80% by 2018 Forum:80% by 2018 Forum:Increasing CRC Screening RatesIncreasing CRC Screening Rates

Implementing a Quality Implementing a Quality Screening Navigation ProgramScreening Navigation Program

Lynn Butterly, MDLynn Butterly, MD

Director, Colorectal Cancer ScreeningDirector, Colorectal Cancer Screening

Dartmouth Hitchcock Medical CenterDartmouth Hitchcock Medical Center

PI and Medical Director, NH CRC Screening PI and Medical Director, NH CRC Screening ProgramProgram

Rationale for Patient Rationale for Patient Navigation in CRC ScreeningNavigation in CRC Screening

Colorectal cancer (CRC) is the second most Colorectal cancer (CRC) is the second most common cause of death from cancer in the U.S.common cause of death from cancer in the U.S.

CRC can be CRC can be preventedprevented through screening, in through screening, in addition to early detection to prolong survivaladdition to early detection to prolong survival

Despite compelling evidence for CRC screening Despite compelling evidence for CRC screening those rates remain low, those rates remain low, particularly for low particularly for low income individuals and racial and ethnic income individuals and racial and ethnic minoritiesminorities

NHCRCSP Patient NHCRCSP Patient NavigationNavigation

NHCRCSP provided free colonoscopies to NHCRCSP provided free colonoscopies to low low income, uninsuredincome, uninsured and under-insured NH and under-insured NH residents for six yearsresidents for six years

Patient Navigation has proven highly effective Patient Navigation has proven highly effective for for adherenceadherence, provision of , provision of high-qualityhigh-quality screening, and appropriate and timely screening, and appropriate and timely follow-upfollow-up

Program was statewide, so Program was statewide, so telephonic telephonic navigationnavigation was provided by two nurse Patient was provided by two nurse Patient NavigatorsNavigators

NHCRCSP Patient NavigationNHCRCSP Patient Navigation

Colonoscopy screening navigation included:Colonoscopy screening navigation included:

– Patients are medically appropriate and cleared Patients are medically appropriate and cleared for testfor test

– Understanding of test including travel and appt Understanding of test including travel and appt detailsdetails

– Details of preparationDetails of preparation– Results and recommended follow-upResults and recommended follow-up– Communication with and between providersCommunication with and between providers– BarriersBarriers identified and addressed throughout the identified and addressed throughout the

processprocess

Patient Navigators address Patient Navigators address client barriers client barriers including: including:

- lack of knowledge, fear- lack of knowledge, fear

- language- language

- transportation, location of endoscopy site, ride home- transportation, location of endoscopy site, ride home

- practical issues: no permanent home, limited phone - practical issues: no permanent home, limited phone

- obtaining and taking test preparation- obtaining and taking test preparation

- cultural or social issues- cultural or social issues

- test results and recommended follow-up from - test results and recommended follow-up from providerprovider

- compliance with subsequent follow-up- compliance with subsequent follow-up

Barriers to ColonoscopyBarriers to Colonoscopy

Details of NHCRCSP Details of NHCRCSP NavigationNavigation

Defined series of calls per patientDefined series of calls per patient Comprehensive data collectionComprehensive data collection Review with Medical DirectorReview with Medical Director Assessment of patient satisfactionAssessment of patient satisfaction Evaluation of outcomes for patients, Evaluation of outcomes for patients,

endoscopy sites, and for the endoscopy sites, and for the programprogram

Ensuring appropriate follow upEnsuring appropriate follow up

NHCRCSP OutcomesNHCRCSP Outcomes

Two no-shows for ~ 2000 colonoscopiesTwo no-shows for ~ 2000 colonoscopies

Only 1% of clients had an inadequate Only 1% of clients had an inadequate colonoscopy preparation.colonoscopy preparation.

