Qualitative Learnings from BeneFITs First-Year Implementation - - PowerPoint PPT Presentation

BeneFIT: A Mailed FIT Program to Increase Colorectal Cancer Screening in Two Medicaid/Medicare Health Insurance Plans

Qualitative Learnings from BeneFIT’s First-Year Implementation

Laura-Mae Baldwin Jen Schneider Malaika Schwartz Jen Rivelli Bev Green Amanda Petrik Gloria Coronado 11th Annual Conference on the Science of Dissemination and Implementation in Health December 5, 2018

Ac Acknowled edgem emen ents

§ The authors thank the health insurance plans that have worked with the study team as they implemented mailed FIT programs to improve colorectal cancer screening in their enrollee populations. § This presentation is a product of a Health Promotion and Disease Prevention Research Center grant supported by Cooperative Agreement Number U48DP005013 from the Centers for Disease Control and Prevention. The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Wha What t is is Be BeneFIT? §A colorectal cancer screening program, §administered by Medicaid/Medicare health insurance plans, §that mails fecal test kits to eligible enrollees, §aiming to increase colorectal cancer screening

Wh Why Be BeneFIT?

§ Timely colorectal cancer screening saves lives, but screening rates remain well below the Healthy People 2020 target of 70.5%

62.2% 47.4% 24.8% 0% 10% 20% 30% 40% 50% 60% 70%

Privately insured Medicaid-insured Uninsured

Wh Why Be BeneFIT?

§ US Preventive Services Task Force recommends CRC screening with any of a number of approaches

• - Annual fecal testing (gFOBT, FIT, FIT-

DNA)

• - Sigmoidoscopy
• - Colonoscopy
• - CT colonography

Po Population-Ba Based M Mailed F FIT P T Progr

• grams

ar are Effectiv tive

§ Clinics and health care systems have increased CRC screening rates by using population-based mailed fecal immunochemical testing (FIT) programs

0% 20% 40% 60% 80%

Proportion Current for Screening Over 2 Years

Usual Care (1,166) Mailed FIT Only (1,169) Mailed FIT + Phone Assistance (1,159) Mailed FIT + Phone Assistance + Navigation (1,170)

Screen to Prevent (STOP) Colorectal Cancer Smart Options for Screening (SOS) Trial

Ov Overcom

• min

ing im imple lementation tion ch challe allenges s by mo moving ng ma mailed d FIT T pr programs ms to the he level of f the he he health h insur nsuranc nce pl plan n

§ Health plans have:

§QI departments that regularly conduct population management programs §Relationships with vendors §Access to claims data for identifying enrollees eligible for CRC screening §Motivation to improve care quality §Published performance on quality measures §Incentives (e.g., Medicare five-star program)

§ Study team provided expertise to the quality teams at the health plans § Quality teams designed their own programs to fit their contexts § The health plans developed two very different models § Studied the implementation process to provide guidance to health plans interested in developing their own mailed FIT programs

Be BeneFI FIT study team worked with two health in insuran ance ce plan lans in in WA A an and OR OR to

• develop

lop an and im imple lement t maile ailed FIT prog

• gram

ams

Be BeneFIT Or Oregon: A Collaborative model

Medicaid Health Plan Print Vendor Health Center 1 Health Center 2 Health Center 3 FIT kit returned Claim received

Medicaid Health Plan Centralized Lab Clinics/PCPs FIT kit returned Results received

Kit Ordering/ Print/Mail/ Follow-up Vendor

Positive results received Claims received

Be BeneFIT Wa Washington: A Centralized Model

Me Methods

§ Consolidated Framework for Implementation Research (CFIR) used as the guiding framework. § In-depth interviews with all health plan leaders/staff (5 in each plan) instrumental in designing and executing the mailed FIT programs 6-9 months after implementation. § The interviews explored:

• - implementation activities
• - challenges and successes related to implementation
• - enrollee and provider reaction/feedback
• - strengths and weaknesses of the program model
• - reaction to initial program results
• - reflections on improvements.

