.

Dale Shepard, MD, PhD: And I guess just to take a step back for people who may be listening and maybe have some experience with navigation, and that takes on a lot of different ways to work. Are the navigators in this program, are they sort of working on that primary contact to get them set up in the system, or are they following in a longitudinal way?

Miriam Hernandez: They are doing both. So if we have patients that have never been seen at any of our centers, they are the first contact for them. They're entering information and guiding them through what's needed initially. And then once they've been established as one of our patients, they're able to follow them through on any of the services that we provide.

Dale Shepard, MD, PhD: And how do we integrate what's happening on main campus with our regional hospitals and family health centers? So the efforts we're making from an outreach standpoint, does that encompass all of those facilities as well?

Miriam Hernandez: It absolutely does. So our team has grown, and currently we have our director, we have six program managers that oversee six different zones. That's how we delineate our coverage. We have one clinical APP that's a part of our team as well as four patient navigators and one research coordinator. And so for the program managers in those zones, we are actually spread from the east main campus side of Cleveland to a little bit southern into the Warrensville area, my area, which is the Lutheran Hospital, and near west side of Cleveland. We have another program manager that shares my area closely as well as Lorain County. And then most recently our newest program manager oversees the Mansfield area. So we are able to provide services and education and screening opportunities for individuals in all of those areas.

Dale Shepard, MD, PhD: That's impressive. So when we think about cancer care, we think about screening. We think about treatment. We think about survivorship. Do we have activities going on in each of those areas? Can you tell me a little bit about that?

Miriam Hernandez: Absolutely. So we had the opportunity to partner not only with our internal partners in our hospitals and our family health centers, but we've also had the opportunity to partner with the Federally Qualified Health Centers. And so we've been able to provide things like onsite mammogram clinics, whether that's onsite Cleveland Clinic facilities, or onsite with some of our Federally Qualified Health Centers, by bringing in a mobile mammogram clinic service. We've also been able to have a prostate clinic, colonoscopy clinics, throughout the different locations within Cleveland Clinic. We are working on our HPV outreach, HPV vaccinations as well. So we have a variety of things that we are able to provide for our patients.

Dale Shepard, MD, PhD: So a lot of this outreach by nature means that you have to go out and talk to people and, well, interact with them. What's been the impact of COVID? How has that affected what you've been doing and how have you guys been able to accommodate that?

Miriam Hernandez: When COVID first started, I think our entire team, as well as other individuals, thought that community outreach was definitely going to be impacted and sidelined. And we actually found that we were as busy if not busier than we were in the past. And so what we initially did once we were able to come back and things started to open a little bit more, we implemented a concierge type of service for mammogram clinics where we provided the women that were coming in curbside check-in, set up. So we provided everything COVID related. So hand sanitation, masking, temperature, question and answer screening services for COVID. And we were able to escort these women that were receiving these services into the mammogram suite, allowing them to be as contactless and as brief within the facility as possible.

And so that really allowed us to see that the women that were coming in were not only very grateful for having the opportunity to come in while COVID was still having a big impact on the services that they were able to receive, but they loved the fact that we were giving him the special extra attention where we met them and greeted them, and we're able to provide some goodies for them from coming in and just making them feel special. And so we've grown that idea this year into some of the other services that we provide. So the colonoscopy clinics, we've been doing the same. We're able to meet them at the front area. We take them to registration, push all the elevator buttons, open all the doors kind of scenario and do the same thing for them. Dale Shepard, MD, PhD: That's excellent. So certainly, it's something that is a big undertaking and there are other organizations, other groups that are also trying to help out with community outreach and providing care. How do we work with other partner organizations in the community, and how have we have been able to engage with other groups to sort of maximize what we and they're able to provide for these patients?

Miriam Hernandez: So we've been able to work with them by helping them to help us to spread the word. And so we've provided things like rack cards that we've developed. We worked on our community outreach website that now provides breakdown of what we provide and what we do, as well as the ability to connect to our Cleveland Clinic resource page, where they're able to see and print out any information that they may need.

Dale Shepard, MD, PhD: That's great. So when you look at different groups, it's like when we say underserved populations, it's really a diverse group of populations. Are there some things that work better with some groups than others, have you found along the way?

Miriam Hernandez: Yes. So one of the things that we found is that bringing the mobile mammography unit, for example, directly to a homeless shelter has definitely provided a large number of women being screened on that day. Because you don't know with the homeless population, if they'll be able to get to the appointment or where you're going to send transportation services to pick them up, bringing it directly to them and meeting them where they are, has definitely worked. That also goes along with the language piece that we talked about earlier, having the ability for that person to contact someone directly and be able to ask questions has definitely worked for us. We've also recently started a program where we are providing the prep materials for colonoscopies. So we're able to provide over the counter products, and we've seen a great increase in the number of people that are actually showing up well-prepared for their colonoscopies, rather than having them be turned away because they're not fully prepared.

Dale Shepard, MD, PhD: That's great. So you guys have made great strides. What do you see as the biggest gaps? What's the next big thing that needs to change to make a big step forward?

Miriam Hernandez: I think we need to continue to reach the individuals that we haven't reached. And so I think there's large groups of populations that we may not have reached. Currently myself and another program manager, we focus on the Latinx community. We have a program manager that focuses on the LGBTQ community. We've moved into the rural areas. And so I think expanding and promoting the services within the community and gaining the trust to have those individuals actually come in and receive those services is definitely something that's a challenge that we continue to undertake every day.

Dale Shepard, MD, PhD: So this program has been around in some way, and it's certainly grown since 2008. So it's been a little while and you guys have gathered lots of experience. If there are other places that would like to set up community outreach and sort of provide this for their communities, what do you think have been the biggest wins and what have been some of the disappointments and things that just didn't work? What kind of guidance can you provide?

Miriam Hernandez: Don't give up, definitely. Continue trying. Finding the way to reach those within your own communities, finding what their biggest needs are. In one place, it may be transportation because you're in a rural setting and so you need to figure that part out. In another place, it could be financial. In another place, it could be language. So I think it really just depends on your area and knowing your demographic, your catchment area, and figuring out what is best for those individuals there.

Dale Shepard, MD, PhD: So, Miriam, thanks for all of your insight today. You guys are doing really great work with community outreach, and I'd like to thank you for being here.

Miriam Hernandez: So much for having me, Dr. Shepard, it was a pleasure being able to share what our team does.

Dale Shepard, MD, PhD: To learn more about our community outreach team, visit clevelandclinic.org/cancercommunityoutreach. This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, clevelandclinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. And don't forget, you can access real-time updates from Cleveland Clinic's Cancer Center experts on our Consult QD website at consultqd.clevelandclinic.org/cancer. Thank you for listening. Please join us again soon.

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