Virginity, Pain, and Confusion: Overcoming Barriers to Cancer

Screening at Federally Qualified Health Centers-Nilani Downs and Chris

Espersen

Pop Quiz

• A 66-year old female walks into your clinic for a physical, upon review of her chart you note that she has not had a pap test in over 10 years. Do you perform a pap test on her?

a)Yes

b)No

Cervical Cancer The American Cancer Society estimates in 2014:

About 12,360 new cases of cervical cancer will be diagnosed

About 4,020 women will die from cervical cancer However, 60%-80% of women with advanced

cervical cancer have not had a pap test in the past 5 years

More than 15% of cases of cervical cancer are found in women over 65. These cancers rarely occur in women who received regular screenings prior to 65.

Breast Cancer The second most common cancer in the U.S. and

the second deadliest in women In 2013:

More than 232,000 new cases Nearly 40,000 deaths

Over 2 million Americans living with Breast Cancer Death rates have fallen steadily over the past 20

years

Colorectal Cancer Third most common cancer, 2nd deadliest In 2013

~140,000 new cases Nearly 50,000 deaths Highest incidence and death rates in:

African American

American Indian/Alaska Native

1.2 million individuals living with current or past CRC

Pop Quiz

What proportion of people who have never been screened have health

insurance?

Example:Who’s Not Screened

Barriers to Screening at Iowa FQHCs

Patient comfort Cultural beliefs Lack of education on screening Misunderstanding of the Pap Test Lack of reminder system Uninsured/underinsured Physician discomfort Lack of support for screening

70-year old Spanish-speaking male patient with multiple conditions including Diabetes, HTN, and obesity. This patient is best described as one who makes good use of resources. He is on the ball. The patient frequently enlisted the help of the Nurse Care Manager for help in getting his prescriptions and diabetic supplies, including diabetic shoes.In one instance the patient was scheduled to see Iowa Orthopedics. The patient was having problems with scheduling, so he contacted the Nurse Care Manager.In another instance, the provider felt that the patient was doing well and he could discontinue Metformin. The patient went to see his urologist for a prostate problem & was told he had sugar in his urine. The patient promptly returned to the clinic to request Metformin. The patient was compliant in getting colonoscopy done and as of April 2014, he was going to schedule his annual diabetic eye exam with his own eye doctor. The patient regularly follows-up with his urologist for prostate issue and oncologist for past history of pharyngeal cancer.

Pt came in for appointment in tears, reporting much anxiety and hopeless feelings. Recently had a heart attack and reports that it was the first time he really looked at his own mortality. Also recently lost a brother to suicide. Spent approx an hour with pt allowing him to vent and utilizing MI skills to elicit some root causes to his anxiety. One thing he was finally able to share at the end of the visit was that he didn’t have enough money for food and didn’t get his check until the next week. We discussed ways to help make that stretch and I offered him a food box referral. You could actually see the relief wash over his face and shoulders.

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Source: Centers for Disease Control and Prevention

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Disparity Data

2013 Health Center Data

2011 2012 2013 2011 – 2013

Trend % Change

Quality Care Indicators/Health OutcomesPerinatal Health Cervical Cancer Screening

Iowa Data 49.9% 47.2% 50.4% 0.9%

National Data 57.8% 57.2% 57.8% 0.1%

Colorectal Cancer Screening

Iowa Data - 20.1% 29.7% -

National Data - 30.2% 32.6% -Source: HRSA Health Center Program Grantee Data

Increasing Screening Rates

This is a 58-year old female patient with mental health and cardiovascular issues, tobacco use & obesity. The Nurse Care Manager initially saw this patient in Feb. The patient was 5’ 4” and weighed 201.4 lbs. (34.7 BMI). The patient was seeing a cardiologist . She had mitral stenosis and mitral regurgitation. The patient complained she had no energy and did not want to do anything. The patient required a mitral valve replacement; however, she needed to be smoke-free for 2 months prior to the surgery. The patient was smoking 10cigs/day at this time. The patient was most concerned with smoking cessation so she could have open heart surgery. The Nurse Care Manager provided the patient with Healthwise Handbook and went over sections on smoking cessation and healthy weight. The patient was happy the last time she was seen in April 2014. Patient reported she was completely stopped smoking. She no longer needed the nicotine patch and had been smoke-free for over 2 months. The pt. continues to see the cardiologist; does not add salt to her food; and continues with weight loss efforts.. Next goal will be to have the patient agree to have a mammogram.

Huddle Sheets

Motivational Interviewing

Recalls and Community Opportunities

Barriers to Screening: Opportunistic vs. Organized Preventive Care

Most preventive care for adults in the U.S. is opportunistic, i.e. occurs incidentally during encounters with healthcare professionals

Opportunistic care depends on a coincidence of encounters, circumstances, and interests between patient and provider

This means some adults get some preventive care on some occasions and at some interval

Few adults receive the full package, or even the majority of recommended preventive services

Screening Toolkit• The Guide outlines efficient

ways for practices to get every eligible patient the colorectal cancer screening tests he or she needs

• Developed to introduce clinicians and staff to concepts & tools included in the full toolkit

• To facilitate efforts of office-based clinicians to reduce disparities by applying screening guidelines on a universal basis to the age-appropriate population

http://nccrt.org/about/provider-education/crc-clinician-guide/

Staff Involvement

• Key Point…..the clinicians can’t do it all!

• Time that patients spend with non-clinician staff is underutilized

Standing orders can empower nurses, intake staff, etc. to distribute educational materials, schedule appointments for mammography, etc.

• Involve staff in meetings to discuss progress in achieving office goals for improving the delivery of preventive services

Make a Recommendation:Recognize Potential Barriers to Screening

In making recommendations we must be sensitive to and address: Fear of cancer diagnosis Lack of understanding of need for asymptomatic

screening Misconceptions about cancer causes and risks Embarrassment Concern over discomfort of screening tests Cultural issues Patient preferences

Screening Policies: Factors to Consider in Your Office Policy

1. Individual Risk Level (“risk stratification”)

2. Medical resources (pap test providers)

3. State and federal program policies and processes (BCCEDP)

4. Patient Knowledge, Beliefs, Concerns

5. Insurance (insured? deductible? copay?)

a. Impact of Affordable Care Act on preventive services

Reminder Systems:Physician & Patient Reminders

Physician Reminders

Chart Prompts

Problem lists

Screening schedules

Integrated summaries

Alerts – “Flags” placed in chart

Follow-Up Reminders

Logs and Tracking

Electronic Reminder Systems

Patient Reminders Cues to Action Education

Measure Practice Progress:Tracking Practice Progress

• Determine baseline screening rate

• Set realistic goals

• Chart audits or other tracking measures (i.e. EHR reports)

• Provide staff-specific feedback on performance

• Seek patient feedback

• Identify strengths and weaknesses, barriers, opportunities to improve efficiency

• Track progress and periodically reassess goals

Resources

“Action Plan” Toolkit Version

• Eight page guide introduces clinicians and staff to concepts and tools provided in the full Toolkit

• Contains links to the full Toolkit, tools and resources

• Not colorectal-specific

• Practical, action-oriented assistance that can be used in the office to improve screening rates for multiple cancer sites (colorectal, breast and cervical)

Available at http://nccrt.org/about/provider-education/crc-clinician-guide/

Office Wall Chart

Thank you!