Population Health: Colorectal Cancer Screening: Success Stories

Transcription

1 Population Health: Colorectal Cancer Screening: Success Stories Nikki Medalen, MS, BSN, APHN-BC, Quality Health Associates Kayla Abrahamson, DNP, MS, Northland Community Health Center Donna Lunday, RD, & Marianne Young Eagle, RN, Turtle Mountain Tribal Health

2 Objectives Describe the Four Essentials to improve colorectal cancer screening rates Explore implementation of community-based programs to improve colorectal cancer screening rates 2

3 The barrier to reducing the number of deaths from colorectal cancer is not a lack of scientific data, but a lack of organizations, financial, and societal commitment. Daniel K Podolsky, MD (NEJM 7/20/2000) 3

4 The Pledge is Just the First Step The nation has become energized by the goal of 80% by Signing a pledge is easy Action after signing the pledge What is it really going to take?

5 Give me three good reasons 1. 4 th most common cancer and 2 nd most common cause of cancer incidence and death in North Dakota 2. 42% of North Dakota CRC cases diagnosed at late stage Survival Rates by Disease Stage* 5-yr Survival % 70.4% 12.5% Local Regional Distant Stage of Detection 5

6 North Dakota Colorectal Cancer Screening Rates Medicare Claims Data (Age 50-75): 4Q2015 through 3Q2016 Divide 38.6% Williams 38.2% McKenzie 39.7% Billings 38.9% Burke 46.5% Mountrail 37.5% Dunn 39.8% Stark 42.8% Renville 39.3% Ward 49.6% McLean 44.4% Mercer 46.6% Oliver 46.2% Morton 48.4% Bottineau 42.2% McHenry 41.2% Sheridan 40.8% Burleigh 49.9% Rolette 30.2% Towner Pierce 38.6% Wells 34.6% Kidder 50.7% 39.6% Benson 40.5% Cavalier 49.6% Ramsey 46.5% Eddy 49.3% Foster 48.4% Stutsman 49.9% Nelson 45.1% Griggs 39.5% Barnes 52.6% Pembina 41.4% Walsh 44.1% Grand Forks 48.5% Steele 45.9% Traill 44.5% Cass 47.0% Reason 3 Slope 17.9% Bowman 35.7% Hettinger 38.6% Adams 40.9% Grant 38.2% Sioux 35.1% *Screening tests included: Colonoscopy, Sigmoidoscopy, FOBT, Barium Enema Lowest Group 2 nd Group Logan 43.8% Emmons 42.0% McIntosh 33.6% Middle Group State Rate 45.7% LaMoure 49.9% Dickey 44.8% Ransom 47.7% 4th Group Sargent 49.6% Highest Group Richland 47.9% This material was prepared by the Great Plains Quality Innovation Network, the Medicare Quality Improvement Organization for Kansas, Nebraska, North Dakota and South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11S0W-GPQIN-ND-CRC-14/0517

7 Four Essential Steps to Improve Screening Rates Make a Recommendation Develop a Screening Policy Communication Measure Practice Progress Be Persistent with Reminders How to Increase Cancer Screening Rates in Practice 7

8 #1: Make a Recommendation Brooks, Durado. 04/12/2017. Improving colorectal cancer screening rates through systems change [PowerPoint]. 8

9 #2: Develop a Screening Policy Brooks, Durado. 04/12/2017. Improving colorectal cancer screening rates through systems change [PowerPoint]. 9

10 #3: Be Persistent with Reminders Brooks, Durado. 04/12/2017. Improving colorectal cancer screening rates through systems change [PowerPoint]. 10

11 #4: Measure Practice Progress Brooks, Durado. 04/12/2017. Improving colorectal cancer screening rates through systems change [PowerPoint]. 11

12 Potential Barriers to Screening* 1. Affordability 2. Lack of symptoms 3. No family history of colon cancer 4. Perceptions of the unpleasantness of the test 5. Doctor didn t recommend it 6. Priority of other health issues Based on 2014 Consumer Surveys (Nationwide) I fear it will be uncomfortable. My doctor had never mentioned it to me, so I just let it go. 12

13 Why Colonoscopy is NOT Gold Standard Evidence does not support best test or gold standard Wide variation in quality (when data is captured and available) Access Patient preference Potential for patient injury 13

