Technical Assistance Webinar Provider/Client Reminder and Recall - - PowerPoint PPT Presentation

Technical Assistance Webinar

Provider/Client Reminder and Recall Systems to Increase Colon Cancer Screening

Presented by: Thomas Rich, MPH Health Systems Manager American Cancer Society

• As a provider accredited by ACCME, ANCC, and ACPE, the IHS

Clinical Support Center must ensure balance, independence,

• bjectivity, and scientific rigor in its educational activities. Course

directors/coordinators, planning committee members, faculty, reviewers and all others who are in a position to control the content

• f this educational activity are required to disclose all relevant

financial relationships with any commercial interest related to the subject matter of the educational activity. Safeguards against commercial bias have been put in place. Faculty will also disclose any off-label and/or investigational use of pharmaceuticals or instruments discussed in their presentation. All those who are in a position to control the content of this educational activity have completed the disclosure process and have indicated that they do not have any significant financial relationships or affiliations with any manufacturers or commercial products to disclose.

Faculty Disclosure Statement

• Funding for this webinar was made possible by the Centers for

Disease Control and Prevention DP17-1701, Cancer Prevention and Control Programs for State, Territorial, and Tribal Programs awarded to the Inter-Tribal Council of Michigan in support of the Three Fires Cancer Consortium. Webinar contents do not necessarily represent the official views of the Centers for Disease Control and Prevention.

• No commercial interest support was used to fund this activity.

Faculty Disclosure Statement

• The Indian health Service (IHS) Clinical Support Center is

accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

• The IHS Clinical Support Center designates this live activity for a

maximum of 1 ¾ AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

• The Indian Health Service Clinical Support Center is accredited

with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

• This activity is designated 1.75 contact hours for nurses.

Accreditation

• Continuing Education guidelines require that the attendance of

all who participate be properly documented.

• To obtain a certificate of continuing education, you must be

registered for the course, participate in the webinar in its entirety and submit a completed post-webinar survey.

• The post-webinar survey will be emailed to you after the

completion of the course.

• Certificates will be mailed to participants within four weeks by

the Indian Health Service Clinical Support Center.

CE Evaluation and Certificate

By the end of this webinar, participants will be able to:

• 1. Examine the current colon cancer disparities among the

American Indian population of Michigan.

• 2. Apply current clinical guidelines to screen and detect colon

cancer.

• 3. Implement a system to alert clinicians and inform patients who

are due or overdue for screening.

Learning Objectives/Outcomes

Provider Reminder and Recall Systems

Tom Rich MPH, American Cancer Society, NC Region February 21, 2018

Objectives

• Recognize the burden of CRC on the NA population.
• Understand the importance of developing and following an
• verall plan.
• Calculate current screening rates
• Design a clinic screening strategy
• Recognize the importance of patient choice
• Develop dissemination strategies to improve use of materials

(e.g. build into EHR)

• Identify and address barriers to screening
• Understand the power of a provider recommendation
• Assess the effectiveness of the plan

AI/AN Cancer Burden

Slide taken from NCCRT presentation: Colorectal Cancer Screening In American Indian & Alaska Native Communities – November 28, 2017, NCCRT, http://nccrt.org/resource-center/

CRC Screening Among IHS User Population (GPRA)

Slide taken from NCCRT presentation: Colorectal Cancer Screening In American Indian & Alaska Native Communities – November 28, 2017, NCCRT, http://nccrt.org/resource-center/

RESULTS

Slide taken from NCCRT presentation: Colorectal Cancer Screening In American Indian & Alaska Native Communities – November 28, 2017, NCCRT, http://nccrt.org/resource-center/

Importance of Developing an Overall Plan

http://nccrt.org/wp-content/uploads/0305.60-Colorectal-Cancer-Manual_FULFILL.pdf

Assess a patient’s risk status and receptivity to screening. Determine screening messages you and your staff will share with patients.

#1: Make a Recommendation

#

Create a standard course of action for screenings, document it, and share it. Ensure patient education & follow-up

#2: Develop a Screening Policy

Determine how your practice will notify patient and physician when screening and follow up is due. Ensure that your system tracks test results and uses reminder prompts for patients and providers.

#3: Be Persistent with Reminders

Discuss how your screening system is working during regular staff meetings and make adjustments as needed. Have staff conduct a screening audit.

