Disclosures No disclosures 2 Objectives Discuss current practices - - PowerPoint PPT Presentation

Ana M. Bedon, MSN, APN, AGCNS-BC, CWON
 Advanced Practice Nurse Navigator
 Advocate Illinois Masonic Medical Center , Chicago, IL
 


Direct Access Screening Colonoscopy: An Innovative Approach to Increasing Colorectal Cancer Screening Rates

November 5, 2016

Disclosures

▪ No disclosures

Objectives

▪ Discuss current practices for colorectal cancer screening guidelines ▪ Discuss barriers to screening ▪ Describe innovative approaches to screening ▪ Describe Direct Access Screening Colonoscopy (DASC) program ▪ Discuss successes and challenges of the DASC program

▪ Partnership of American Cancer Society and Centers for Disease Control and Prevention ▪ Coalition of public and private organizations dedicated to: ▪ reducing incidence and mortality of CRC ▪ educating organizations and the public on screening methods ▪ providing coordinated leadership and strategy of screening efforts ▪ Engage hospital systems, primary care offices, insurance companies, employers, community

• rganizations, survivors and their families

National Colorectal Roundtable

▪ Blah blah

CRC screening modalities

Why Colonoscopy?

▪ Most sensitive ▪ Most specific ▪ Only test that prevents cancer ▪ Given the "Gold Standard" rating above all other screening options by: ▪ American Society for Gastrointestinal Endoscopy (ASGE) ▪ American Gastroenterological Association (AGA) ▪ American College of Gastroenterology (ACG) ▪ American Cancer Society (ACS) ▪ American College of Obstetricians and Gynecologists (ACOG)

Financial Prep Insurance Language Waiting times Fear Communication Indifference

Who We Are

Advocate Health Care

13 Hospitals

• 12 acute care hospitals
• 1 children’s hospital (2 campuses)
• 5 level 1 trauma centers
• 3 major teaching hospitals
• 2 specialty hospitals

2 Physician Groups

• 1,400 employed

Home Care Company Laboratory Joint Venture Over 250 Sites of Care 3.4 Million Patients Served 35,000 Associates; 10,O00 Nurses Total Revenue - $4.6B AA Rating

AIMMC Total Service Area (TSA)

Advocate Illinois Masonic Medical Center

• 408-bed teaching hospital
• Train 225+ residents and 560+ medical

students a year

• 900+ active MDs on staff – voluntary &

employed – representing 43 medical specialties

• One of four Level 1 Trauma Centers in

Chicago

• Level III Neonatal Intensive Care Unit
• Primary Stroke Center

2015 By the Numbers:

Admissions…………….14,600 Outpatient Visits…….180,000+ Births……………….......2,300+ Surgeries……………….. 12,200+ Emergency Visits…….44,290+ Traumas…………….…... 1,040+

The Center for Advanced Care expands and centralizes several key outpatient services, including surgery, cancer care and digestive health. ▪ $100 million investment in our community ▪ 164,000 square feet of added space ▪ 20,000+ patients expected annually ▪ 7x more digestive health treatment space ▪ 6 state-of-the-art operating rooms ▪ 2 linear accelerators for cancer treatment

The Center for Advanced Care

▪ Extensive criteria for eligibility and rigorous application process ▪ Demonstrates commitment to delivering safe and high quality care ▪ Benchmark physician performance e.g. cecal intubation rate, adenoma detection rate ▪ Encourages opportunities to improve patient care based on data e.g adverse event tracking, patient satisfaction surveys

How the Direct Access Screening Colonoscopy (DASC) program was born ▪ 2015 Digestive Health “Road Show”

▪ Medical and surgical directors discovered PCP dissatisfaction regarding access time to colonoscopy (2-3 month average) ▪ Voice of the customer: patients and PCPs wanted a simple way to access this important screening ▪ Clinical Integration ▪ In 2014, the Illinois Masonic PHO missed the CI measure target for patients 50-65 years old screened for CRC by a colonoscopy. ▪ Center for Advanced Care ▪ Increased capacity in the new procedural area

Why reinvent the wheel??

Why reinvent the wheel??

DASC – Program Goals

To accommodate healthy patients who need a screening colonoscopy, we established a program to expedite and simplify the process of scheduling

• colonoscopies. Goals:

▪ Reduce patient colonoscopy wait time from 2-3 months to 2-3 weeks. ▪ Increase access by allowing select patients in stable health to skip the traditional face- to-face consultation with a private gastroenterologist in his/her office. ▪ Achieve the AIMMC PHO CI measure target for CRC screening among 50-65 year olds. ▪ Provide a worry-free, fully navigated experience for patients. ▪ Create a closed loop of communication between Digestive Health providers and referring MDs (i.e. pathology). ▪ Facilitate quality growth and efficient scheduling in the Digestive Health procedural area.

What’s in it for me?

GI Physicians

▪ “How is this different from my own office open access program?” ▪ Maximize their procedural block time ▪ Maximize their own office time due to decreased number of pre-procedure consultations ▪ Patients well educated regarding procedure, prep, and what to expect

What’s in it for me?