14 Making the Best Use of Scarce Resources: Screening colonoscopy vs. FIT Screening colonoscopy (refer 1000 patients) Represents 20 patients FIT Testing (2,000 patients) Eligible population, referred Eligible population Patient refusal, no shows Patients with a positive FIT 20 cancers found in 400 colonoscopies Slide courtesy of Dr. G.Coronado 80 cancers in 160 colonoscopies

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16 Implementation of a Colorectal Cancer Screening Program in a Rural Upper Midwest Federally Qualified Health Center: An Evidence Based Project Kayla M. Abrahamson, RN, BSN, FNP-S & McKenzie R. Peterson, RN, BSN, FNP-S University of Mary Project Chair: Dr. Billie Madler 2 nd Reader: Dr. Annie Gerhardt

17 Problem Identification Colorectal cancer (CRC) - 2nd leading cause of cancerrelated deaths Risk starts increasing at age 40 and drastically rises at age 50 Healthy People 2020 goal: >70% screening for those eligible ND ranked 42nd out of 51 in CRCS rates CRC is preventable with routine screening Estimated 50,000+ deaths a year related to CRC >60% are preventable ACS, 2014; CDC, 2014; CDC, 2016

18 Literature Findings Themes Colorectal Cancer Colorectal Cancer Screening (CRCS) Methods Barriers to CRCS CRCS screening program recommendations

19 Project Recommendation #1 Clinical policy and procedure development and implementation Includes a screening algorithm Academic Detailing Cole et al., 2015; Corey et al., 2009; Davis et al., 2013; Sarfaty, 2008

20 Project Recommendation #2 Optimize the EMR to support improved CRCS rates Documentation protocol Patient reminder system Clinical Decision Support Rule Surveillance Protocol Atlas et al., 2014; Berkowitz et al., 2015; Cole, Esplin, & Baldwin, 2015; Geller et al., 2008; Green et al., 2013; Kern, Edwards, & Kaushal, 2014; Levy et al., 2013

21 Project Recommendation #3 Clinical Navigation Workflow analysis to identify staff available to assist in navigation Navigation involves tracking CRCS Patient reminder letter Green et al., 2013; Levy et al., 2013

22 Project Recommendation #4 CRCS Outreach Events Patient outreach letters Flu/FIT campaign FIT cards in place of FOBT Berkowitz et al., 2015; Cole et al., 2015; Daly et al., 2010; Escoffrey et al., 2014; Green et al., 2013; Kern, Edwards, & Kaushal, 2014; Lee et al., 2014; Levy et al., 2013; Potter et al., 2013; Xu et al., 2015

23 Implementation & Engagement Institutional Review Board Obtained Threats and Barriers High staff turnover Change in routine Increased workflow expectations

24 Project Results

25 Project Results

26 Lessons Learned Process Improvement Data Staff needed for Clinical Navigation Improved EMR optimization Continued Staff Education on Documentation Requirements

27 Sustainability of Interventions Future Directions Continue Flu/FIT Expand FIT card dissemination to lab-only encounters. Further efforts to improve documentation standardization.

28 Conclusion CRC is 2nd leading cause of preventable death in the U.S. (ACS, 2014a) The CRCS program improved CRCS rates Project Interventions: Policy & Procedure EMR Optimization Patient Navigation Outreach Efforts Strategies have potential to improve healthcare quality and outcomes

