Avon Safety Net Program – Detailed Program Description Attachment for Full Application

Name of Applicant Organization:______

Detailed Program Description. Please answer the following questions and then provide a narrative for your proposal.

1. Quality Measures for Breast Health:

MAMMOGRAPHY

What is your total screening mammography annual volume (only those that are asymptomatic)?
What percent of your screening patients were screened in the last two years at any facility?
What was your recall rate (e.g., how many individuals that were screened are brought back for additional testing)?
What is your screening mammography cancer detection rate after full diagnostic workup (e.g., per 1000 women screened last year, how many cancers were detected?)
What is your diagnostic breast imaging annual volume (e.g., women who present with symptoms, excluding those recalled from screening)?
What is your cancer detection rate among women presenting with symptoms (e.g., per 1000 women receiving breast imaging examinations, how many cancers were detected)?
What percentage of cancers diagnosed at your center are minimal cancers (node negative invasive cancers, <1cm or DCIS)?
What percentage of cancers diagnosed at your center are early stage (stage 0, I or II)?
What percentage of cancer diagnosed at your center are later stages (stage IIB, III or IV)?

BREAST CANCER TREATMENT QUALITY

How many breast patients are served by your center per year?
How many breast patients did you navigate last year?
How many new cases of breast cancer are diagnosed at your center per year?
What is the average number of days from initial screen to final diagnosis?
What is the average number of days from diagnosis to initiation of treatment?
What are the surgery rates at your institution? (# lumpectomies and # mastectomies):
# lumpectomies
# mastectomies

2. Geography: What is the geography served by your program? How would you describe the area where your program operates (urban, rural, suburban, frontier, Indian reservation, other)?

3. Demographics:

  • Briefly describe the ethnic demographics of your patients. (Please list by %: Hispanic, not Hispanic)
  • Briefly describe the racial demographics of your patients. (Please list by %: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or other Pacific Islander, White, Other)
  • Briefly describe the socioeconomic demographics of your patients (% under 200% FPL).

4. Insurance: What type of insurance does your patient population have (Please list by %: Medicaid or other public plan, Medicare, Indian Health Service, VA, No insurance/uninsured, Private – individual, Private – employer, other)?

5. If your program did not exist, where would patients seek care? Are there other organizations in the area serving a similar patient population?

6.Program Narrative. Provide a narrative that describes your program and addresses the following questions.

a. Briefly describe:

  • Your program prior to Avon support
  • What you seek support for
  • How Avon funds will make a difference
  • What efforts you’ve taken to ensure program sustainability

b. Describe the specific needs you intend to fulfill and how they will be met with funding from this initiative. Keepin mind that the focus of Avon funding is to support your institution’s ability to deliver high quality breast cancer care to underserved individuals:

(i)If you are requesting support for personnel: Describe the background, time commitment and responsibilities of the personnel. Describe how their services will increase the number of individuals served and/or the quality of services delivered. Attach curriculum vitae or resume of key personnel, if they are in place or have been identified, in the appendix.

(ii)If you are requesting support for a patient navigator, please include:

  1. Where along the continuum of care will the PN be introduced to the client and through what phases will the PN support the client? E.g. at initial screening, abnormal finding, follow-up diagnostics, diagnosis, beginning of treatment, completion of treatment, survivorship/end of life care?
  2. What typical activities will the PN engage in at different phases of care?
  3. Which clients are offered patient navigation services? Specifically state whether metastatic patients are or are not offered navigation services?

(iii)Increase in level of services/numbers of patients: If relevant to your funding request, describe how the funding will enable you to provide service to more underserved individuals and estimate the additional numbers that could be served with support from this initiative.

(iv)Improvement in the quality of care offered to underserved patients: e.g., support for antigen and molecular studies not funded by other sources; support for surgical specialists in breast cancer.

(v)Follow-up services: Describe how your clinical service assists and ensures that women receive the services they need and are enabled to effectively complete diagnostic and treatment regimens to conclusively identify breast disease and treat it.

(vi)Data collection and reporting: Please describe the method by which your breast cancer service maintains data on patients served and outcomes, and how you will evaluate the success of the activities to be funded through this initiative. Include quantitative information on how funding will improve data collection and reporting.

c. If you have received Avon funding previously related to the proposed project, please summarize past program aims, outcomes, achievements, and challenges.

7. OtherSupport:

List all active and pending grant support related to the programs/projects for which you are seeking funding in this proposal.

  • Source of support and identifying number
  • Project title
  • Annual total award amount

8. Detailed Program Timeline:

Please provide a realistic month-by-month timeline for implementing your program.

Begin your timeline on either January 1 or July 1 (See Frequently Asked Questions for a sample timeline).

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Please limit your answers to questions outlined in this template to a maximum of 10 pages. Information in excess of 10 pages will not be considered.