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Cervical Cancer Screening and PCMH PowerPoint Presentation

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  • Slide 1 - BPHC Enrichment Series for Grantees: Improving Cervical Cancer Screening in Health Centers through PCMH Thursday, January 24, 2013 2:00-3:30pm ET
  • Slide 2 - Cervical Cancer Screening & PCMH Learning Objectives Understand the epidemiological basis of cervical cancer and cervical cancer screening Identify barriers to improving cervical cancer screening rates Analyze how to overcome screening barriers using PCMH Describe successful grantee screening programs Identify additional TA and resources on PCMH and cervical cancer screening Widening Perspectives to Improve Outcomes
  • Slide 3 - Agenda in Brief Welcome Seiji Hayashi, HRSA Profile of Cervical Cancer & Cervical Cancer Screening Jacqueline W. Miller, CDC Challenges to Improving Cervical Cancer Screening Rates Nina Brown, HRSA Using PCMH to Improve Cervical Cancer Screening Rates Preeta Chidambaran, HRSA Successful Health Center Cervical Cancer Screening Programs Rise Phillips, T.H.E. Clinic, Inc. Chad Hess, Pueblo Community Health Center
  • Slide 4 - Cervical Cancer Overview CAPT Jacqueline Miller, MD, FACS US Public Health Service Medical Director, National Breast and Cervical Cancer Early Detection Program Program Services Branch National Center for Chronic Disease Prevention and Health Promotion Division of Cancer Prevention and Control
  • Slide 5 - Cervical Cancer Burden In 2009, 12,357 new cervical cancer cases (7.9/100,000)* 3,909 cervical cancer deaths (2.3/100,000)* Over $2 billion per year is spent in the United States on the treatment of cervical cancer Number of new cases and deaths decreasing U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2008 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2012. Available at: www.cdc.gov/uscs.
  • Slide 6 - Trend in Cervical Cancer Incidence and Mortality Rates*, 1975-2006 *Incidence source: Surveillance Epidemiology, and End Results Program ( 9 areas) Mortality source: US Mortality Files, National Center for Health Statistics, CDC Rates are per 100,000 and are age-adjusted to the 2000 US Std Population (19 age groups - Census P25-1130).
  • Slide 7 - Cervical Cancer Incidence Rate by Race, 2009 Source: U.S. Cancer Statistics Available at: http://www.cdc.gov/uscs. Per 100,000
  • Slide 8 - Cervical Cancer Incidence Rate by State, 2009 Source: U.S. Cancer Statistics Available at: http://www.cdc.gov/uscs.
  • Slide 9 - Cervical Cancer Mortality Rate by State, 2009 Source: US Cancer Statistics Available at http://www.cdc.gov/uscs
  • Slide 10 - Cervical Cancer Screening Two goals Prevention Early detection Precancerous lesions can be treated before developing into invasive disease. Main reason for decline in cervical cancer incidence and mortality.
  • Slide 11 - Cervical Cancer Survival by Stage Source: National Cancer Database
  • Slide 12 - USPSTF Screening Guidelines Recommends screening in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. Grade: A Recommendation.
