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80% by 2018 FORUM II
Workshop: Implementing Screening Across Community Health Centers Decatur B
Steps for Increasing Colorectal Cancer Screening Rates:
A Manual for Community Health Centers Laura Makaroff, DO
Senior Director, Cancer Control Intervention American Cancer Society
Structure of Today’s Workshop
Welcome & Introductions – 10 min CRCCP Overview – 20 min Overview of Manual – 15 min Review Group Instructions – 5 min Group Discussion – 30 min Report to Group – 15 min Wrap up – 5 min
3
Objectives
Highlight 4 steps to increase CRC screening: Make a plan Assemble a team Get patients screened Coordinate care across the continuum
Review resources Group discussion
4
How Do I Use this Manual?
Organized into three primary sections Introduction Steps to Increase Cancer Screening
Rates Tools, Templates, Resources
The manual can be used in segments Use live links to navigate throughout
the manual: • "Alt+Left Arrow" on PC • "Command+Left Arrow" on Mac
6
Step #1 Make A Plan
Determine Baseline Screening Rates
• Identify your patients due for screening
• Identify patients who received screening
• Calculate the baseline screening rate
• Improve the accuracy of the baseline screening rate
Design Your Practice's Screening
Strategy • Choose a
screening method • Use a high
sensitivity stool-based test
• Understand insurance complexities.
• Calculate the clinic's need for colonoscopy
• Consider a direct endoscopy referral system
Step #2 Assemble A Team
Form An Internal CHC Leadership
Team • Identify an
internal champion • Define roles of
internal champions
• Utilize patient navigators
• Define roles of patient navigators
• Agree on team tasks
Partner with Colonoscopists
• Identify a physician champion
Step #3 Get Patients Screened
Prepare The Clinic • Conduct a risk
assessment
Prepare The Patient • Provide patient
education materials
Make A Recommendation
• Convince reluctant patients to get screened
Ensure Quality Screening for Stool-
Based Screening Program
Track Return Rates and Follow-Up
Measure and Improve
Performance
Step #4 Coordinate Care Across The
Continuum
Coordinate Follow-Up After
Colonoscopy • Establish a
medical neighborhood
7
Denominator (A) Numerator (B) Screening Rate (C) Total number of patients, age 51-74, with at least one reportable medical visit during the reporting year
Number of active patients, age 51-74, who have received appropriate CRC screening
Number of patients with up to date screening
1000 456 45.6%
8
Step #1: Make a Plan Baseline Screening Rates
See HRSA UDS Manual for full measure definition
Years of life saved through an annual high-quality stool blood screening program are
COMPARABLE to a high-quality colonoscopy-based screening program when positive stool
tests are followed by colonoscopy
Step #1: Make a Plan Design a Screening Strategy
There is no evidence from randomized controlled trials that one screening
method is the “best”
9
Patient Preferences
Inadomi, Arch Intern Med 2012
Stool Test Quality Issues
• Growing evidence that FIT is a superior option for annual stool testing. • Remember that not all FITs are created equal.
• Traditional stool guaiac tests such as the Hemoccult II are no longer recommended
• In-office stool testing and digital rectal exams are not appropriate methods of screening for colorectal cancer.
