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

fwong@cdc.gov

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!