  • Slide 13 - USPSTF Screening Guidelines Recommends against screening in women younger than age 21 years. Grade: D Recommendation Recommends against screening in women older than age 65 years who have had adequate prior screening and are not at high risk . Grade: D Recommendation
  • Slide 14 - USPSTF Screening Guidelines Recommends against screening in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion or cervical cancer. Grade: D Recommendation Recommends against screening with HPV testing alone or in combination with cytology in women younger than age 30 years. Grade: D Recommendation
  • Slide 15 - Screening Guidelines Consistent recommendations from USPSTF, ACS, and ACOG Only for average risk women
  • Slide 16 - U.S. Cervical Cancer Screening Rates, 2010 Data source: Behavioral Risk Factor Surveillance System Data source: Behavioral Risk Factor Surveillance System
  • Slide 17 - Cervical Cancer Screening Trend Data source: National Health Interview Survey Healthy People 2020 goal is 93%. HP2020 goal
  • Slide 18 - Cervical Cancer Screening by Demographics, 2010 CDC. Cancer Screening. MMWR 2012;61:41-45. Data source: National Health Interview Survey
  • Slide 19 - Cervical Cancer Screening by Demographics, 2010 CDC. Cancer Screening. MMWR 2012;61:41-45. Data source: National Health Interview Survey
  • Slide 20 - Human Papilloma Virus (HPV) Majority of cervical cancer associated with HPV High-risk HPV DNA testing added to screening regimen No role for low-risk HPV DNA testing HPV vaccine may decrease disease burden further, but results too early Continue screening despite vaccination status Hopefully begin to monitor national testing rates
  • Slide 21 - Benefits of Screening Usually no early signs May have vaginal bleeding/discharge, pelvic pain, or painful intercourse Cervical cancer is easily detectable and highly treatable Prognosis depends of stage of tumor and patient’s overall health Screening to look for abnormal cells early leads to better prognosis
  • Slide 22 - Improving Cervical Cancer Screening in Health Centers through PCMH Thursday, January 24, 2013 2:00-3:30pm ET BPHC Grantee TA call
  • Slide 23 - Case Study – Undiagnosed Vaginal Bleeding The patient is a 34-year-old gravida 3, para 3 woman with a 2-year history of increasingly profuse vaginal bleeding. Over the past two years, the patient had been placed on oral contraceptives, but these had not stanched the bleeding. The patient reported having a Pap smear approximately 18 months earlier, read as "unsatisfactory, obscured by blood." However, she had not had a follow-up study. Source: http://www.webmm.ahrq.gov/
  • Slide 24 - Case Study – Undiagnosed Vaginal Bleeding A gynecologist had seen her about 6 months earlier, and told her she needed a hysteroscopy and a dilation and curettage (D&C). However, he explained that he did not accept Medicaid, which was her source of health insurance. Her follow-up remained sporadic, and her bleeding continued—profuse enough that she required hospitalization for transfusions twice in the preceding 2 months. Source: http://www.webmm.ahrq.gov/
  • Slide 25 - Case Study – Undiagnosed Vaginal Bleeding Her bleeding increased again, and she presented to the emergency department (ED). Physical exam revealed that the patient had an extremely friable exophytic cervical lesion, which was biopsied and confirmed to be invasive cervical cancer. Upon evaluation by a gynecologic-oncologist, she was found to be Stage IIB cancer. After undergoing radiation therapy and chemotherapy, she still has persistent disease. Her prognosis is currently guarded. Her oncologist believes that her delayed diagnosis profoundly affected her prognosis. Source: http://www.webmm.ahrq.gov/
  • Slide 26 - Cervical Cancer Related Malpractice Concerns/Issues in Health Centers Over the past 10 years, the majority (58%) of incidents involving cervical cancer have involved the following: a failure to diagnose or delay in diagnosis Significant payout per closed event Source: FTCA Claims Data
  • Slide 27 - Cervical Cancer Screening Trends and Goals in Health Centers
  • Slide 28 - Cancer Screening Outcomes among Health Center Patients Source: 2009 Patient Survey and 2010 NHIS
  • Slide 29 - BPHC’s Efforts to Support Cervical Cancer Screening 811 health centers funded $44 million dollars: $55,000 per health center Focus on PCMH transformation as a tool to improve clinical quality Cervical Cancer Screening Improvement
  • Slide 30 - Cervical Cancer Clinical Measure Current Measure Numerator: Number of female patients 24-64 years of age receiving one or more Pap tests during the measurement year or during the two years prior to the measurement year, among those women included in the denominator Denominator (Universe): Number of female patients 24-64 years of age as of December 31 of the measurement year who were seen for a medical encounter at least once during the measurement year and were first seen by the grantee before their 65th birthday 30
  • Slide 31 - Cervical Cancer Clinical Measure Cervical Cancer Clinical Measure Modified for 2013 Whereas the current measure counts as compliant women age 24 to 64 years with 3 year intervals between screenings, the revision allows 5 year intervals for women age 30 to 64 years with a Pap test accompanied by an HPV test.  This change aligns with the 2012 recommendation of the U.S Preventive Services Task Force.