Primary Care Providers

▪ You will get your patients screened! ▪ Timely ▪ Easy ▪ Meet your quality measures ▪ Easy access to results ▪ Nurse navigator closes the loop ▪ Nurse navigator keeps you informed ▪ This program will not replace your established referral patterns

What’s in it for me?

Patients

▪ Save time ▪ Save copay/out of pocket expense ▪ High touch experience with nurse navigator ▪ Education ▪ Decrease barriers ▪ Prompt follow up for results or concerns ▪ Flexible scheduling ▪ Depending on insurance, can be scheduled within a week

Engage hospital leadership

▪ Utilizing current resources ▪ Increasing volume of procedures of GI lab ▪ Fully navigated patient experience ▪ Patient safety ▪ Patient satisfaction ▪ Achieving target quality measures ▪ Engage PCPs in service area that refer to other healthcare facilities

Engaging GIs

▪ Participation in program offered to all GI’s ▪ Needed to abide by program “rules” ▪ Set aside protected time for DASC patients ▪ Allow those patients to be screened and prepped by nurse navigator ▪ Provide adequate follow up on pathology results with patient and PCP ▪ Maintain open communication between private office and DASC program ▪ Maintain quality measures ▪ Inappropriate referrals would be excluded/referred to office

Exclusions for DASC

▪ Any GI symptoms ▪ Personal history of GI cancer ▪ Strong family history GI cancer ▪ BMI > 35 ▪ Age >70 ▪ Sleep apnea/use of CPAP ▪ Heart conditions ▪ Lung conditions ▪ Uncontrolled medical conditions ▪ Coagulopathy or use of anticoagulants ▪ Inability to consent ▪ Chronic use of anti-anxiety medications or narcotic pain medications

Engage GI lab staff

▪ Introduce program as an adjunct to current operations ▪ All patients would be a “complete package”

▪ Decreased workload for pre-procedure education

▪ Patient concerns should be addressed to nurse navigator directly or via GI lab manager ▪ This is not your regular open access!

Initial Steps

Piloted DASC with a non-aligned, Advocate employed PCP office

▪ Patients from this office were referred to a competitor hospital ▪ Aligned one gastroenterology group with that office to pilot ▪ Allowed for GI provider consistency – a PCP concern ▪ Used lessons learned to refine DASC processes as we expanded ▪ Communicate, when possible, through EMR ▪ Revamped internal processes for scheduling efficiently ▪ Established tracking metrics ▪ Closing the loop re: pathology and next steps with PCPs

Process Map – What We Thought

Patient enters DASC*

(Multiple entry points)

Digestive Health RN navigator screens patient H&P remotely If patient meets program criteria, RN schedules colonoscopy in 2-4 weeks RN communicates timeline to PCP RN uses a rotating list of DASC participating GIs to fairly assign patients RN gives prep instructions and hospital/appt. details to the patient After the procedure, the RN ensures the pathology report/next steps are communicated to PCP RN ensures the patient receives follow-up instructions/care

Process Map - Reality

Challenges

Insurance

▪ Different payors ▪ Different plans ▪ Different rules for prior authorizations/referrals ▪ Not all GI providers accept all plans

Challenges

Patients

▪ Confusion regarding program ▪ Who do I call if????? ▪ Level of engagement ▪ Follow up

Challenges

GI physicians

▪ Loss of control ▪ Appropriateness of referral ▪ Developing rapport with patient

DASC by the numbers: July 2015 to October 2016

Patients referred

• Included
• Complete

d

Nurse Navigated DASC ADR= 32.5% ASGE ADR= 25%

Advocate Physician Partners (PHO) AIMMC Clinical Integration Rates

10% 25% 40% 55% 70%

July 2014 July 2015 July 2016

69% 44% 17% 59% 30% 26%

50-65 >65

Partnership with PHO director for targeted

• utreach to patients

needing CRC screening Patients sent informational letter followed by phone call from nurse navigator Information updated as needed or navigated through DASC program

Patient satisfaction: Traditional vs DASC

CC 61F

▪ 5/26 PCP visit- referred to DASC ▪ Attempted phone calls 6/9, 6/16, 6/23 ▪ PCP notified of contact fail on 6/23 ▪ PCP contacted patient on 6/24 and encouraged her to call ▪ 7/18 patient re-referred to DASC ▪ Contacted patient on 7/21 ▪ Scheduled on 7/26 for colonoscopy ▪ Colonoscopy on 7/26 ▪ Found to have colitis and a rectal mass ▪ She was asymptomatic ▪ After her workup, began chemotherapy and radiation 1 month after her procedure

HL 74M

▪ Cantonese speaking only ▪ Wellness visit with PCP . Labs done ▪ FOBT+ ▪ Referred to DASC but did not qualify due to age and need for diagnostic procedure ▪ Contacted patient via interpreter to schedule appointment with provider for consultation ▪ Colonoscopy done- his first one! ▪ One 10 mm polyp in the cecum ▪ Two 8 to 12 mm polyps in the transverse colon ▪ Two 20 mm polyps in the descending colon ▪ One 14 mm polyp in the proximal sigmoid colon ▪ Colon resection done- CURED! Adenocarcinoma

You can have your own program too!

▪ Accessible ▪ Beneficial ▪ Convenient

Questions?