29 References American Cancer Society (2014). Colorectal Cancer Facts & Figures Atlanta, GA: American Cancer Society. Retrieved from Release- Detail.aspx?ItemID=795#.VrkLOeaCrbV Atlas, S. J., Zai, A. H., Ashburner, J. M., Chang, Y., Percac-Lima, S., Levy, D. E.,... & Grant, R. W. (2014). Nonvisit based cancer screening using a novel population management system. Journal of the American Board of Family Medicine, 27(4), Berkowitz, S. A., Percac-Lima, S., Ashburner, J. M., Chang. Y., Zai, A. H., He, W.,... Atlas, S. J. (2015). Building equity improvement into quality improvement: Reducing socioeconomic disparities in colorectal cancer screening as part of population health management. Journal of General Internal Medicine, 30(7), doi: /s Centers for Disease Control and Prevention [CDC]. (2014). Colorectal (Colon) Cancer: Colorectal Cancer Rates by State. Retrieved from Centers for Disease Control and Prevention [CDC]. (2016). Colorectal Cancer Statistics. Retrieved from Cole, A. M., Esplin, A., & Baldwin, L. (2015). Adaptation of an evidence-based colorectal cancer screening program using the consolidated framework for implementation research. Preventing Chronic Disease, 12(e213). doi: Corey, P., Gorski, J., Schaper, A., & Newberry, S. (2009). Nurses use motivational interviewing to improve colorectal cancer screening rates. Oncology Nursing Forum, 36(3), 24. Davis, T., Arnold, C., Rademaker, A., Bennett, C., Bailey, S., Platt, D.,... Wolf, M. (2013). Improving colon cancer screening in community clinics. Cancer, 119, Doi: /cncr.28272

30 References Escoffery, C., Rodgers, K. C., Kegler, M. C., Haardorfer, R., Howard, D. H., Liang, S.,... Coronado, G. D. (2014). A systematic review of special events to promote breast, cervical, and colorectal cancer screening in the United States. BMC Public Health, 14 (274), Retrieved from Green, B. B., Wang, C.-Y., Anderson, M. L., Chubak, J., Meenan, R. T., Vernon, S. W., & Fuller, S. (2013). An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening. Annals of Internal Medicine, 158(5), Healthy People 2020 (2016). Cancer. Retrieved from the Office of Disease Prevention and Health Promotion website at Heydari, A., & Khorashadizadeh, F. (2014). Pender s health promotion model in medical research. Journal of the Pakistan Medical Association, 64(9), Retrieved from HRSA Health Center Program (2014) Health Center Profile: Northland Health Partners Community Health Center Turtle Lake, ND. Retrieved from the U.S. Department of Health and Human Services at Kaminski, J. (2016). Diffusion of Innovation theory. Canadian Journal of Nursing Informatic, 6(2), Retrieved from the Theory in Nursing Informatics Column at Kern, L. M., Edwards, A., & Kaushal, R. (2014). The Patient-Centered Medical Home, electronic health records, and quality of care. Annals of Internal Medicine, 160(11), doi: /M Levy, B. T., Daly, J. M., Schmidt, E. J., & Xu, Y. (2012). The need for office systems to improve colorectal cancer screening. Journal of Primary Care & Community Health, 3(3), doi: /

31 References Pender, N. (2011). Health Promotion Model Manual. University of Michigan. Retrieved from MANUAL_Rev_ pdf Peterson, S. J., & Bredow, T. S. (2013). Middle Range Theories: Application to Nursing Research, (3rd, ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Potter, M. B., Ackerson, L. M., Gomez, V., Walsh, J. M. E., Green, L. W., Levin, T. R., & Somkin, C. P. (2013). Effectiveness and reach of the FLU-FIT Program in an integrated health care: A multisite randomized trial. American Journal of Public Health, 103(6), Doi: /AJPH Rogers, E. M. (1983). Diffusions of Innovation (3rd ed.). New York, NY: The Free Press. Retrieved from of-innovations.pdf Sanson-Fischer, R. W. (2004). Diffusion of innovation theory for clinical change. The Medical Journal of Australia, 180(6 suppl), S55. Retrieved from Sarfaty, M. (2008). How to increase colorectal cancer screening rates in practice: A primary care clinician s evidence-based toolkit and guide. The National Colorectal Cancer Roundtable. Retrieved from Xu, Y., Levy, B. T., Daly, J. M., Bergus, G. R., & Dunkelberg, J. C. (2015). Comparison of patient preferences for fecal immunochemical test or colonoscopy using the analytic hierarchy process. BMC Health Services Research, 15, doi: /s

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33 Northern Plains Comprehensive Cancer Control and Great Plains Mini Grant UR : Strategies to Improve Colorectal Cancer Screening Donna Lunday- Tribal Health Educator Marianne Young Eagle, MSN/MHA BSN RN

34 GOAL: OBJECTIVES: 1. Increase access to CRC Screening 2. Increase the number of Tribal members that receive CRC screening through use of the Fecal Immunochemical Blood Test (FIT) 1. Increase the number of tribal members who receive CRC screening through FIT test from 0 to Increase the number of tribal members who receive information about CRC screening, through education and screening events, from 0 to 500

35 What is GPRA The Government Performance and Results Act (GPRA) is a Federal Law It requires IHS to demonstrate funds are used effectively to meet their mission GPRA is a critical part of the annual budget request for IHS. There are annual performance measures with specific targets IHS reports 20 clinical GPRA measures; one being Colorectal Screening.