100% of clients received follow up 100% of clients received follow up recommendations from their recommendations from their endoscopist following their colonoscopyendoscopist following their colonoscopy

NHCRCSP Navigation Outcomes: NHCRCSP Navigation Outcomes: Ensuring Quality Ensuring Quality

Patient navigation not only improves Patient navigation not only improves colorectal cancer screening colorectal cancer screening rates rates

but – of critical importance – but – of critical importance –

navigation can improve the navigation can improve the qualityquality of of colorectal cancer screeningcolorectal cancer screening

Quality is essential for effective and cost-Quality is essential for effective and cost-effective colorectal cancer screeningeffective colorectal cancer screening

Patient Navigation TopicsPatient Navigation Topics

Does your program need a navigator(s)?Does your program need a navigator(s)? How to select a navigatorHow to select a navigator Organize a navigation processOrganize a navigation process How to approach patientsHow to approach patients Assessing and addressing barriersAssessing and addressing barriers Patient satisfaction (navigator and Patient satisfaction (navigator and

process)process) Frequent data collection for outcomes Frequent data collection for outcomes

evaluation and process improvementevaluation and process improvement

NHCRCSP Processes to Ensure NHCRCSP Processes to Ensure QualityQuality

Medical ReviewMedical Review: : Pre-ProcedurePre-Procedure Review Review– Assess significance of Assess significance of symptomssymptoms (PNs with (PNs with

MD)MD) Appropriate patients and fewer patient exclusionsAppropriate patients and fewer patient exclusions

– Determine Determine appropriatenessappropriateness for current exam for current exam based on patient personal and family historybased on patient personal and family history

– Provide useful Provide useful informationinformation to endoscopy sites: to endoscopy sites: Important medical factors addressed (need for Important medical factors addressed (need for

anesthesia, anticoagulation issues, cultural issues)anesthesia, anticoagulation issues, cultural issues)

– Ensure good bowel Ensure good bowel preparationpreparation

NHCRCSPNHCRCSP Processes to Ensure Processes to Ensure QualityQuality

Data ReviewData Review: : Post-ProcedurePost-Procedure review review– Patient past history of adenoma or CRCPatient past history of adenoma or CRC– Patient family history Patient family history – Completeness of exam (to cecum)Completeness of exam (to cecum)– Quality of prepQuality of prep– Withdrawal timeWithdrawal time– Polyp pathology: type, number, size, locationPolyp pathology: type, number, size, location– Completeness of polypectomyCompleteness of polypectomy– Follow-up recommendations Follow-up recommendations – Notification of patient about results and Notification of patient about results and

follow-upfollow-up

NHCRCSPNHCRCSP Processes to Ensure Processes to Ensure QualityQuality

Additional Patient Navigation ProcessesAdditional Patient Navigation Processes– Referral to Quit Line, BCCP, medical homeReferral to Quit Line, BCCP, medical home– Referral of ineligible patients to other resourcesReferral of ineligible patients to other resources– Communication with endoscopy site contacts to clarify Communication with endoscopy site contacts to clarify

history, findings, follow-up, or patient questionshistory, findings, follow-up, or patient questions– Through Data Review, observe (confirm via database) Through Data Review, observe (confirm via database)

provider practice patterns needing to be addressed provider practice patterns needing to be addressed

(for example: % fair preps, incomplete polypectomies, (for example: % fair preps, incomplete polypectomies, short withdrawal time, missing or inappropriate follow-short withdrawal time, missing or inappropriate follow-up recommendations that do not follow Guidelines)up recommendations that do not follow Guidelines)

Research Review of Navigation Research Review of Navigation for Colorectal Cancer for Colorectal Cancer ScreeningScreening

3 Randomized Controlled Trials for CRC3 Randomized Controlled Trials for CRC

Additional Research: RCT Evidence for Additional Research: RCT Evidence for Telephonic Patient NavigationTelephonic Patient Navigation

Formal CDC evaluation of the NHCRCSP Formal CDC evaluation of the NHCRCSP navigation program is currently navigation program is currently underwayunderway

RCT of Patient Navigation in RCT of Patient Navigation in Colorectal Cancer ScreeningColorectal Cancer Screening

Targeted low-income minoritiesTargeted low-income minorities 21 average-risk patients referred by PCP21 average-risk patients referred by PCP Plus or minus navigation for colonoscopyPlus or minus navigation for colonoscopy Of 13 PN +: 54% had colo; of 8 PN - : 13%Of 13 PN +: 54% had colo; of 8 PN - : 13% Conclusion: PN improves compliance with Conclusion: PN improves compliance with

screeningscreening Christie J, Itzkowitz S, Lihau-Nkanza I et. al. A Christie J, Itzkowitz S, Lihau-Nkanza I et. al. A

Randomized Controlled Trial Using Patient Navigation Randomized Controlled Trial Using Patient Navigation to Increase Colonoscopy Screening among Low-Income to Increase Colonoscopy Screening among Low-Income Minorities. Minorities.

