Colorectal Cancer Screening Summer School

Evidence Based InterventionsJune 28, 2018

Agenda

• Colorectal Cancer Screening Program in South Carolina (CCSPSC): Evidence Based Interventions – Dr. Heather M. Brandt, University of South Carolina

• The Role of the Patient Navigation and Strategies to Sustain Improvement –Sara Romeo, Falls Community Health

• Q&A

Colorectal Cancer Screening Program in South Carolina (CCSPSC):

Evidence-Based Interventions

Heather M. Brandt, PhD, CHESAssociate Dean for Professional Development, Graduate School

Associate Professor, Arnold School of Public HealthUniversity of South Carolina

e: hbrandt@sc.edu t: 803.777.7096

The Colorectal Cancer Screening Program in South Carolina is funded by the Centers for Disease Control and Prevention (Grant #: NU58DP006137). The grant is awarded to Dr. Heather Brandt in the Arnold School of Public Health and Dr. Frank Berger of the Center for Colon Cancer Research at the University of South Carolina. Contact: Hiluv Johnson, program coordinator, hsjohnso@mailbox.sc.edu

• Overview of the Colorectal Cancer Screening Program in South Carolina (CCSPSC)

• Evidence-Based Interventions to Increase Colorectal Cancer (CRC) Screening

• Implementing Evidence-Based Interventions: The Good, The Bad, and The Unknown

• In Closing: What does success look like?

Today’s Session of Summer School

Overview of the Colorectal Cancer Screening Program in

South Carolina

https://www.cdc.gov/cancer/crccp/

University of South Carolina

Programs in 23 state health departments, 1 American Indian tribe, and 6 universities

Colorectal Cancer Screening Program in South Carolina

Long-term Outcome: Decreased CRC mortality through increased participation in CRC screening

The purpose of the Colorectal Cancer Screening

Program in South Carolina (CCSPSC) is to increase

participation in CRC screening by working with partner

health systems to implement priority evidence-based

strategies.

http://cccr.sc.edu/outreach/ccspsc/ccspsc-program

CCSPSC Partners• South Carolina Primary Health Care

Association• American Cancer Society• Colorectal Cancer Prevention

Network• Eight FQHC systems in South

Carolina:– CareSouth Carolina– Carolina Health Centers– Eau Claire Cooperative Health

Centers– HopeHealth– Little River Medical Center– New Horizon Family Health Services– ReGenesis Health Care– Sandhills Medical Foundation

• Advisory Council• Evaluation Committee• Other partners

MOA Complete Sites SelectionBuilding Partnership with

FQHC System

Develop Implementation PlanCollect Baseline Data

Conduct Training Go Live!Conduct Professional

Education

Monitor Implementation

Conduct Technical Assistance (TA)

Support Implementation of

Evidence-based Strategies

Phase 1Building Partnerships

Phase 2Collecting Baseline Data and Planning

Phase 3Implementing

Evidence-based Strategies

Phase 4Supporting and

Monitoring Implementation

Collect Annual DataEvaluation-Activities

CCSPSC Phased Approach to Implementation with Partners

Ongoing TAFocus on Sustainability

Collect Annual DataEvaluation Activities

Annual Review Process

Phase 5Sustainability and

Maintenance

Evidence-Based Interventions to Increase

CRC Screening

What is evidence?

“the available body of facts or information indicating whether a belief is true or valid”

Brownson R.C., Baker, E.A., Leet T.L., Gillespie, K.N. (2003). Evidence-Based Public Health. New York: Oxford University Press.

What is an evidence-based intervention?

• Intervention could include programs, practices, policies, and/or guidelines

• Interventions with proven efficacy and effectiveness at improving health behaviors, health outcomes, or health-related environments

Rabin, B. A., Brownson, R. C., Haire-Joshu, D., Kreuter, M. W., & Weaver, N. L. (2008). A glossary for dissemination and implementation research in health. Journal of Public Health Management and Practice, 14(2), 117-123.Brown CH, Curran G, Palinkas LA, Aarons GA< Wells KB, Jones L., et al. An overview of research and evaluation designs for dissemination and implementation. Annu Rev Public Health,. 2017; 38:1-22

Evidence-Based Interventionsto Increase CRC Screening

https://www.thecommunityguide.org/

CCSPSC: Evidence-Based Interventions to Increase CRC Screening

Select at least two priority, evidence-based interventions:• Provider assessment and feedback• Provider reminders and recall• Client (patient) reminders

Optional supportive activities:• Professional education• Small media

Additional activities:• Standard procedures (policies)• 80% by 2018 pledge

Multi-component interventions

Provider Assessment and Feedback

• Evaluate provider performance in delivering or offering colorectal cancer screening to clients (assessment).

