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Building Clinical Pathways With an Emphasis on Specific Community Needs

Authored by

JCP Editors


J Clin Pathways. 2020;6(10):20-22.

An interview with Carla Baker, RN, chief operating officer, Common Table Health Alliance; project director, Memphis Breast Cancer Consortium

Carla BakerPayers, providers, health systems, and third-party vendors have traditionally been the designers of clinical pathways algorithms and programs, using the classic paradigm of assessing clinical efficacy, toxicity, and cost (in that order) for treatment inclusion on a pathway. Other stakeholders and organizations are beginning to take more of a leadership role in pathways design, though, as the potential of clinical pathways to reduce costs while improving care becomes more apparent. Specifically, patient advocacy groups have taken the concept of clinical pathways and reimagined them by using patient supports, care preferences, cultural experiences, and community environments as starting points for pathway design. Their aim is to better integrate patient needs and socioeconomic environment into the foundations of pathway design while also preserving the original clinical purpose of pathways from a therapeutic standpoint.

Memphis Breast Cancer Consortium (MBCC) is a community partnership whose purpose is to bring together organizations and individuals committed to the fight against breast cancer inequalities in Memphis and Shelby County, Tennessee. They engage individuals, funding partners, and policymakers in the following areas: Awareness, Access to Care, Patient Services, Community-facing Events, Treatment, Quality of Care, Data Sharing, and Quality Improvement. In a new clinical pathways initiative, they have started to research existing pathways programs and their own community needs and resources to create pathways that meet the specific needs of those in their region, which has been found to have disproportionately high breast cancer mortality rates in the African American population.

Journal of Clinical Pathways (JCP) spoke with Carla Baker, RN, to better understand MBCC’s overall mission, organizational structure, and approach to pathways design.

JCP: Please tell us about the MBCC and describe your role there.

Ms Baker: The Memphis Breast Cancer Consortium came into existence in 2014. It was founded after the Avon Breast Cancer Crusade (launched in 1992 as part of the beauty company’s breast cancer awareness activities) did some research looking at breast cancer in 50 of the major cities across the United States. Unfortunately, Memphis, TN, had the distinction of being number 1 of 50 cities where African American women were dying at a rate at two times that of Caucasian women. We were a little shocked about that because you always think you are doing pretty well in your city. Unfortunately, we have been hit with several additional negative sets of statistics related to eating habits, obesity, and things like that, so breast cancer joined those.

There was a group of individuals who came together who wanted to address the disparity. We said to ourselves: “We have got to get off of this list because we’re talking about mothers, heads of households, wives, and also the impact to the economy here in Memphis.” MBCC started meeting right after the 2014 data release from Avon, then became a formal organization in 2016. That is when we got all the members to sign pledges and commitments, and we have been going strong since 2016.

We started out with about 12 individuals, but we have grown to 38 organizations all working together with one common goal—to reduce the incidents and mortality rate for African American women in Memphis and Shelby County. Though the project is mostly geared toward African American women, we know that you cannot help one set of women in a community without helping the other. We always are very inclusive to make sure that whatever we do is beneficial to the entire population of Memphis and Shelby County. You may hear me refer to the Memphis metro region; Memphis sits right on three state lines, bordering Mississippi and Arkansas, so we have many women that either live in Arkansas or Mississippi who receive their care in the Memphis and Shelby County area. So those women are included when I say the Memphis metro area.

Our administrative home is Common Table Health Alliance, a regional health care improvement organization that focuses on community-based collaboration and has been around for over 21 years. MBCC falls under that as one of the projects. They are our administrative home and our legal authority.

Within the MBCC, our 38 members comprise survivor groups, hospitals, health plans, and various advocacy groups. Anybody that could have an impact on a woman’s life or increase the quality of the services that they may be provided are welcome to participate in the Memphis Breast Cancer Consortium. We have been working diligently to increase the women and providers’ awareness of the status of breast cancer in this area. Anybody that will listen to us, we will come before that audience to spread the word about the negative statistics and the services of MBCC. We also work with colleges and universities because you need that research arm to advance your initiatives. For example, you need epidemiologists to assess data collected through outreach and interventional efforts. In addition, we also work closely with our local health department and our Tennessee Department of Health who actively collaborate with us and really help us with our data on the state and local level.

We spend much of our time spreading awareness of the statistics and disparities as well as the ways people can get access to services. We published a report in 2019 called “Breast Cancer 901” (our zip code here in Memphis is 901). We explored, if every woman in Memphis and Shelby County that needed to get a mammogram wanted to get a mammogram, could we actually perform the services? We also wanted to look at the quality of the facilities here in Memphis. We got 17 of the 23 facilities in Memphis to participate in a year-long study and were able to identify or find out that, number one, we have the equipment, capacity, and staff to perform the mammograms. But we found that in some of the high mortality and high incident zip codes, there was not a mammogram facility in that particular area. Where we did not have a freestanding facility in an area, we developed plans where mobile mammogram units could actually go to those areas and do the mammograms, which increased the number of women getting mammograms. Two of our hospitals stepped up to increase their capacity on their mobile van units, and we worked closely with our federally qualified health centers to increase their promotion of mammograms.