#4: Measure Practice Progress

• Reminders inform health care providers it is time for a client’s

cancer screening test (called a “reminder”) or that the client is

• verdue for screening (called a “recall”).
• The Community Preventive Services Task Force

(CPSTF) recommends provider reminder systems based on strong evidence of their effectiveness in increasing colorectal cancer screening by fecal occult blood test (FOBT) and sufficient evidence of their effectiveness in increasing colorectal cancer screening by flexible sigmoidoscopy.

The Intervention

Considerations

• Link to other preventive services.
• Clinic may not have the technology or

manpower.

• Only good for those you see.
• Must conform to the community.

USPSTF CRC Screening Guidelines (June 2016)

Where to Start

• Patients who appear for regular check-ups;
• Patients who come for other preventive services;
• Patients who had been screened before;
• Patients who receive regular care for chronic conditions;
• Patients who come in only when they have a problem;
• Patients who are part of your practice, but almost never

come in.

Patient Preference

• Diverse sample of 323 adults given detailed side-by-side description of FOBT and

colonoscopy (DeBourcy et al. 2007)

• 53% preferred FOBT
• Almost half felt very strongly about their preference
• 212 patients at 4 health centers rated different screening options with different attributes

(Hawley et al. 2008)

• 31% preferred FOBT
• 37% preferred colonoscopy
• Nationally representative sample of 2068 VA patients given brief descriptions of each

screening mode (Powell et al. 2009)

• 29% preferred FOBT
• 37% preferred colonoscopy

Inadomi, Arch Intern Med 2012

Patient Preference

Colonoscopy Limitations

Frequently referred to as “gold standard,” but evidence shows:

• Colonoscopy misses ~10% of

significant lesions in expert settings

• More costly on a one-time basis
• Higher potential for patient injury

than other tests

• Wide variation in quality (when

data are captured and available) Also:

• Greater patient requirements for

successful completion

• Requires bowel prep and

facility visit, pre-procedure visit, chaperone for post- procedure

• Access
• Limited by insurance status,

local resources

• Patient preference

Types of Stool Tests

Tests that detect blood (Fecal Occult Blood Tests)

• Two types (but multiple brands, variable performance)
• Guaiac-based FOBT
• Immunochemical (FIT)

Tests that detect aberrant DNA

• One test (Cologuard) available in U.S.
• Combines DNA mutation test with FIT
• Recently added to USPSTF screening guideline (June

2016)

*Stool tests are only appropriate for average risk patients

Clinical Screening Strategy

Key Questions

• What are you doing now to make sure eligible patients are being

screened for CRC?

• Are you using evidence-based interventions to screen patients for

CRC?

• What has worked and not worked in the past when you have tried to

increase CRC screenings?

• What has worked and not worked in the past when you tried to

increase screening for other diseases such as breast cancer, cervical cancer, or diabetes? Are there lessons learned that could be applied to CRC screening?

Creating a Plan Creating a Plan

Sample Policy/Procedure

Standing Orders

Advantages

• Easy to implement.

Disadvantages

• Only reaches patients already contacting the health care

system.

• No opportunity for patient input.

Chart Reminders

Advantages

• Inexpensive and efficient (reviewing health maintenance inventories

with patients on average requires less than 4 minutes with the patients and quickly becomes part of the physician’s routine). Disadvantages

• Only reaches patients with scheduled office visits and chart

reminders may be more effective in managed care organizations as compared with fee-for-service practices since cost to the patient may be a barrier to vaccination in a fee-for-service practice.

Barriers

• Medical practice is demand (patient) driven.
• Practice demands are numerous and diverse.
• Few practices currently have mechanisms to

assure that every eligible patient gets an appropriate recommendation for screening.