• Present providers with information about their performance in providing screening services (feedback).

• Feedback may describe the performance of a group of providers (e.g., mean performance for a practice) or an individual provider, and may be compared with a goal or standard.

Guide to Community Preventive Serviceshttp://www.thecommunityguide.org/cancer/screening/provider-oriented/assessment.html

Provider Reminders

• Reminders inform health care providers it is time for a client’s cancer screening test (called a “reminder”) or that the client is overdue for screening (called a “recall reminder”).

• Reminders can be provided in different ways, such as flagged appointment lists, notes in client charts, “blue star” on the exam room, by e-mail, etc.

Client Reminders

• Client reminders are written (letter, postcard, email, text) or telephone messages (including automated messages) advising people that they are due for screening.

• Client reminders may be enhanced by one or more of the following:– Follow-up written or telephone reminders– Additional text or discussion with information about indications for,

benefits of, and ways to overcome barriers to screening– Assistance in scheduling appointments

• These interventions can be untailored to address the overall target population or tailored with the intent to reach one specific person, based on characteristics unique to that person, related to the outcome of interest, and derived from an individual assessment.

Implementing Evidence-Based Interventions:

The Good, The Bad, and The Unknown

Implementation Research Methods

Proctor, E.K., et.al., 2009; Implementation Research Methods slides adapted from a presentation by Dr. Prajakta Adsul of the National Cancer Institute.

What?

Evidence Based Interventions

How?

ImplementationStrategies

ServiceOutcomes*

EfficiencySafety

EffectivenessEquity

Patient-centeredness

Timeliness

Health Outcomes

SatisfactionFunction

Health status/symptoms

*IOM Standards of Care

Implementation Research Methods

Implementation Outcomes

FeasibilityFidelity

PenetrationAcceptabilitySustainability

UptakeCosts

What?

Evidence Based Interventions

How?

ImplementationStrategies

ServiceOutcomes*

EfficiencySafety

EffectivenessEquity

Patient-centeredness

Timeliness

Health Outcomes

SatisfactionFunction

Health status/symptoms

*IOM Standards of Care

Implementation Research Methods

Implementation Outcomes

FeasibilityFidelity

PenetrationAcceptabilitySustainability

UptakeCosts

Implementation Research Methods

Proctor, E.K., et.al., 2009; Implementation Research Methods slides adapted from a presentation by Dr. Prajakta Adsul of the National Cancer Institute.

THE WHAT

Select at least two priority, evidence-based interventions:• Provider assessment and feedback• Provider reminders and recall• Client (patient) reminders

Optional supportive activities:• Professional education• Small media

Additional activities:• Standard procedures (policies)• 80% by 2018 pledge

Multi-component interventions

THE HOW

• WHAT: Evidence-based strategies that need to be implemented with FQHCs.

• How to do this?

• Factors to consider:– Retain flexible, adaptive, and iterative approach to

implementation– Ensure high quality implementation– Working with busy partners, busy settings, busy

people

CCSPSC Implementation Challenges

• What constitutes each strategy? For example, what constitutes a provider reminder?– SOLUTIONS:

• Determine key components for each priority strategy. • Examine and monitor “intensity” of each strategy.• Document, document, document.

• How is a flexible and adaptive approach congruent with fidelity? (Or is it even possible?)– SOLUTIONS:

• Approach fidelity with key components of each strategy within each partner FQHC site as the main determinants.

• Observe regularly.• Document, document, document.

CCSPSC Implementation Strategies

• Initial strategies inherent to our approach (planned), e.g.,– Assess for readiness and identify barriers and facilitators (assess

contextual factors)– Develop a formal implementation blueprint– Conduct educational meetings and outreach visits– Became program’s PRIMARY IMPLEMENTATION STRATEGIES

• Strategies as a result of our approach (emergent), e.g., – Champions– Change record systems– Create new clinical teams– Became program’s SECONDARY IMPLEMENTATION STRATEGIES

Powell et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science 2015 10:21

What?

Evidence Based Interventions

How?

ImplementationStrategies

ServiceOutcomes*

EfficiencySafety

EffectivenessEquity

Patient-centeredness

Timeliness

Health Outcomes

SatisfactionFunction

Health status/symptoms

*IOM Standards of Care

Implementation Research Methods

Implementation Outcomes

FeasibilityFidelity

PenetrationAcceptabilitySustainability

UptakeCosts

Implementation Research Methods

Proctor, E.K., et.al., 2009; Implementation Research Methods slides adapted from a presentation by Dr. Prajakta Adsul of the National Cancer Institute.