• All positive stool tests must be followed up with colonoscopy
12
Step #2: Assemble a Team
• Find your internal and external champions! • Your champions can help you establish team
workflows and links of care
13
A recommendation from a provider is the most influential factor on
patient screening behavior
Step #3: Get Patients Screened
14
The creation of a medical neighborhood is critical to coordinate care
Includes the facility, pathology, anesthesia, back up surgery, radiology,
hospital, and possibly oncology
Step #4: Coordinate Care Across the Continuum
17
Appendix A Work Sheets for Completing the Action Steps
Appendix B Electronic Health Record Screen Shots
Appendix C Program Tools and Materials
Appendix D Resources
Tools, Templates and Resources
18
Increasing Quality Colorectal Cancer Screening: An Action Guide for Working with Health Systems Source: Centers for Disease Control and Prevention. Increasing Colorectal Cancer Screening: An Action Guide for Working with Health Systems. Atlanta: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2013. Page 55
Appendix A-7: Action Plan
19
Appendix A-8: Tracking Template
20
Sample NextGen Screenshot How to Order Colonoscopy in EHR
Appendix B-1: Electronic Health Records
21
Sample E Clinical Works Screen Shot How to Generate a Report on Colonoscopies Ordered
Appendix B-2: Electronic Health Records
22
Appendix C-1: Sample Screening Policy
Source: Adapted from the New Hampshire Colorectal Cancer Screening Program 23
Appendix C-6: Preparation Checklist
Source: Colonoscopy Preparation Navigator Checklist from New Haven CHC 24
Appendix C-6: Preparation Checklist
Source: Colonoscopy Preparation Navigator Checklist from New Haven CHC
Appendix C-6: Preparation Checklist
Source: Colonoscopy Preparation Navigator Checklist from New Haven CHC
Appendix D – Additional Resources
1 - Patient Education Materials 2 – Guidelines on CRC Screening (ACS, USPSTF) 3 - Patient Navigation (Training Programs) 4 - Electronic Health Records 5 - Practice Management
27
Appendix D-1: Resources Centers for Disease Control and Prevention cdc.gov/cancer/dcpc/publications/colorectal.htm cdc.gov/cancer/crccp/pdf/guidance_measuring_crc_screening_rates.pdf Screen for Life Campaign Materials ・Fact Sheets, Brochures, Brochure Inserts, Posters, Print Ads, Other TA National Cancer Institute cancer.gov/cancertopics/pdq/screening/colorectal/Patient Patient information about colorectal cancer, colorectal cancer screening, and other topics National Colorectal Cancer Roundtable nccrt.org/tools/ Tools and Resources
28
Appendix D-1: Resources
Prevent Cancer Foundation http://preventcancer.org/learn/preventable-cancers/colorectal/ (Materials available in Spanish): Fact Sheet: Colorectal Cancer 2009 Fact Sheet American Cancer Society cancer.org/colonmd (Materials available in Spanish and Asian languages): ColonMD: Clinicians・Information Source Videos, Wall Charts, Brochures, Booklets ・Guidelines, Scientific Articles, Presentations, Sample Reminders, Toolbox, CME Course,Medicare Coverage, Facts & Figures, Journals
Workshop Group Discussion
Instructions for Group Discussion
1. Which resources from the manual are key to increasing CRC screening rates in your state?
2. How are you going to mobilize and effect change within your state team?
3. What preliminary ideas do you have for your state action plans (to be developed on day 2)?
31
Select a facilitator and note taker Discuss the following questions:
Group Discussion – 30 min Report to Group – 15 min Wrap up – 5 min
32
The national goal is to increase the colorectal screening rate to 80% by
the year 2018
We can get there together!
Faye L. Wong, MPH Chief, Program Services Branch
CDC’s Colorectal Cancer Control Program
July 18, 2017
RELIABLE TRUSTED SCIENTIFIC
Objectives
• To present an overview of…
• CDC’s Colorectal Cancer Control Program (CRCCP)
• CRCCP year 1 findings and some lessons learned
RELIABLE TRUSTED SCIENTIFIC
CDC currently funds 30 CRCCP grantees
23 states 6 universities 1 tribe
CDC DP15-1502 CRCCP Grantees
RELIABLE TRUSTED SCIENTIFIC
The program consists of two distinct components:
Component 2 6 Grantees Only
Provide high quality CRC screening, diagnostic, patient navigation, and other support services to eligible patients. Patient eligibility criteria: • Un- or underinsured • <250% of the federal poverty level • 50-64 years-old
Component 1 All 30 Grantees
Partner with health systems to implement evidence-based interventions (EBIs) and supportive activities (SAs). EBIs: • Patient reminders • Provider reminders • Provider assessment & feedback • Reducing structural barriers
SAs: • Small media • Patient navigation/community health workers • Provider education
What does CRCCP evaluation data tell us so far?