  • Slide 32 - Qualitative Study of PCMH Supplemental 2012 Key Barriers to PCMH Transformation to Improve Cervical Cancer Screening 32
  • Slide 33 - Patient Level Barriers Access to care Patient Demographics (SES factors) Geographic Issues Patient Engagement Cultural Competency * Workflow Issues Type of providers Care coordination between multiple providers Financial Barriers 33
  • Slide 34 - Provider Level Barriers Workflow Issues Disconnect between QI staff and clinicians Significant gaps between patients identified by registry and scheduling appointments Training and Technical Assistance Turnover of staff or high growth rate in staff Software training Best Practice Guidelines including recent changes to screening recommendations 34
  • Slide 35 - System Level Barriers Clinical Process and workflow issues EHR Decision Support systems Technical and data integrity issues Resources for outreach and education programs 35
  • Slide 36 - Demographics of Health Center Female Patients Source: 2009 Patient Survey 36
  • Slide 37 - Barriers Related to Cultural Competency Need for interpretive services Need for special outreach programs Need for multilingual patient education materials 37
  • Slide 38 - Qualitative Study of PCMH Supplemental 2012 Solutions to PCMH Transformation to Improve Cervical Cancer Screening 38
  • Slide 39 - Solutions Targeting Patients Workflow Appropriate matching of patients to providers for first visit EHR: Patient registries, automatic prompts, Follow up Reminders, Patient Portal Patient Education Materials 39 Source: FY2012 PCMH Supplemental Application Qualitative Review
  • Slide 40 - Solutions Targeting Patients Outreach Follow up on referrals, Batch mailings, Appointment Reminders Advertisement Media, Women’s health fair Finance Discounted fee for screening (PAP tests, lab fees) Incentive gift cards, One time cash rewards Use funds for out of state patients who don’t qualify for in state programs
  • Slide 41 - Solutions Targeting Patients Source: FY2012 PCMH Supplemental Application Qualitative Review
  • Slide 42 - Solutions Targeting Providers Workflow Pre visit planning Standing orders Peer review, quarterly data reports Access to care Increase clinic hours, walk ins, bundling approach Hiring dedicated staff for care coordination, referral follow up Additional staff resources Training Evidence based guidelines, PCMH, Software, Lab protocols Outreach Efforts 42 Source: FY2012 PCMH Supplemental Application Qualitative Review
  • Slide 43 - Solutions Targeting Providers Source: FY2012 PCMH Supplemental Application Qualitative Review
  • Slide 44 - System Based Solutions Organizational Policy and Procedures Identifying cervical cancer screening measure as a Health Center goal Leadership commitment to internal policy changes Quality Improvement QI Identifying quality gaps Pursuing PCMH/ Accreditation Participating in BPHC quality initiatives HIT EHR system (registries, educational resources, decision support system) Training 44 Source: FY2012 PCMH Supplemental Application Qualitative Review
  • Slide 45 - Systems Based Solutions Source: FY2012 PCMH Supplemental Application Qualitative Review
  • Slide 46 - Solutions Related to Cultural Competency* Multi lingual patient education materials Interpretive services for appointments and front desk Multi lingual patient education classes Culturally competent events ex: Hmong Tea Ceremony Training staff on cultural competency * Corresponding NCQA PCMH Domain PCMH 1: Enhance Access and Continuity- Element 1f: Culturally and Linguistically Appropriate Services PCMH 2: Identify and Manage patient Populations - Element 2a: Patient Information 46 Source: FY2012 PCMH Supplemental Application Qualitative Review