36 Colorectal Cancer Screening Denominator: Active Clinical patients ages 50 through 75 without a documented history of colorectal cancer or total colectomy Numerator: 1. Patients who have had any Colorectal Cancer (CRC) Screening, defined as any of the following: Fecal Occult Blood Test (FOBT) or Fecal Immunochemical Test (FIT) during the report period Flexible sigmoidoscopy in the past 5 years. Colonoscopy in the past 10 years 2. Patients with FOBT or FIT during the report period.

37 Tribal Health Education Grant Tribal Health was awarded a Grant, part of which was used to assist Indian Health Services (IHS) to increase their GPRA numbers THE purchases Gift cards with a portion of the grant money. Gift cards were $25.00, (with a $2.00 processing fee). One grant used 54% for gift cards and another grant used 96% for gift cards. Sponsored Events include: March 2016-Community CRC Screening a the Sky Dancer Casino Presentation on Colorectal Cancer Colorectal Bingo with prizes Rollin Color-inflatable colon Door Prizes

38 Key Players Community Health Representatives (CHR s) Tribal Health/Public Health Nurses Lab Primary Cary Providers (MD, Surgeon, PA)

39 Function of Community Health Representatives (CHR s) Educated the individuals about CRC Screening using the Colorectal Health Flip Chart. Provided by the American Indian Cancer Foundation. The CHR s were trained by Joy Riveria to provide CRC Screening

40 Function of Public Health Nurses/Tribal Health Educator Combined the FluFIT test Demonstrated on how to use the FIT test. Patient were asked if they wanted a flu shot An incentive card was provided to patient to bring back to Lab PHN would provide the PCP with Names and DOB of individuals who were screened with the FIT Test individuals who received the FIT test.

41 Function of Lab Lab provided the FIT Test to the patient to take home, after receiving a lab order from the PCP Patient returned the FIT Test specimen, and Lab signed off on the card for the incentive. The signed card was returned to Tribal Health Education Tribal Health provided the $25.00 Gift card Test results were available in the Electronic Health Record (EHR) for PCP to review.

42 Function of the Primary Care provider PCP would write an order in the Electronic Health Record (EHR) for the Lab to run the FIT Test. Lab results were returned to the PCP Every patient receives a letter to inform them of the results of the FIT test, whether it was positive or negative. If the patient had a positive result, a referral was initiated for further work up. A Surgeon is on staff to do colonoscopies, if needed. If the colonoscopy showed evidence of cancer, the patient is referred to a higher level of care.

43 MEASURE

44 Results Northern Plains (NP) Mini grant -$ $ incentive cards (100 cards)-54% Purchased items, FIT Test kits, door prizes, Bingo prizes 193 participants 109 returns 73 Female 36 male Great Plains Grant (GP) Participants 313 returned FIT Test Gender results not available at this time.

45 Conclusion-Key to success Collaborating- with Key Players Prevention- Patients are aware and know that Cancer is a silent killer, the test is easy and is done in the privacy of their home. Education- used of the visual flipcharts is a great tool for culturally sensitive information. Easy Access- Providing an incentive so individual are able to spend it at the local stores.

46 QUESTIONS

47 Contact Information Nikki Medalen Quality Improvement Specialist P: area-a.hcqis.org Donna Lunday Health Educator P: yahoo.com Kayla Abrahamson Family Nurse Practitioner, DNP P: northlandchc.org Marianne Young Eagle Public Health Nurse P: Quality Health Associates of North Dakota 3520 North Broadway Minot, ND P: This material was prepared by the Great Plains Quality Innovation Network, the Medicare Quality Improvement Organization for Kansas, Nebraska, North Dakota and South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11S0W-GPQIN-ND-CRC-17/