• Opportunistic vs organized screening.
• Knowledge and skills of the provider.
• Extraneous barriers

Barriers - Providers

Barriers to Screening

36

• Unscreened have lower income than screened counterparts
• More likely to be uninsured
• Newly insured don’t know it’s covered

Affordability

• Symptoms drive doctor visits
• Misconception about disease

Lack of symptoms

• Perception that heredity is only risk factor
• Reduced sense of urgency

No family history

• Focus on acute illnesses and issues of more concern
• Not a top priority
• No personal connection to cancer

More pressing health issues

• Connotation of test being unpleasant, invasive, embarrassing
• Fear of test-prep compounds negativity

Negative perceptions about the test

• Utilize medical neighborhood
• Avoids doctors/no routine physicals or wellness visits
• Think they’re healthy already

No regular primary care to reinforce message

• #1 reason among African Americans
• #3 reason among Hispanics

Doctor does not recommend it

Barriers - Patients

Measure and Improve Performance

• Measure the colorectal cancer screening rate in your

practice; it may not be as high as you think.

• Set goals to get screening rates up.
• Recognize clinicians in your practice who are meeting

screening goals.

• Share advice with those who can be doing better.
• Promote tools that are available to help your staff

understand how to accurately measure screening rates.

Measuring Outcomes

Calculate Screening Rates

HEDIS

• Assesses adults 50–75 years of

age who had appropriate screening for colorectal cancer with any of the following tests: annual fecal occult blood test; flexible sigmoidoscopy every five years; or colonoscopy every ten years.

http://www.ncqa.org/report-cards/health- plans/state-of-health-care-quality/2016-table-

• f-contents/colorectal-cancer

CMS130v6

Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:

• Fecal occult blood test (FOBT) during the

measurement period

• Flexible sigmoidoscopy during the

measurement period or the four years prior to the measurement period

• Colonoscopy during the measurement period
• r the nine years prior to the measurement

period

• FIT-DNA during the measurement period or the

two years prior to the measurement period

• CT Colonography during the measurement

period or the four years prior to the measurement period https://ecqi.healthit.gov/ecqm/measur es/cms130v6

CRC Screening Measures

Direct Method

Numerator

Patients who have had any CRC screening, defined as any of the following:

• Fecal Occult Blood Test

(FOBT) or Fecal Immunochemical Test (FIT) during the report period (i.e. during the current GPRA year)

• Flexible Sigmoidoscopy in the

past 5 years

• Colonoscopy in the past 10

years

Denominator

Active Clinical patients ages 50 through 75 without a documented history of colorectal cancer or total colectomy. The denominator for this measure does not include any patients who have ever had a diagnosis of one

• f the following:
• Colorectal Cancer
• Total Colectomy

Sample Method

• 1. Identify the patient population to be sampled (the universe).
• Include all active (measurement year) patients
• Include all sites in the scope of the project
• Include contracted medical services.
• 2. Determine the sample size for manual chart review.
• 3. Select the random sample.
• 4. Review the sample of records to determine having met the

measurement standard with the clinical measure.

• 5. Replace patients that should be excluded from the sample.

Resources

Communications Guidebook

• Infographics
• Press release template
• Social media messages
• Web banner ads
• Cobranded inter-office TV

slides

• 80X 2018 core messaging
• “Ways to Get Involved” tools

Tools, Resources & Publications

Available at: National Colorectal Roundtable nccrt.org

More Resources

• www.cancer.org/colonmd
• www.cancer.org/professionals

Questions?

Thank you!

For additional information, contact: Tom Rich thomas.rich@cancer.org 517-664-1422 cancer.org | 1.800.227.2345

Client Reminders

Tom Rich MPH, American Cancer Society, NC Region February 21, 2018

Objectives

• Calculate current screening rates by various methods
• Determine and select the target screening population
• Identify and understand the basic reasons for not being

screened

• Craft the right message to address those reasons
• Recognize and utilize the different types of reminders,

e.g. paper, electronic, social media, clinic measures

• Locate and obtain resources and materials
• Assess the effectiveness of the reminder initiative

AI/AN Cancer Burden

Slide taken from NCCRT presentation: Colorectal Cancer Screening In American Indian & Alaska Native Communities – November 28, 2017, NCCRT, http://nccrt.org/resource-center/

CRC Screening Among IHS User Population (GPRA)

Slide taken from NCCRT presentation: Colorectal Cancer Screening In American Indian & Alaska Native Communities – November 28, 2017, NCCRT, http://nccrt.org/resource-center/

CRC Screening: GPRA 2016 Results

Slide taken from NCCRT presentation: Colorectal Cancer Screening In American Indian & Alaska Native Communities – November 28, 2017, NCCRT, http://nccrt.org/resource-center/

Client reminders are written (letter, postcard, email) or telephone messages (including automated messages) advising people that they are due for screening. Client reminders may be enhanced by one or more of the following:

• Follow-up printed or telephone reminders;
• Additional text or discussion with information about indications for,

benefits of, and ways to overcome barriers to screening;

• Assistance in scheduling appointments.