  • Slide 47 - Case Study – Undiagnosed Vaginal Bleeding The patient is a 34-year-old (Automatic prompt for preventive care service- PAP) gravida 3, para 3 woman with a 2-year history of increasingly profuse vaginal bleeding. Over the past two years, the patient had been placed on oral contraceptives, but these had not stanched the bleeding. The patient reported having a Pap smear approximately 18 months earlier, read as "unsatisfactory, obscured by blood." However, she had not had a follow-up study.(Protocol for appropriate follow up on lab result) 47 Source: http://www.webmm.ahrq.gov/
  • Slide 48 - Case Study – Undiagnosed Vaginal Bleeding A gynecologist had seen her about 6 months earlier,(Missed opportunity to repeat PAP, better care coordination and documentation between providers) and told her she needed a hysteroscopy and a dilation and curettage (D&C). However, he explained that he did not accept Medicaid, which was her source of health insurance. Her follow-up remained sporadic, (Adequate follow up on referral) and her bleeding continued—profuse enough that she required hospitalization for transfusions twice in the preceding 2 months. (Consolidated records from multiple providers) 48 Source: http://www.webmm.ahrq.gov/
  • Slide 49 - Case Study – Undiagnosed Vaginal Bleeding Her bleeding increased again, and she presented to the emergency department (ED). Physical exam revealed that the patient had an extremely friable exophytic cervical lesion, which was biopsied and confirmed to be invasive cervical cancer. Upon evaluation by a gynecologic-oncologist, she was found to be Stage IIB cancer. After undergoing radiation therapy and chemotherapy, she still has persistent disease. Her prognosis is currently guarded. Her oncologist believes that her delayed diagnosis profoundly affected her prognosis. 49 Source: http://www.webmm.ahrq.gov/
  • Slide 50 - FY12 Supplemental Important Dates and Reminders Survey Submission for at least 1 site or Site Visit Scheduling June 1, 2013 Interim Report Due: Including proof of submission or schedules site visit June 3, 2013 Achieve PCMH Recognition September 30, 2013 Final Reports Due: Including Proof of PCMH Recognition November 1, 2013 50
  • Slide 51 - CHCs and CDC Working Together to Improve Outcomes CAPT Jacqueline Miller, MD, FACS US Public Health Service Medical Director, National Breast and Cervical Cancer Early Detection Program Program Services Branch National Center for Chronic Disease Prevention and Health Promotion Division of Cancer Prevention and Control
  • Slide 52 - CHC’s and CDC’s National Breast and Cervical Cancer Early Detection Program NBCCEDP target population are never screened and rarely screened women 60% of invasive cervical cancer occurs in this population Contract with many CHC’s across the U.S. to provide clinical services
  • Slide 53 - CHC’s and CDC’s National Breast and Cervical Cancer Early Detection Program NBCCEDP eligible population Low income (< 250% FPL) Women aged 21 to 64 years Uninsured or underinsured
  • Slide 54 - CHC’s and CDC’s National Breast and Cervical Cancer Early Detection Program Outreach In-reach Public education Patient navigation Case management
  • Slide 55 - CHC’s and CDC’s National Breast and Cervical Cancer Early Detection Program Quality assessment and quality improvement Using data to monitor quality indicators Completeness of care 90% of abnormal screens must get final diagnosis Timeliness of care 90 days for final diagnosis 60 days to begin treatment
  • Slide 56 - For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion Division of Cancer Prevention and Control Thank You! JMiller5@cdc.gov
  • Slide 57 - Cervical Cancer Screening for Success: T.H.E. (To Help Everyone) Clinic Risë K. Phillips, MPH, MBA President and CEO T.H.E. Clinic, Inc.
