Workshop: Implementing a Quality Screening Navigation ... · NH Colorectal Cancer Screening Program...

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80% by 2018 FORUM II Workshop: Implementing a Quality Screening Navigation Program Decatur B

Transcript of Workshop: Implementing a Quality Screening Navigation ... · NH Colorectal Cancer Screening Program...

Page 1: Workshop: Implementing a Quality Screening Navigation ... · NH Colorectal Cancer Screening Program NHCRCSP Patient Navigation NHCRCSP provided free colonoscopies to low income, uninsured

80% by 2018 FORUM II

Workshop: Implementing a Quality Screening Navigation Program Decatur B

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80% by 2018 Forum II: Increasing CRC Screening Rates

Implementing a Quality Screening Navigation Program July 18, 2017

Lynn Butterly, MD

Director, Colorectal Cancer Screening Dartmouth Hitchcock Medical Center PI and Medical Director, NH CRC Screening Program

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Rationale for Patient Navigation in CRC Screening

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

CRC can be prevented through screening, in

addition to early detection to prolong survival Despite compelling evidence for CRC screening

those rates remain low, particularly for low income individuals and racial and ethnic minorities

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NHCRCSP Patient Navigation (PN) Model

The New Hampshire Colorectal Cancer Screening Program (NHCRCSP) has been a statewide, CDC funded program (CRCCP) since 2009

As part of our work, the NHCRCSP designed and implemented a Patient Navigation model for the free colonoscopy program (2009-2015)

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Initial Goals of the NHCRCSP

Increase CRC screening for all NH individuals over age 50 to 80% (80% by 2018 Initiative)

Address Disparities: Offer high quality free

colonoscopies to low income, uninsured or underinsured individuals

NHCRCSP works with NH health centers (FQHCs,

CHCs, health systems) to reach the 80% goal

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NHCRCSP FQHC COLLABORATION: General Approach and Groundwork

Get FQHC and endo unit leadership commitment – Financial incentive for prevention through screening

Identify and train internal champions Agree on health center screening policy

– Incorporate CRC screening education – Recognize specific barriers for underserved:

Language, cultural, travel, missed work time, etc

Identify appropriate endoscopy sites and establish consistent policies and procedures

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NHCRCSP Background Information

Central Organization: Patients referred to NHCRCSP NHCRCSP referred to 12 endoscopy sites (hospital-based and ASCs) for colonoscopies, selected by their geographic proximity for the referred (underserved) population Endo sites have hospital affiliations and all hospitals agreed (NHCRCSP policy) to cover cost of care for CRCs found through the program, and colonoscopy complications

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Key Elements of CRC Screening Program

Central infrastructure (NHCRCSP) connects CHC patients to needed venues of CRC screening and cancer care

NHCRCSP establishes referral policies and procedures

with FQHCs, endoscopy sites, and hospitals Must also establish agreements and/or contracts if needed

with PCPs and endoscopy sites (pathology, anesthesia)

Maximize partnerships that support the process

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NH Colorectal Cancer Screening Program NHCRCSP Patient Navigation

NHCRCSP provided free colonoscopies to low income, uninsured NH residents for six years, and developed and implemented a PN program.

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

Program was statewide, so telephonic navigation

was provided by two nurse Patient Navigators

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NHCRCSP Patient Navigation

NHCRCSP provided over 2000 colonoscopies for uninsured NH residents at or below 250% of the federal poverty level.

Patients were navigated throughout screening process:

– Medically appropriate – Had understanding of test and prep – Received results and recommended follow-up – Barriers identified and addressed throughout the

process

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Patient Navigators address patient barriers: - Cultural or social issues - Lack of knowledge about screening - Language - Practical issues: transportation (ride home) - Obtaining and taking test preparation - Test results and recommended follow-up from provider

Barriers to Colonoscopy

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NHCRCSP Patient Navigation Outcomes

>96% completion of colonoscopy

0.1% no-shows (2 out of 2000)

< 1% inadequate preparations

100% of patients and PCPs received

report and follow-up recommendations

Extremely high patient satisfaction

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NHCRCSP Navigation: Evaluation

NHCRCSP Navigation Results: Excellent Patient Outcomes High Patient Satisfaction Comprehensive Data Collection

CDC Evaluation: Case Study and Quasi-Experimental Comparison Group Study as well as a pending Cost Study

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CDC Evaluation Study: Outcomes measured to determine effectiveness

Colonoscopy completion Bowel prep quality Appointment no-shows Cancelled appointments Communication of test results to patients

and PCPs Appropriate rescreening interval

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11 times more likely to complete

colonoscopy than non-navigated patients.

40 times less likely to miss the

colonoscopy appointment.

6 times more likely

to have adequate bowel prep than

non-navigated patients.