PY1 PY2 PY4 PY3 PY5
We are here
Our data are here
We’ve got a lot of program left to evaluate!
RELIABLE TRUSTED SCIENTIFIC
In Program Year 1, CRCCP grantees have partnered with a number of health systems and clinics.
413 Clinics
140 Health
Systems
3,438 Providers
706,128 Patients,
aged 50 to 75
RELIABLE TRUSTED SCIENTIFIC
CRCCP grantees are partnering with the right clinics.
413 CRCCP Clinics
72% are Federally-
Qualified Health Centers (FQHCs)
46% serve high
percentages of uninsured patients
(≥10%)
53% use FOBT/FIT tests as the primary CRC screening test type
A closer look at CRCCP partner clinics:
RELIABLE TRUSTED SCIENTIFIC
CRCCP clinics across the US: Grantees are primarily working with FQHCs.
41
Source: Clinic data submission, Component 1 only, all 30 reporting, April 2017
RELIABLE TRUSTED SCIENTIFIC
In Program Year 1, grantees implemented or enhanced a variety of EBIs and SAs.
113
58
113 110
153
36
70
100
189
139
155
109
132
12
111
138
0
50
100
150
200
250
300
PatientReminders
ProviderReminders
ProviderAssessment and
Feedback
ReducingStructuralBarriers
Small Media CommunityHealth Workers
PatientNavigation
ProviderEducation
# of
clin
ics
Implemented new activity
Enhanced existing activity
Supporting Activities Priority EBIs
RELIABLE TRUSTED SCIENTIFIC
CRCCP grantees’ also worked with a variety of non-health system partners.
Partner Activities The five most frequently reported activities were: 1. Provider education and
professional development. 2. Quality improvement. 3. Health information technology to
improve electronic health record systems.
4. Patient reminders. 5. Small media.
Grantees’ five most common partners:
RELIABLE TRUSTED SCIENTIFIC
What did CRCCP achieve in Year 1?
6% INCREASE
IN CRC SCREENING
RATES
413 Clinics
140 Health
Systems
3,438 Providers
706,128 Patients,
aged 50 to 75
RELIABLE TRUSTED SCIENTIFIC
Year 1 findings:
• Increases in CRC screening was higher in:
• Urban and Metro clinics vs rural clinics
• Medium size clinics vs small and large clinics
• Clinic using FIT vs colonoscopy or FOBT
• Clinics with an internal CRC screening champion vs no champion
• Clinics with a written CRC screening policy vs no policy
• Most clinics received monthly implementation support
RELIABLE TRUSTED SCIENTIFIC
Lessons Learned (so far):
Grantees successfully launched this evidence-based, public health model for increasing CRC screening rates in clinics serving high-need populations.
Grantees are targeting clinics with low screening rates and implementing EBIs and Supportive Activities.
Baseline data suggest potential for significant reach and impact as grantees recruit more clinics to participate.
Measurement and evaluation is important.
Funded and non-funded partners are critical to successful implementation.
Obtaining accurate screening rate data from EHRs is challenging.
The Big Picture of efforts to increase colorectal cancer
screening
Leveraging Partnerships
NCCRT >1000 80 by 2018 Partner-Signed
Pledges
CDC CRCCP 30 w/health systems
intervention $$
6 w/screening support $$
65 CDC CCC Grantees
22 CRC state teams
CCC National
Partners
A C A Prevention Benefits – covers CRC screening @ no cost
Private Sector • Insurers • Hospitals • GI specialists • Physicians • Venders • Others…
PCAs
HCCNs
PRCs/CPCRNs
Universities
80 by 2018 Screening Goal
ACS • Health Systems
Managers • Media and
Communications
NCI & NCI Cancer
Centers
HRSA FQHCs
9/2015: 11 CRC state teams 7/2017: 11 CRC state teams
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.
Go to the official federal source of cancer prevention information:
www.cdc.gov/cancer
@CDC_Cancer Follow DCPC Online!