  • Slide 58 - T.H.E. Clinic
  • Slide 59 - Relevant Facts concerning T.H.E and its Patient Population T.H.E. (To Help Everyone) Clinic was founded in 1974 as a women’s clinic Expanded to serve families within a decade Serves over 12,500 patients with over 36,000 visits in six sites throughout South and Southwest Los Angeles Staff speak over 12 languages
  • Slide 60 - T.H.E. Patient Demographics
  • Slide 61 - T.H.E. Patient Demographics
  • Slide 62 - Target Patient Demographics (continued) Female population ages 21 to 64 composed of N=5,752 representing 47.5% of total clinic population
  • Slide 63 - T.H.E. Clinic Female Population Ages 21 to 64 as of Dec. 31, 2011
  • Slide 64 - T.H.E. Clinic Cervical Cancer Risk Factors High rates of sexually transmitted infection (STIs including HPV and HIV) Lack of regular Pap tests Weakened immune systems Age over 40 – represent 55.8% of total female patient population
  • Slide 65 - T.H.E. Clinic Cervical Cancer Risk Factors (continued) Sexual history – many partners or partner with many partners High percentage of cigarette smokers High percentage using birth control pills for 5 or more years
  • Slide 66 - Cervical Cancer Screening Challenges Women without a regular primary care provider and medical home less likely to have reported a recent Pap test Transient populations -- Homeless, Hard-to-reach Patients not knowing or understanding their risk for cervical cancer
  • Slide 67 - Screening Challenges (continued) Cultural and language barriers to cervical cancer screening -- Mistrust of medical care providers -- Lack of culturally sensitive screening & treatment environments -- Modesty, fatalism, cultural prohibitions against examinations by male providers
  • Slide 68 - Overcoming Cervical Cancer Screening Challenges Developed a patient-centered Women’s Health practice with a cervical cancer screening initiative -- Identify all eligible female patients between ages 21 to 64 -- Assess pap test records via electronic medical records (EMR)
  • Slide 69 - Overcoming Cervical Cancer Screening Challenges (cont.) Formed Women’s Health Teams with Health Coaches to reinforce positive sexual health and behavioral goals by patients -- Assess and create screening plan for all target female patients
  • Slide 70 - Overcoming Cervical Cancer Screening Challenges (cont.) Women’s Health Team -- Report measures and outcomes regularly during medical quality improvement meetings -- Discuss ways to enhance the patient experience and how to communicate difficult test results
  • Slide 71 - Overcoming Cervical Cancer Screening Challenges (cont.) Performance measures generated through EMR and patient tracking systems -- Team benefits by being able to adjust strategies to impact and enhance the patient experience at all sites
  • Slide 72 - Overcoming Cervical Cancer Screening Challenges (cont.) Non-clinical activities to support patient-centered outreach -- Patients receive “Happy Birthday” telephone calls with a reminder to come to the clinic for their annual exam -- Social media & other community outreach -- Patient satisfaction surveys
  • Slide 73 - How Quality Incentives from BPHC May Have Been Used to Help Achieve Results Behavioral change prevention strategies discussed with patients -- Avoidance of STIs (including HPV) by modifying sexual behavior -- Avoidance of cigarette smoking -- Better family planning
  • Slide 74 - How Quality Incentives from BPHC May Have Been Used to Help Achieve Results (continued) Risks and benefits of cervical cancer screening discussed with each individual patient -- individual risk -- fear of diagnosis -- harm from screenings/treatments -- cultural influences -- values -- perceived barriers to screening
  • Slide 75 - Results/Data of Screenings 85.7% or higher of eligible patients ages 21 to 64 received a Pap Test -- 2% had abnormal cervical findings 2012/2013 goals set for 90% or higher screening goals Enhanced communication between patient and Women’s Health Team leads to better patient experience
  • Slide 76 - Lessons Learned Know your patient population and tailor patient-centered screening strategies Develop Team approach with Health Coaches to reinforce patient behaviors Analyze patient outcome data regularly and change strategies to enhance quality, patient experience & satisfaction
  • Slide 77 - Successful Private/Public Partnerships Helping Cervical Cancer Screening Program Partnership with LA County Health Services for referrals/specialty care Shared clinical best practices within the Community Clinic Association of LA County
  • Slide 78 - Contact Information Ms. Risë K. Phillips, MPH, MBA President and CEO (213)730-1920 ext. 3053 rphillips@theclinicinc.org www.theclinicinc.org
  • Slide 79 - Cervical Cancer Screening Chad Hess PA-C, RN, MBA Director of Nursing Services