§ Interviews were audio-recorded and transcribed

Me Methods

§ Transcripts from interviews were

• - formally coded in Atlas.ti
• - content analyzed for themes
• - stratified by state, since the programs had such

different models

§ Triangulated results using other data sources:

• - field notes during planning meetings between

health plans and study team

• - internal research team debrief meetings

Ch Challenges i in k key a y areas

Program design

§ time consuming to set up § some health centers or providers didn’t want to participate

Vendor Experience

§ complex/time consuming to work with vendors § vendor delays

“At the very beginning we did have a few provider groups that opted

• ut because they were already providing kits to their members.”

“The largest barrier we encountered was around patients receiving the FIT kits from the vendor…it took longer than we anticipated for the pre-letter mailing to go

• ut [from vendor]… and unfortunately the

kits were not mailed out [by vendor] until a month after the pre-letter went out.”

Ch Challenges in

in key ar areas as

Engagement and Communication

§ lack of communication across the health plans about the program

Reaction/Satisfaction of Stakeholders

§ patient and provider resistance to FIT and CRC screening

“The customer service people at [health plan] didn’t really know about the program and should have because they would get [member] phone calls – so we should have written something up for them beforehand.” “There is still that resistance to using FIT out there in some areas…we had one health center group that had very little penetration of patients touched by the BeneFIT program, and [in those] we have a high percentage of clinics where provider groups are still pushing colonoscopy.”

Ch Challenges sp s specific t to t the Co Collaborative M Model

Program design

• - kits were sent to patients who hadn’t yet

established care in the clinics Processing/Returning of Mailed Kits

• - unestablished patients completed kits, but

they could not be processed

Ch Challenges sp s specific t to t the Ce Centralized M Model

Vendor experience

• - difficult to oversee vendor adequately to

make sure all program processes being followed as expected Engagement and Communication

• - lack of health plan staffing to conduct

follow-up that was planned for positive FITs Reaction/Satisfaction of Stakeholders

• - providers/health centers wanted to know

results before data available

Mo More e succes esses es than challen enges es

Program design

• - flexibility to design to context

Reaction/Satisfaction of Stakeholders

• - health plan enrollees appreciative and

engaged Processing/Returning Mailed Kit

• - established workflows
• - early results showed more enrollees

screened

Mo More e succes esses es than challen enges es

Compatibility with Health Plan §fit health plans’ mission and goals

“From a program perspective I think it gets to what is needed and necessary for improving access to the tests and for more testing to be completed – so as a program it runs well.” “This whole approach of collaboration…is another big driving factor for this… [Health plan] has a really strong ethos of working with clinics to help their patients get healthier and to push out preventive care.”

Mo More e succes esses es than challen enges es

Broader Impacts §provided roadmap for other population health efforts §increased engagement with enrollees §increased awareness of providers and patients of health plan quality efforts

“Members were very appreciative…We often don’t get a sense of member [satisfaction] but through this we were able to do a lot of member outreach.” “Providers are very grateful that this is just another way that we can tap into getting them in for screening…and the resources required at clinic level were so low… …and another success is that we are getting more provider engagement around the intervention and understanding around what we are doing here in the quality department.”

Con Conclusion

• ns

§ Supporting the health plans with resources and expertise allowed their development of mailed FIT programs highly adapted to their culture and resources. § Program implementation challenges were focused largely in two domains of the Consolidated Framework for Implementation Research §Characteristics of the intervention -- time consuming §Outer setting – vendor challenges

Con Conclusion

• ns

§ Program implementation successes were focused in CFIR domains of: §Inner Setting §leveraged existing health plan QI staff and processes for the program and to identify eligible enrollees for program §Outer Setting §strengthened relationships between health plan and health systems and patients §built on existing vendor relationships

Con Conclusion

• ns

§ Documenting shared as well as individual successes and challenges from health plans using two very different implementation models can guide health plans in adapting these programs to their own culture and resources, and prepare them for potential obstacles.

Fo For more information, contact:

Laura-Mae Baldwin, MD MPH University of Washington lmb@uw.edu