Staff from the Multnomah County Health Department stand in the Strollin' Colon display to promote Colon Cancer Awareness in Seattle in March 2015

STOP Colon Cancer: A practical approach to boosting screening rates

By Brieshon D’Agostini, Primary Care Operations Manager, Multnomah County Health Department Colorectal cancer (CRC) is the second-leading cause of cancer death in the United States, yet it is 90% curable with timely detection and appropriate treatment. Nearly half of U.S. adults are not up to date on their recommended CRC screenings, and screening is extremely low among minorities. The Multnomah County Health Department (MCHD) is part of Screen to Prevent (STOP) Colon Cancer, an innovative effort to address this disparity that involves more than 22 federally qualified health centers (FQHCs) in Oregon. While colonoscopy is considered the gold standard by many health care professionals, it may not be the ideal primary screening method. Colonoscopy complications, limited endoscopic capacity, high procedural costs, limited access, and patient preferences for alternative testing methods are several of the reasons why our program emphasizes primary screening using fecal testing, with follow-up colonoscopy screening only for those with positive test results. The STOP Colon Cancer program is a practical, health system-based research program funded by the National Cancer Institute. As part of STOP Colon Cancer, we have helped develop and test a culturally tailored low-cost intervention to improve CRC screening rates in our community-based collaborative Health Information Network, OCHIN. OCHIN is the largest single FQHC network in the country. Six MCHD primary care clinics participated in the study; three clinics direct mailed the new fecal immunochemical testing (FIT) kits to patients’ homes and at three other clinics providers handed patients FIT kits to complete at home. Challenges for our patient population MCHD’s clinics actively serve more than 72,000 patients making nearly 300,000 visits per year. Our population is a fragile one. Over 85 percent of our population falls below the federal poverty line, and more than 80 percent are on Medicaid. Barriers include language, culture, transportation, fear of uncovered health care costs, and many others. More than a fifth of our patients speak a language other than English or Spanish—the two languages in which most health promotion materials are typically printed. A large percentage of our population are immigrants and refugees or have not received primary care services in many years. A significant challenge for many of our patients is not understanding the U.S. health care system, what to expect, or be able to navigate complicated insurance coverage issues. To address language barriers, wordless instructions for the FIT kits were created by a medical illustrator. We repackaged the kits after receiving them from the manufacturer to include our own pre-postage-paid envelopes, instructions, and materials. By mailing the kits directly, access and many cultural barriers were removed. Lessons Learned = Program Improvements Based on our experiences, we are putting several changes in place to improve the program:
  • Improve instructions to patients to note the date the sample was taken on the label. This significantly decreases the number of returned samples than cannot be processed.
  • Switch from the two-sample Insure kits to the one-sample Polymedco OC Micro kits to decrease confusion as well as the number of false positives.
  • Process returned samples at our own labs versus externally.
  • Improve packaging for returned kits (biohazard bag and vial vs. post-card smear) to ease concerns expressed by patients (and the post office).
  • Expand the direct mail mode for all MCHD clinics due to a better return rate and broader reach than the comparison visit-based approach in the study. Providers will still discuss and distribute kits at appointments when appropriate.
  • Program bulk orders for FIT kits in Epic (instead of placing orders one by one).
  • Incorporate placing orders for the kits into the work of our new Preventive Care Medical Assistants, who perform outreach for patients due for preventive screenings and care for chronic conditions.
  • Fund a permanent position in the Health Department for direct mailing of kits.
Five Secrets to a Successful Program We have increased our CRC screening rate from 26 percent to nearly 43 percent in just two years’ time and are confident it will continue to rise as we continue rolling out improvements. If you are planning to implement a new program of your own, we offer these five key insights that have contributed to our successful experience:
  1. Make CRC screening a priority for your entire organization.
  2. Communicate about it with staff at all levels from the very beginning.
  3. If you have the opportunity to participate in a study, do it! You’ll get farther, gain invaluable insights and support, and build new connections.
  4. Involve patients in the discussion.
  5. Gather data. Use it to inform improvements to your program.

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