Screening More Patients for Colorectal Cancer

Studies have found that socioeconomic status (SES), more than race or ethnicity, predicts the likelihood of an individual developing and surviving cancer. Individuals from medically underserved populations are more likely to:

• Be diagnosed with late-stage diseases.
• Have behavioral risk factors such as tobacco smoking, physical inactivity, obesity, excessive alcohol intake, poor health status and challenges in following cancer screening recommendations. 
• Face significant barriers in access to healthcare and preventative services.
• Manage the burden of daily subsistence.
• Have an inconsistent connection with the health care system because of the absence of health insurance.
• Receive limited recommendations by providers for screening
• Encounter difficult logistics of some tests (e.g. colonoscopy) make cancer detection and treatment unlikely.

To address these disparities, Maine Medical Center Cancer Institute worked with community partners* to overcome barriers and facilitate screening.

• Social workers and nurse navigators used the Fecal Immunochemical Test (FIT) to screen homeless participants.
• Community partners identified barriers in the process, monitored all test results and helped patients testing positive navigate to colonoscopy resources.
• Small incentives of $10 food cards were provided for those participating in the screening event. 

Outcomes

In Portland, 39 were screened using FIT--28 men and 11 women. There were 8 positive results, 3 participants completed colonoscopies, 1 refused, 1 left Maine, 1 lost to follow up, and 2 had a substance abuse barrier. All colonoscopies were negative for malignancy.

*Partners included Preble Street Resource Center, Casco Bay Surgery, NorDx, MaineHealth CarePartners and Homeless HealthPartners Case Managers and Maine Medical Center Magnet Council

Franklin Community Health Network is a member of the National Colorectal Round Table Hall of Fame for screening 80 percent of their eligible patients by November 2017. They have seen seen a significant increase (36 percent) in screening colonoscopies, and an overall 42 percent increase in screening (FIT and colonoscopy).

How did they do it?

In 2015, Franklin Community Health Network began a three year project funded by the Maine Cancer Foundation to improve access to colorectal cancer education, prevention, and screening. This work has included several strategies to address their identified challenges to screening:

• Patient willingness: Home paramedicine and FIT helped address this barrier. 
• Social and financial barriers: Patient navigators were utilized for scheduling and to provide guidance on any needed follow through. FIT kits were provided by NorDx for free through physician offices.
• Availability of colonoscopy appointments: Two new general surgeons were hired to increase capacity—from 800 colonoscopies per year to 1300 per year.

In partnership with the Healthy Community Coalition and their Mobile Health Unit, access to colorectal cancer education was also improved; colorectal screening education and FIT kit instructions were delivered directly to the community. Nearly 100 FIT kits have been returned with 16 percent of those testing positive and referred to follow up.

Electronic Health Records were used to identify and remind patients eligible for screening. Other useful resources included:

• Maine CDC Colon Cancer/ScreenME patient education brochures
• US CDC Screen for Life Colorectal Cancer Patient Education Materials
• Colon Cancer Coalition Patient story cards

In collaboration with Maine Medical Partners and the MaineHealth colorectal cancer screening quality improvement workgroups, Maine Medical Partners implemented a standardized workflow to streamline outreach efforts for screening. Since implementation in October 2016, Maine Medical Partners has increased screening rates over 13 percent--from 68.4 percent to 77.7% percent as of January 2019.

This workflow tool demonstrates the number of strategies used to identify and engage patients at each phase of the work flow.

Using the workflow tool has allowed Maine Medical Partners to shift their focus to proactively identifying eligible patients and tailoring their messages and techniques to meet patient needs. The Population Health team is a crucial resource to provide dedicated time to Fecal Immunochemical Test (FIT) outreach, follow up and quality assurance.  Some successful interventions include:

• Targeting outreach with letters and phone calls when appropriate
• Offering Fecal Immunochemical Test (FIT) if appropriate
• Making PUP (Pick Up Prescription) appointments for non-English-speaking
• Grouping outreaches to patients who require interpreters
• Identifying patients who need referral to Care Managers
• Having a physician champion, as well as a dedicated Colorectal Cancer Screening work group, to identify barriers, pilot new protocols, an improve processes
• Increasing patient and provider education on available tests
• Increasing FIT return rates by increasing follow up protocols 

Lincoln Medical Partners improved their workflow and optimized their Electronic Health Record system to identify and tailor outreach to patients who were not following screening recommendations. They also created a sub-flow chart called, "Incomplete Fecal Immunochemical Test (FIT ) Orders Protocol" outlining communication steps for follow-up with their patients.

Additionally, Lincoln Medical Partners created patient education materials and standardized their patient reminder letter. The patient education materials included:

• Why colorectal cancer screening is so important
• How to talk to your doctor to choose the right test

Workflow strategies included:

• Chart reviews by Medical Assistants for patients who appear overdue for screening in order to find and document previously completed colon cancer screening.
• Reports created to show pending FIT orders on a weekly basis. Medical Assistants use these reports to identify and call patients to discuss their pending order and the importance of completing the test.
• A flowsheet to standardize the above discussion.
• Letters sent to patients who are overdue for screening, along with patient education on the importance of being tested.

Outcomes

As of  January, 2019, Lincoln Health practices reported screening 82.4% of their eligible patients, exceeding the target to reach their 80 percent goal by December 2018!

St. Mary’s is a proud member of the National Colorectal Round Table Hall of Fame for screening 80 percent of their patients by 2018.

How did they do it?

St. Mary's strategies for reaching 80 percent included:

• Identifying eligible patients (using Electronic Health Records) to who have not had a colorectal cancer screening test and persistently follow-up with these patients.
• Using a “pre-visit” questionnaire to make recommendations on which test (FIT or Colonoscopy) is right for the patient. Note: Providers do try to offer the colonoscopy first. Currently, St. Mary's is in the process of replacing the FOBTg, which requires 3 samples, with the FIT, which requires only one sample and is considered more accurate.
• Utilizing media to make patients aware of the availability of the Fecal Immunochemical Test (FIT).
• Utilizing digital displays in office waiting areas to educate patients.

The Lewiston/Auburn area is also home to many recent immigrants and refugees from central Africa, making communication regarding this sensitive topic challenging. Pictograms and translated materials were developed to increase patient compliance with FIT orders, and improve shared decision making between patients and providers. Part of that effort was the production of video patients could watch in the comfort of their own home.

St. Mary's also used patient navigators to help meet their screening goals. Navigators help identify eligible patients, and those in need of follow-up, and call them to schedule procedures.

As of January, 2019 St. Mary's surpassed their goal by screening 81% of eligible patients!

MaineGeneral has been successful in increasing colorectal cancer screening rates among their eligible patients through the proactive use of Community Health Outreach Workers.

• Patients are identified using quality reports from Electronic Health Record.
• Patients are contacted by a Community Health Outreach Worker, either by phone or home visit.

Outcomes

• Only 16 percent of patients contacted by a Community Health Outreach Worker who were due for screening refused.
• The two primary care practices involved in this project each reported an increase in screenings for eligible patients.
  • One practice increased their overall screening rate by 11 percent from 65.6 percent to 72.86 percent.
  • The second practice increased the rate by 16 percent from 65.9 percent to 76.88 percent.
  • Each of these practices have modestly projected they will reach 80 percent screening rates by 2020.