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80% by 2018 FORUM II
Workshop: Implementing a Quality Screening Navigation Program Decatur B
80% by 2018 Forum II: Increasing CRC Screening Rates
Implementing a Quality Screening Navigation Program July 18, 2017
Lynn Butterly, MD
Director, Colorectal Cancer Screening Dartmouth Hitchcock Medical Center PI and Medical Director, NH CRC Screening Program
Rationale for Patient Navigation in CRC Screening
Colorectal cancer (CRC) is the second most common cause of death from cancer in the U.S.
CRC can be prevented through screening, in
addition to early detection to prolong survival Despite compelling evidence for CRC screening
those rates remain low, particularly for low income individuals and racial and ethnic minorities
NHCRCSP Patient Navigation (PN) Model
The New Hampshire Colorectal Cancer Screening Program (NHCRCSP) has been a statewide, CDC funded program (CRCCP) since 2009
As part of our work, the NHCRCSP designed and implemented a Patient Navigation model for the free colonoscopy program (2009-2015)
Initial Goals of the NHCRCSP
Increase CRC screening for all NH individuals over age 50 to 80% (80% by 2018 Initiative)
Address Disparities: Offer high quality free
colonoscopies to low income, uninsured or underinsured individuals
NHCRCSP works with NH health centers (FQHCs,
CHCs, health systems) to reach the 80% goal
NHCRCSP FQHC COLLABORATION: General Approach and Groundwork
Get FQHC and endo unit leadership commitment – Financial incentive for prevention through screening
Identify and train internal champions Agree on health center screening policy
– Incorporate CRC screening education – Recognize specific barriers for underserved:
Language, cultural, travel, missed work time, etc
Identify appropriate endoscopy sites and establish consistent policies and procedures
NHCRCSP Background Information
Central Organization: Patients referred to NHCRCSP NHCRCSP referred to 12 endoscopy sites (hospital-based and ASCs) for colonoscopies, selected by their geographic proximity for the referred (underserved) population Endo sites have hospital affiliations and all hospitals agreed (NHCRCSP policy) to cover cost of care for CRCs found through the program, and colonoscopy complications
Key Elements of CRC Screening Program
Central infrastructure (NHCRCSP) connects CHC patients to needed venues of CRC screening and cancer care
NHCRCSP establishes referral policies and procedures
with FQHCs, endoscopy sites, and hospitals Must also establish agreements and/or contracts if needed
with PCPs and endoscopy sites (pathology, anesthesia)
Maximize partnerships that support the process
NH Colorectal Cancer Screening Program NHCRCSP Patient Navigation
NHCRCSP provided free colonoscopies to low income, uninsured NH residents for six years, and developed and implemented a PN program.
Patient Navigation has proven highly effective for adherence, provision of high-quality screening, and appropriate and timely follow-up
Program was statewide, so telephonic navigation
was provided by two nurse Patient Navigators
NHCRCSP Patient Navigation
NHCRCSP provided over 2000 colonoscopies for uninsured NH residents at or below 250% of the federal poverty level.
Patients were navigated throughout screening process:
– Medically appropriate – Had understanding of test and prep – Received results and recommended follow-up – Barriers identified and addressed throughout the
process
Patient Navigators address patient barriers: - Cultural or social issues - Lack of knowledge about screening - Language - Practical issues: transportation (ride home) - Obtaining and taking test preparation - Test results and recommended follow-up from provider
Barriers to Colonoscopy
NHCRCSP Patient Navigation Outcomes
>96% completion of colonoscopy
0.1% no-shows (2 out of 2000)
< 1% inadequate preparations
100% of patients and PCPs received
report and follow-up recommendations
Extremely high patient satisfaction
NHCRCSP Navigation: Evaluation
NHCRCSP Navigation Results: Excellent Patient Outcomes High Patient Satisfaction Comprehensive Data Collection
CDC Evaluation: Case Study and Quasi-Experimental Comparison Group Study as well as a pending Cost Study
CDC Evaluation Study: Outcomes measured to determine effectiveness
Colonoscopy completion Bowel prep quality Appointment no-shows Cancelled appointments Communication of test results to patients
and PCPs Appropriate rescreening interval
11 times more likely to complete
colonoscopy than non-navigated patients.
40 times less likely to miss the
colonoscopy appointment.
6 times more likely
to have adequate bowel prep than
non-navigated patients.