J Natl Med Assoc. J Natl Med Assoc. 20082008; 100: 278-284; 100: 278-284

RCT of Patient Navigation in RCT of Patient Navigation in Colorectal Cancer ScreeningColorectal Cancer Screening

Culturally tailored intervention to increase CRC Culturally tailored intervention to increase CRC screening for low-income, non-English speaking patientsscreening for low-income, non-English speaking patients

Single urban community health centerSingle urban community health center 1223 patients: PN (409) vs. usual care (814)1223 patients: PN (409) vs. usual care (814) Colonoscopy completion: Colonoscopy completion:

– 21% of navigated vs. 10% of usual care patients21% of navigated vs. 10% of usual care patients Conclusion: statistically significant (p=<0.001) Conclusion: statistically significant (p=<0.001)

differencedifference

Percac-Lima S, Grant RW, Green AR, et. al. A Culturally Tailored Percac-Lima S, Grant RW, Green AR, et. al. A Culturally Tailored

Navigator Program for Colorectal Cancer Screening in a Community Navigator Program for Colorectal Cancer Screening in a Community Health Center: A Randomized, Controlled Trial Health Center: A Randomized, Controlled Trial

J Gen Intern Med J Gen Intern Med 20092009; 24: 211-217; 24: 211-217

RCT of Patient Navigation in RCT of Patient Navigation in Colorectal Cancer ScreeningColorectal Cancer Screening

465 patients from 4 CHCs and 2 public hospital clinics465 patients from 4 CHCs and 2 public hospital clinics Randomly assigned to navigation or usual careRandomly assigned to navigation or usual care PN: language-concordant telephone contactsPN: language-concordant telephone contacts CRC screening: 33.6% with PN vs. 20% without PNCRC screening: 33.6% with PN vs. 20% without PN Navigation was particularly helpful for black or non-Navigation was particularly helpful for black or non-

English speaking patients and may be English speaking patients and may be useful in useful in reducing disparitiesreducing disparities

Lasser KE, Murillo J, Lisboa S, et al. Colorectal Cancer Screening Lasser KE, Murillo J, Lisboa S, et al. Colorectal Cancer Screening

AmongAmong

Ethnically Diverse, Low-Income Patients. A Randomized Controlled Ethnically Diverse, Low-Income Patients. A Randomized Controlled TrialTrial

Arch Intern Med Arch Intern Med 20112011; 171 (10): 906-912; 171 (10): 906-912

Evidence for Telephonic Evidence for Telephonic NavigationNavigation

Telephone Outreach to Increase Colon Cancer Telephone Outreach to Increase Colon Cancer Screening in Medicaid Managed Care Organizations: A Screening in Medicaid Managed Care Organizations: A Randomized Controlled TrialRandomized Controlled Trial

Conclusion: Telephone outreach by MMCO staff Conclusion: Telephone outreach by MMCO staff increased CRC screening over usual careincreased CRC screening over usual care

Dietrich AJ, Tobin JN, Robinson CM et al.Dietrich AJ, Tobin JN, Robinson CM et al. Annals of Family Medicine Annals of Family Medicine 20132013; 11: 335-343; 11: 335-343

NHCRCSP NavigationNHCRCSP Navigation

Patient SatisfactionPatient Satisfaction

ConclusionConclusion Patient Navigation is an extremely Patient Navigation is an extremely

effective method of increasing effective method of increasing compliance with colorectal cancer compliance with colorectal cancer screening while simultaneously screening while simultaneously ensuring screening quality. ensuring screening quality.