  • Slide 80 - ppt slide no 80 content not found
  • Slide 81 - About Pueblo Community Health Center Since 1983, Pueblo Community Health Center’s mission has been to provide primary health care to those in need. PCHC served 23,104 individual patients with 106,927 medical, dental and mental health visits in 2011 PCHC has grown by 45% since 2003
  • Slide 82 - About Pueblo Community Health Center (cont’d) Uninsured = 33%; Medicaid = 43%; Public/Private Insurance = 9%; and Medicare = 15% Nearly 40% of Pueblo County is Latino/a Over 60% of PCHC’s patients represent ethnic minority populations
  • Slide 83 - Cervical Cancer Screening Outreach
  • Slide 84 - Cervical Cancer Screening Outreach-In-Reach and Challenges-2000 Send Patient Reminder Card Provider\MA to identify patients (tickler system) Free Pregnancy Tests Provision of OB & GYN Services No Electronic Data base
  • Slide 85 - Patient Focus Group (Barrier’s) Provider-Gender Preference Appointment Availability Patient’s not assigned to a PCP Evening Clinics (reserved for Acute Care Only) Patient Perceived Need of Service Patient Concern of Cost For Screening Lack of Specialty Care if abnormality is found
  • Slide 86 - Cervical Cancer Screening Outreach Outreach- modeled from Well Women’s Connection program (WWC) Designed a Cancer Screening Clinic Provide Patient Reminders Provide Preventative Health Education Schedule Appointments Monitor Compliance Coordinates Patient Care Patient Advocate
  • Slide 87 - Cervical Cancer Screening Outreach Bilingual Case Managers Cultural Sensitivity Competence Patient’s Word of Mouth Radio PSA’s –Women Cancer Screening Clinics Community Health Fair Participation Organization’s Web Page (Women’s Cancer Screening) Close Collaboration with Community Partners
  • Slide 88 - Cervical Cancer Screening In-reach by Medical & Nursing Staff Patient emphasis on Preventative Health Health Care Maintenance Flow Sheet Provide Updates for Nursing Staff PCP-Continuity of Medical Care Acute Care Visit Opportunities Nurse Visit Opportunities
  • Slide 89 - Cervical Cancer Screening Rates 31% of women age 40-64 are screened annually 29% of women age 21-39 are screened annually 13% abnormal findings
  • Slide 90 - Where Screening Takes Place 40% -Women’s Cancer Screening Clinic 55%-Primary Care Provider 5%-Evening Clinic Option * Patient Preference
  • Slide 91 - Cervical Cancer Screening Challenges Identify Patients who are currently not following ACOG Screening Guidelines Medical and Nursing Staff-ACOG Guidelines Patient’s ability to pay for Screening if not eligible for WWC Patient compliance with scheduled appointments
  • Slide 92 - Cervical Cancer Screening Challenges Patient Perspective on Preventative Health HPV vaccine-uninsured Myths and taboo of why Cervical Cancer Screening is necessary Database inefficiencies in support of case management
  • Slide 93 - How Cervical Cancer Screening Challenges Were Overcome Patient education of current ACOG screening recommendations Provide Medical and Nursing Staff updates of ACOG screening recommendations Quality Improvement Activities Medical Peer Review
  • Slide 94 - How Quality Incentives from BPHC May Have Been Used to Help Achieve Results Develop Cervical Cancer Screening database Plan to duplicate within E HR Generate Patient Compliance Reports Provider\Nurse-Patient Chart Flag Cost of Service Information HPV Vaccine Subsidy Program
  • Slide 95 - Cervical Cancer Screening Rates 87% of Women between 21-39 are screened every 3 yrs if previous Pap Smear\HPV has been nl\neg. 91% of Women between 40-64 are screened every 3 yrs if previous Pap Smear\HPV has been nl\neg. * 2020 Healthy People Goal is 93% for Women 21-65 yrs
  • Slide 96 - Lessons Learned Understand Patient Needs Centralize case management (Patient ID, Scheduling, Tracking) Design Cervical Cancer Screening Clinics within a Family Practice Model Provide Female Medical Provider Provide training to nursing and medical staff
  • Slide 97 - Lessons Learned Remove cultural and language barriers Standing Medical Director orders Monitor “Missed Opportunities” Gynecologist onsite Develop Electronic Database Measure and Report Outcomes
  • Slide 98 - Successful Private/Public Partnerships Helping Cervical Cancer Screening Program Well Women’s Connection Contract Colorado Community Health Network (CCHN) CCHN-WWC Advisory Committee Member Colorado Dept of Public Health & Environment (CDPHE) WWC Quality Indicators CDPHE Monthly Health Improvement Team Calls
  • Slide 99 - Contact Information Bernadette Lujan MA (WWC CM) blujan@pueblochc.org Linda Thurman-Sanchez BSN, RN (Clinical Programs Nursing Manager) lsanchez@pueblochc.org www.PuebloCHC.org

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