Provider Assessment and Feedback

Example of Provider Assessment and Feedback: New Horizon – Greer

• Greer uses charts to show the percentage of patients who completed CRC screening by provider.

Example of Provider Assessment and Feedback: New Horizon – Greer

Provider Assessment and Feedback: Challenges and Successes

• Challenges:– Providers are not always receptive to criticism

– Can be difficult with provider turnover

• Successes:– Systematic method of delivery

– Helps providers to understand where gaps in screening occur and act accordingly

– Healthy competition

Provider Reminders

Example of Provider Reminders: Little River – Main

• Little River Main’s primary provider reminder is a daily report of eligible patients

• Little River Main’s supportive provider reminders are care team huddles and emailed reports for providers with a list of eligible patients

Example of Provider Reminders: Little River – Main

Provider Reminders:Challenges and Successes

• Challenges:– Malfunctioning EHR systems – Providers too busy to pay attention to reminders– May not address reason for provider not to recommend

screening– Too many reminders (“click fatigue”)

• Successes:– Quick and easy way for providers to see if patient is eligible

for screening– Can be a very time- and cost-efficient EBI– Multicomponent approaches seem to be promising

Client Reminders

Example of Client Reminders: HopeHealth – Timmonsville

Example of Client Reminders: HopeHealth – Timmonsville

Client Reminders: Challenges and Successes

• Challenges:– Can be time consuming to produce birthday cards, make phone

calls, or set up a phone campaign– Some patients do not realize birthday cards are a reminder to

get screened– Difficult to track

• Successes:– Can remind patients to make appointment for CRC screening– Can remind patients to make general check-up appointment– Great way to make patients feel appreciated

In Closing:What does success look like?

Increase CRC

Screeningper USPSTF guidelines

Provider Assessment

and Feedback

Provider Reminders

Client Reminders

Primary implementation strategies: 23• Program-wide

implementation strategies

Secondary implementation strategies: 7• Used variably

throughout the program, not program-wide

Implementation Strategies

EBI Strategies Outcome

Overall Increases in CRC Screening

As of June 2018; across entire program; includes data from 8 of 15 sites

CRC Screening2015

CRC Screening2017

33% 51%

This represents an actual increase of 18%.

Overall Increases in CRC Screening

As of June 2018; across entire program; includes data from 13 of 15 sites

CRC Screening2016

CRC Screening2017

36% 47%

This represents an actual increase of 11%.

Overall Program Challenges

• Cost of CRC screening

– Cost of initial CRC test

– Cost of follow-up/diagnostic testing, as applicable

– Cost of treatment, as applicable

• Limited resources for uninsured/underinsured in our state

• Competing demands

• Staff turnover in FQHCs

Overall Program Successes

• Capitalized on high level of interest in increasing CRC screening among partners

• Channeled energy into action – improvements in CRC screening observed

• Developed an approach aligned with operations of FQHCs

• Increases in outcome, i.e. increases in CRC screening

Working together to increase

colorectal cancer screening in

South Carolina!

Acknowledgments

• Hiluv Johnson, Cindy Calef, Ranina Outing, Minjee Lee, Maria Zubizarreta • Core for Applied Research and Evaluation (CARE), Arnold School of Public Health,

University of South Carolina (led by Dr. Lauren Workman)• South Carolina Primary Health Care Association• American Cancer Society• Colorectal Cancer Prevention Network of the Center for Colon Cancer Research• Eight federally-qualified health center (FQHC) systems in South Carolina (15 FQHC

sites across the eight systems)• Advisory Council• Evaluation Committee• Other partners

The Colorectal Cancer Screening Program in South Carolina is funded by the Centers for Disease Control and Prevention (Grant #: NU58DP006137). The grant is awarded to Dr. Heather Brandt in the Arnold School of Public Health and Dr. Frank Berger of the Center for Colon Cancer Research at the University of South Carolina. Contact: Hiluv Johnson, program coordinator, hsjohnso@mailbox.sc.edu

The Role of the Patient

Navigation and Strategies

to Sustain ImprovementSara Romeo, RN, BSN

CRC Navigator

Falls Community Health

Falls Community Health

Sioux Falls, SDOur Clinic

We are a Federally Qualified Health Center

We serve approximately 13,000 pts a year

Around 21% of our pts are best served in another language other than English

In 2017, we documented the use of 33 different languages

49% of our patient population is uninsured

Majority of these patients qualify for a sliding fee discount based on their income

In 2017 we also had 1300 pts identify as being homeless

We are also a recognized level 3 Patient Centered Medical Home

Know the Facts!