The Intervention

Calculate Screening Rates

Direct Method

Numerator

Patients who have had any CRC screening, defined as any of the following:

• Fecal Occult Blood Test

(FOBT) or Fecal Immunochemical Test (FIT) during the report period (i.e. during the current GPRA year)

• Flexible Sigmoidoscopy in the

past 5 years

• Colonoscopy in the past 10

years

Denominator

Active Clinical patients ages 50 through 75 without a documented history of colorectal cancer or total colectomy. The denominator for this measure does not include any patients who have ever had a diagnosis of one

• f the following:
• Colorectal Cancer
• Total Colectomy

Sample Method

• 1. Identify the patient population to be sampled (the universe).
• Include all active (measurement year) patients
• Include all sites in the scope of the project
• Include contracted medical services.
• 2. Determine the sample size for manual chart review
• 3. Select the random sample
• 4. Review the sample of records to determine having met the

measurement standard with the clinical measure

• 5. Replace patients that should be excluded from the sample

Target Screening Population

Choices

All Age Appropriate Patients Advantages

• Easy to generate mailing list.
• Simple, generalized message.
• No need for confidentiality.

Drawbacks

• Reaching the compliant.
• Additional costs in mailing of

reminders.

• Viewed as junk mail.

Patients Showing Gaps in Care

Advantages

• Specific to the individual.
• Detailed call to action

Drawbacks

• More difficult to compile list.
• Non-discriminatory language.

(Section 1557)

• Additional costs in production

and mailing.

Crafting the Message

Profile of the Unscreened

Top Barriers To Screening

Motivation

Consumers: Likelihood To Get CRC Test if Knew Each of the Following

Keys to Successful Messaging

Key Messages

There are several screening options available, including simple take home options. Talk to your doctor about getting screened. Colorectal cancer is the second leading cause of cancer death in the US, when men and women are combined, yet it can be prevented or detected at an early stage. Preventing colon cancer or finding it early doesn’t have to be expensive. There are simple, affordable tests available. Get screened! Call your doctor today.

Sample Postcards

MIYO

Make It Your Own

Sample Letter

If you’re avoiding a colonoscopy, you’re not alone. A lot of our members and patients are concerned about the test and

• preparation. But I have good news: there are quick and easy

alternatives to a colonoscopy. One option I tell people about is the FIT, a stool test you do at home with no special diet to prepare for it. Both the FIT and colonoscopies are 100 percent covered by your HealthPartners insurance. You don’t need to meet your deductible first (that’s the amount you have to pay each year before your plan starts paying). There’s no cost to you. Colon cancer is the second leading cause of cancer deaths in the U.S., but if caught early, it’s 90 percent curable. That’s why screening is so important.

Tools To Reach the Priority Populations

Power of a Provider Recommendation

Assess a patient’s risk status and receptivity to screening.

At the Appointment

Determine screening messages you and your staff will share with patients.

Assessing Effectiveness

Steps in Evaluation

Step 1: Describe and map your program Step 2: Prioritize evaluation questions Step 3: Design the evaluation Step 4: Identify or develop data collection instruments Step 5: Collect the data Step 6: Organize and analyze information Step 7: Using and sharing evaluation results

Taken from: How to Evaluate Activities to Increase Colorectal Cancer and Awareness Version 4 Evaluation Toolkit, NCCRT http://nccrt.org/wp-content/uploads/NationalColorectalCancerRoundtable_Version4_EvaluationToolkit_7-10-17.pdf

Resources

Communications Guidebook

• Infographics
• Press release template
• Social media messages
• Web banner ads
• Cobranded inter-office TV

slides

• 80X 2018 core messaging
• “Ways to Get Involved” tools

Tools, Resources & Publications

Available at: National Colorectal Roundtable nccrt.org

More Resources

• www.cancer.org/colonmd
• www.cancer.org/professionals

Questions?

Thank you!

For additional information, contact: Tom Rich thomas.rich@cancer.org 517-664-1422 cancer.org | 1.800.227.2345