Evidence For NHCRCSP PN Model

Outcomes of the Comparison Study

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Details of NHCRCSP Navigation

Defined series of calls per patient Effective program management Real-time data collection Patient review with Medical Director Assessment of patient satisfaction Evaluation of outcomes for patients,

endoscopy sites, and for the program Ensuring appropriate follow up

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NHCRCSP Navigation Outcomes: Ensuring Quality

Patient navigation not only improves colorectal cancer screening rates

but – of critical importance – navigation can improve the quality of

colorectal cancer screening Quality is essential for effective and cost-

effective colorectal cancer screening

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Patient Navigation Topics

Does your program need a navigator(s)? How to select a navigator Organize a navigation process How to approach patients Assessing and addressing barriers Patient satisfaction (navigator and process) Frequent data collection for outcomes

evaluation and process improvement

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NHCRCSP Patient Navigation Model

CORE ELEMENTS

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Core Element 1: Nurse Navigators Navigators are the heart of the

NHCRCSP PN model Model specifically developed to

recognize and resolve patient barriers Registered nurses as Navigators

because of their clinical expertise Psychosocial assessment skills

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Core Element 2: PN Champion with Clinical CRC Screening Expertise

Champion is vital to the PN intervention Ensures there is organizational support Promotes the program’s vision and value Key qualities include leadership and

expertise in CRC screening

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Core Element 3: Medical Oversight of the Navigation Intervention

M.D. with significant clinical expertise in endoscopy and CRC screening

Can be a “door opener” to engage clinical sites and providers

Clinical oversight, ongoing mentoring, and guidance

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Core Element 4: Partnerships

Develop and sustain strong working relationships with key partners

Develop internal champions at the endoscopy site

Partnerships improve communication and patient care

Critical to both program implementation and effective functioning

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NHCRCSP STRATEGIES TO INCREASE HIGH QUALITY CRC SCREENING: Partnerships Create Synergy

Partnerships and Collaborations: – Internal champion(s) critical to success – CDC CRCCP in applicable states, DHHS – NCCRT, ACS, CDC, NCI, GI Societies (AGA) – Comprehensive Cancer Control (CCC) groups – EMR system leaders and experts (FQHC CHAN) – Insurers (address barriers together) – Endoscopists

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Core Element 5: Six-Topic Navigation Protocol

Six important topics discussed at defined time intervals throughout the screening process

Includes patient education and assessment

and resolution of barriers Not just the number of calls, but the content

of the calls and the navigator’s relationship with the patient

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Core Element 6: An Effective Data System

Comprehensive and secure data system

Supports quality monitoring and evaluation Real-time data system to track and monitor

outcomes, with regular review and reports

Team communication and use of data

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Core Element 7: Philosophy of Shared Success

Guiding principle of the NHCRCSP PN model

Navigators coached patients but did not schedule appointments for them

Navigated patients were better prepared to take a more active role in their overall healthcare.

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NHCRCSP Patient Navigation Replication Manual

The web address to download the manual:

https://www.cdc.gov/cancer/crccp/pn-replication-manual.htm Send comments, questions, and suggestions to [email protected].

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NHCRCSP Processes to Ensure Quality: Additional Processes

– Referral to Quit Line, BCCP, medical home – Referral of ineligible patients to other resources – Communication with endoscopy sites to clarify

history, findings, follow-up, or patient questions – Through data review, recognize any provider

practice patterns needing to be addressed (for example: % fair preps, incomplete polypectomies,

short withdrawal time, missing or inappropriate follow-up recommendations that do not follow Guidelines)

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NHCRCSP Navigation

Patient Satisfaction

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Cost Considerations: Navigation for CRC Screening

Reducing endoscopy no-shows and last minute cancellations

Reduces inappropriate repeat testing Reduces repeat testing from inadequate

preparations Costs from CRC treatment ($14

billion/year in the U.S. for a preventable disease)

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Cost Considerations: Navigation for CRC Screening

Financial cost of lost productivity may be large:

– Bradley JNCI 2008: every CRC death is associated with > $210,000 in lost productivity

– CRC deaths in 2010 estimated to account for $12 billion in economic losses due to lost productivity

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Cost Considerations: Navigation for CRC Screening

The ultimate benefit of increasing CRC screening comes from long-term outcomes of decreased incidence and mortality of CRC

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The Compelling Case

Second most common cause of ca death in US, despite being preventable

Providing patients with high-quality CRC

screening can save thousands of lives

Colorectal cancer, a preventable disease, has an estimated annual national cost of $14 billion

Patient navigation can increase CRC screening

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Comparison Study Conclusion

PN program is highly effective in increasing colonoscopy completion and reducing appointment no-shows and cancellations, and improving bowel preparation Findings further advance the evidence-base for PN as an important public health practice

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Conclusion Patient Navigation is an extremely

effective method of increasing CRC screening and reducing disparities, while simultaneously ensuring high-quality and appropriate follow up

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