It was nice to see that most of the facilities in Memphis went above and beyond just the required qualifications needed to have a mammogram facility too. Most of them went for the higher accreditation standards. We have two breast centers that are national accredited programs, the NAPBC, and we have two facilities that are Diagnostic Imaging Centers of Excellence. We have facilities that are designated as Breast Imaging Centers of Excellence as well. Our centers just did not settle for the bare minimum of accreditation but went above and beyond. We tell women, whether you need initial screening or treatment, you’ve got some of the best centers located right here in the Memphis metro area, so there is no need to have to travel outside of the city to get the treatment that you need.

In our research, we have identified an estimated 84,000 women who are eligible to get mammograms but are still not getting them, so the push is still on. We know there is a lot of fear, misinformation, and myths surrounding screening and cancer, so we have tried to dispel those particular types of myths. As I mentioned, we do a lot of work in spreading awareness and education. COVID-19 has dampened some of that, but we still create seminars and facilitate learning collaboratives. We have been working more closely with some of the manufacturing plants and businesses so we can use Zoom and talk to their employees about general health, wellness, and breast screenings.

JCP: What specific community supports do you promote/provide that are often overlooked as being essential for quality health care outcomes?

Ms Baker: We do the health fairs and all of those types of things. We also create educational materials that people can keep and hold in their hand, because you have some people who like to feel and touch a real document. Then we increased our presence online through our website, and we developed what we call our Pink Ribbon Resource Directory. For this directory, we collected resources about mammogram center locations, how to find and apply for financial support, how to get care without insurance, and other similar FAQ info—all of those different resources that an individual may need to have better breast health care. For example, we list organizations who give money for copays to help pay for mammograms, who do research, who pay for transportation, who pay for food, etc. We are in our fourth or fifth reprint of the Pink Ribbon Resource Directory. It is a hot commodity.Quote 1

The other thing that we created—which may be more of a Southern thing—are those personal little fans that people use to fan themselves in the heat but with breast cancer and mammogram statistics on them. People love those fans, and they don’t throw them away like they would a flyer, you know. They’re a hit. Companies are always asking for them.

We have a dedicated medical advisory board to make sure that the educational materials we create and post are all medically sound. We actually have about 12 physicians from hospitals all over the city plus our health departments that participate in this effort. We also have what we call a Data Analysis Committee. They evaluate and double check our data, and this includes epidemiologists to make sure that any data that we publish is sound and well vetted.

JCP: Can you tell us about the decision support tool for which you are currently in the discovery phase of information gathering? What are the cultural and the socioeconomic factors that you are exploring?

Ms Baker: We are very thankful for Amgen giving us this opportunity to do this clinical and care pathways program. We are presently working with West Cancer Research Institute here in Memphis on this. We are beginning to look at their systems and getting ready to start mapping their process from screening through diagnosis through treatment to better understand how they are delivering their care and where we may be able to help.Quote 2

We want a pathways program that will truly enhance the quality of services within the facility. We will look at facilities’ standards of excellence and see if we can help boost those standards and best practices based on our knowledge of real-world patient needs. Then we will share them with other facilities that are part of MBCC and then eventually with anyone in the Memphis community as well.

Margaret Thorman Hartig, PhD, APN-BC, FAANP, is the principal investigator for the MBCC, and she is a professor at the University of Tennessee Health Science Center, which is one of the largest teaching institutes in  Tennessee. She is working on determining the questions surrounding the pathways program, like who, what, where, why, and will people understand it, and will both the academic community accept it and will the grassroot community accept it. She will ensure that what we create is effective in the real world.

This program is mostly sensitive to African American women, as there is such a large disparity, but, again, anything we can do to improve the general care experience for everyone, we will do. We will explore how well facilities listen to all patients. Many people talk about patient-centered care, but are we really doing patient-centered care? Are we listening to the patients? What does that look like and how do you teach that and implement that in a busy facility? We will be looking at some of their surveys and questionnaires that they use to see what patient involvement there is and if it should be increased.

We are hoping ultimately to improve outcomes by providing a mechanism to coordinate care and reduce fragmentation, and hopefully we will be able to reduce costs as well. We know that the facilities have the NCCN Guidelines, but what other support type system could be a part of their tools that they wouldn’t even have to think about?

JCP: How can your learnings from this research help inform community organizations, health care organizations, and physicians?

Ms Baker: What we want to do is take back all of our learnings to all the member groups and organizations to share the best practices. Maybe they thought they were doing something to the best of their ability but now realize there is an opportunity to do it better. It could be an enhancement to the electronic medical records or a streamlined process that may guarantee that every patient has access to the best treatments or trials. We want these things to become consistent across the hospital systems and the treatment centers in Memphis and Shelby County.

JCP: How do you imagine the clinical pathways program, or decision-support tool, will look or be designed when it comes to executing it in practice?

Ms Baker: We are still working on what it may look like in practice. As I said, we want to look at any barriers or challenges that are causing fragmentation or variation that may not be including the patient perspective or not including even the institution’s perspective. Are there things that people are doing that we end up not getting paid for, which can hurt an organization?

The tool itself could be designed like a decision tree with prompts and certain elements built in. We have been talking to various organizations around the country as far as the different processes that they use and how they implement them. Some of them started out thinking they were going to do one thing but ended up going a different direction based on what they found in their region or specific needs they had. We are starting out with the decision-tree type model for now, but it will all depend on what our full analysis points to.

We believe we need to have the right tools in place and to make sure those tools will get used consistently and properly. The right tool and surrounding training or support will help us to better coordinate the care, and get rid of the fragmentation and unnecessary costs. Once we get through with a detailed assessment of where we are at and digest it, then we can figure out the best way to go that will suit many stakeholders and patients.

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