Colorectal Cancer is the second-leading cause of cancer death in

the United States(1)

In 2017, South Dakota expected 410 new colorectal cancer cases

and 160 deaths to this cancer. It is estimated 135,430 newly

diagnosed colorectal cancer cases and 50,260 deaths are

projected within the United States(2)

If we achieve the 80% goal, we could prevent 277,000 new cases

and 203,000 deaths over the next several years.(1)

CRC Screening Improvement Strategies

In 2016 the SDDOH received a grant

This has allowed us to hire a part-time nurse navigator as a supporting strategy to implement evidence-based interventions.

Nurse Navigator Role including, but not limited to:

Education and Reduction of Barriers

Screening with iFOBT kits

Colonoscopy Appointments

Continuous Yearly Screening Follow-up

Research for funding Colonoscopies

Improving Cancer Screening Rates using

Four Essentials

At FCH we have implemented this evidence-based practice

from American Cancer Society into our daily work to

increase screening rates amongst our patients.(2)

1. Make a Recommendation

2. Develop a Screening Policy

3. Be Persistent with Reminders

4. Measure Practice Progress

Four Essentials to Screening

1. Make a Recommendation

Education is Key to patients ages 50-75 and those with

a family history

Risk stratification for those with family history

Discuss the importance of being screened

Happy Birthday Postcard

Happy Birthday Postcard

Four Essentials to Screening

2. Develop a Screening Policy

Engage your team!

CRC Screening form Updated

Screen everyone ages 50-75 years of age.

Four Essentials to Screening

3. Be Persistent with Reminders

Phone Call or Letter 1st, 2nd, 3rd Week after patient is

given an iFOBT kit.

Annual Reminders

Sorry We Missed You

Four Essentials to Screening

4. Measure Practice Progress

Excel Spreadsheet

Distributed & Received iFOBTs

Annual Reminders, Happy Birthday, New Patient,

CRC Letter

Positive Results and Colonoscopy Follow-Ups

Provider/Nurse Assessment and

Feedback

Dashboards on a quarterly basis

List of Unscreened Patients: CRC Letter

Chart Alerts

Weekly Quality Board Update

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JAN FEB MAR APR MAY JUN JULY AUG SEP OCT NOV DEC

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Navigator Role Continues

+iFOBT Communication with Provider

Colonoscopy Referrals

Assist with Removing Barriers: Funding,

Transportation, Education

Colonoscopy Completion through the New Hampshire

Navigation through Colonoscopies

In April 2017, FCH received a grant to fund Colonoscopies.

New Hampshire Colorectal Cancer Screening Program (3)

Six Topic Navigation Protocol:

Engagement & Barrier Assessment

Prep Education & Barrier Resolution

Prep Review and Re-addressing Barriers

Assessment of Prep and Confirmation of Test Day Details

Day of Colonoscopy

Follow-Up and Patient Understanding of Results

11 out of 12 Patients completed their Colonoscopy

All but 2 Colonoscopies had findings

Benefits to the Navigator Position

Increased Patient Compliance

Increased Screening Rates

Return Rates over 50%

Greater Compliance with Colonoscopy completions

References

(1) 80% Screening Goal. http://cancer.org/colon. The American Cancer Society,

the National Colorectal Cancer Roundtable. 2017

(3) Butterfly, Lynn F. MD. New Hampshire Colorectal Cancer Screening Program:

Patient Navigation Model for Increasing Colonoscopy Quality and

Completion. New Hampshire: 2016.

(2) Sarafaty, Mona. How to Increase Colorectal Cancer Screening Rates in

Practice: A Primary Care Clinician’s Evidence-Based Toolbox and Guide

2008. Eds. Karen Peterson and Richard Wender. Atlanta: The American

Cancer Society, the National Colorectal Cancer Roundtable, and Thomas

Jefferson University 2006, Revised 2008.

Please don’t drop out of Summer School, join us next month!

Tuesday, July 31 @ 12-1 PM CST

Navigating Patients Through CRC Screening with Dr. Lynn Butterly of Dartmouth-Hitchcock Medical Center in New Hampshire

Tuesday, August 28 @ 12-1 PM CST

Improving CRC Screening Access for Uninsured Patients with Dr. Erica Sutton of Jewish Hospital and St. Mary’s Hospital in Louisville, Kentucky.