Evidence For NHCRCSP PN Model
Outcomes of the Comparison Study
Details of NHCRCSP Navigation
Defined series of calls per patient Effective program management Real-time data collection Patient review with Medical Director Assessment of patient satisfaction Evaluation of outcomes for patients,
endoscopy sites, and for the program Ensuring appropriate follow up
NHCRCSP Navigation Outcomes: Ensuring Quality
Patient navigation not only improves colorectal cancer screening rates
but – of critical importance – navigation can improve the quality of
colorectal cancer screening Quality is essential for effective and cost-
effective colorectal cancer screening
Patient Navigation Topics
Does your program need a navigator(s)? How to select a navigator Organize a navigation process How to approach patients Assessing and addressing barriers Patient satisfaction (navigator and process) Frequent data collection for outcomes
evaluation and process improvement
NHCRCSP Patient Navigation Model
CORE ELEMENTS
Core Element 1: Nurse Navigators Navigators are the heart of the
NHCRCSP PN model Model specifically developed to
recognize and resolve patient barriers Registered nurses as Navigators
because of their clinical expertise Psychosocial assessment skills
Core Element 2: PN Champion with Clinical CRC Screening Expertise
Champion is vital to the PN intervention Ensures there is organizational support Promotes the program’s vision and value Key qualities include leadership and
expertise in CRC screening
Core Element 3: Medical Oversight of the Navigation Intervention
M.D. with significant clinical expertise in endoscopy and CRC screening
Can be a “door opener” to engage clinical sites and providers
Clinical oversight, ongoing mentoring, and guidance
Core Element 4: Partnerships
Develop and sustain strong working relationships with key partners
Develop internal champions at the endoscopy site
Partnerships improve communication and patient care
Critical to both program implementation and effective functioning
NHCRCSP STRATEGIES TO INCREASE HIGH QUALITY CRC SCREENING: Partnerships Create Synergy
Partnerships and Collaborations: – Internal champion(s) critical to success – CDC CRCCP in applicable states, DHHS – NCCRT, ACS, CDC, NCI, GI Societies (AGA) – Comprehensive Cancer Control (CCC) groups – EMR system leaders and experts (FQHC CHAN) – Insurers (address barriers together) – Endoscopists
Core Element 5: Six-Topic Navigation Protocol
Six important topics discussed at defined time intervals throughout the screening process
Includes patient education and assessment
and resolution of barriers Not just the number of calls, but the content
of the calls and the navigator’s relationship with the patient
Core Element 6: An Effective Data System
Comprehensive and secure data system
Supports quality monitoring and evaluation Real-time data system to track and monitor
outcomes, with regular review and reports
Team communication and use of data
Core Element 7: Philosophy of Shared Success
Guiding principle of the NHCRCSP PN model
Navigators coached patients but did not schedule appointments for them
Navigated patients were better prepared to take a more active role in their overall healthcare.
NHCRCSP Patient Navigation Replication Manual
The web address to download the manual:
https://www.cdc.gov/cancer/crccp/pn-replication-manual.htm Send comments, questions, and suggestions to [email protected].
NHCRCSP Processes to Ensure Quality: Additional Processes
– Referral to Quit Line, BCCP, medical home – Referral of ineligible patients to other resources – Communication with endoscopy sites to clarify
history, findings, follow-up, or patient questions – Through data review, recognize any provider
practice patterns needing to be addressed (for example: % fair preps, incomplete polypectomies,
short withdrawal time, missing or inappropriate follow-up recommendations that do not follow Guidelines)
NHCRCSP Navigation
Patient Satisfaction
Cost Considerations: Navigation for CRC Screening
Reducing endoscopy no-shows and last minute cancellations
Reduces inappropriate repeat testing Reduces repeat testing from inadequate
preparations Costs from CRC treatment ($14
billion/year in the U.S. for a preventable disease)
Cost Considerations: Navigation for CRC Screening
Financial cost of lost productivity may be large:
– Bradley JNCI 2008: every CRC death is associated with > $210,000 in lost productivity
– CRC deaths in 2010 estimated to account for $12 billion in economic losses due to lost productivity
Cost Considerations: Navigation for CRC Screening
The ultimate benefit of increasing CRC screening comes from long-term outcomes of decreased incidence and mortality of CRC
The Compelling Case
Second most common cause of ca death in US, despite being preventable
Providing patients with high-quality CRC
screening can save thousands of lives
Colorectal cancer, a preventable disease, has an estimated annual national cost of $14 billion
Patient navigation can increase CRC screening
Comparison Study Conclusion
PN program is highly effective in increasing colonoscopy completion and reducing appointment no-shows and cancellations, and improving bowel preparation Findings further advance the evidence-base for PN as an important public health practice
Conclusion Patient Navigation is an extremely
effective method of increasing CRC screening and reducing disparities, while simultaneously ensuring high-quality and appropriate follow up