This woman made an appointment to see the doctor for one specific health concern -- a cold. In this appointment, the doctor treated her only for a cold. What you can’t see is that this woman has other health concerns – she wants to start using a family planning method – but she thinks she needs to make a separate appointment, so she doesn’t ask the doctor about it. The patient is also overweight, which the MA noted on her chart before the doctor entered the room, but the doctor worries that bringing it up might make the patient uncomfortable, and anyway, she doesn’t have time to order a pre-diabetes test. So she only treats her for the cold.Systematic screening addresses this situation. It has been successfully tested in developing countries and is considered a best practices in global reproductive health programs. It has been found to detect unmet needs (and thus, improve patient health) and simultaneously improve clinic efficiency by addressing multiple needs in a single visit.
Now for the first time, systematic screening is being tested in the United States. In this study, Golden Valley Health Centers (GVHC) of central California is collaborating with the Institute for Reproductive Health at Georgetown University to determine if systematic screening is feasible and effective in an underserved population in the United States. GVHC provides comprehensive primary medical care to Central California’s San Joaquin Valley through a network of 25 clinics. GVHC serves an ethnically diverse population, including migrant and seasonal farm workers, Southeast Asian refugees, and the homeless. This study provides a unique opportunity for diffusion of innovations from the global south to the U.S. If successful, it has the potential to significantly improve the health of underserved populations throughout the country.
In this study, we are integrating family planning counseling with diabetes care and other services. So the idea is that by using a systematic screening checklist we will:-increase use of FP services-increase use of STI screening & treatment-increase diabetic screening & counseling-improve clinic efficiency by increasing the number of services provided in a single visitOVERALL: to improve patient health outcomes (though the intervention phase of this study is too short to enable us to determine that)
GVHC primarily serves low-income Latinos (77%). This is a population with disparities in diabetes, obesity, and unintended pregnancy. Obese and diabetic women have worse pregnancy outcomes and require more intensive prenatal care than non-diabetic women. The best way to increase the chances for a healthy pregnancy and baby among diabetic women is through planned pregnancies and preconception counseling. This includes using FP methods to postpone pregnancy until glucose levels are controlled.
Systematic screening is a standardized set of questions – usually just a few yes/no questions – to identify each patient’s need for services. In our case, we are looking for needs in 4 areas (weight management, diabetes, FP, and STIs).If there is an identified need, the clinician offers the corresponding services during that same visit. If there is a service that cannot be provided immediately, the clinician provides a referral or makes an appointment for a future date. This is the systematic screening tool we developed based on formative research with clinic staff and patients, and in-use testing.
Eligible patients include:-18+ years old-Not pregnant
We are using a pre/posttest experimental design which compares results in four intervention clinics with matched control clinics. Baseline and endline measures include patient surveys, chart reviews, and provider interviews. Service statistics are used to monitor services provided per visit. During the implementation of systematic screening, provider shadowing was conducted to assess intervention fidelity. We have also collected cycle time analysis to determine whether the intervention has any influence, positive or negative, on clinic efficiency.During the first year of this study, formative research was conducted, the systematic screening approach was designed and baseline data was collected. The intervention was tested over a three-month period last year and we are currently completing collection and analysis of the endline data.
Baseline results show that about half of patients expressed a desire for additional services and one quarter received them. The top reasons for not receiving the services they desired were that they didn’t ask for the service, were not aware they could request an additional service or simply planned to make an appt. in the future. (about 10% each).The services patients were most interested in were nutrition and weight loss counseling, diabetes information and birth control.
26 interviews were conducted with GVHC staff (front and back office, clinicians and health promotion personnel)It to assess their understanding of the SS intervention, obtain their ideas on what worked well and what did not and gather their recommendations for moving forward. Staff found the tool attractive and user friendly, but some were unsure whether it was meant only to remind them to ask questions or to show to the patients. Staff appreciated the BMI chart and the legitimacy it provides for broaching conversations on sensitive topics. As seen in other settings around the world, fidelity to the intervention posed a challenge. One MA said, “Keeping this going was hard when you guys weren't around. I'd forget that the tool was even in the chart.
Staff were asked to discuss the benefits of the tool and some of the challenges they faced implementing the tool. Staff commented that SS raised awareness of available services and improved provider-patient communication. A few clinicians, however, felt that they already offered multiple services, so it is not needed. Staff found implementing SS challenging due to high patient volume and lack of private space, especially in high volume clinics. One MA commented, “If you have time, you'll slip it in, but when it's just me and the provider is waiting I can't do it. With a stack of charts waiting it's just impossible. Staff found administering the tool at repeat visits a problem because patients became impatient when asked the screening questions on subsequent visits. Difficulty getting patients in for additional services was also identified as a problem. For example, health educators, who provide weight and nutrition counseling, were not available for same day appointments and had few open appointment slots.
-Even though the systematic screening tool is a simple tool, it is challenging to integrate it into existing processes, across multiple systems. -In addition, GVHC transitioned to EMRs during the project period, which diverted attention from this intervention, as staff were being trained in the new EMRs. This has implications for fully integrating systematic screening into services. -Staff motivation waned somewhat throughout the intervention period. Supportive supervision and monitoring helped, but was difficult to maintain, due to competing clinic demands. - The new skill of asking the systematic screening questions about sensitive topics including weight and STI risk was a departure from the typical job function of the MA. For some, this was welcomed, as they became for fully incorporated into the health care team. Others felt it was an additional task that they were not prepared for, and needed additional training and time to practice questioning skills.Would integrating screening questions into EMRs improve implementation? Are there other ways to encourage providers to implement the strategy?
What have we learned thus far? -We know that participatory formative research with providers and patients is key to developing a relevant screening tool. Incorporating staff and clinician input was also important in achieving compliance with screening procedures. -Patients would like integrated services and in-reach strategies like systematic screening may increase service utilization.-ImplicationsSystematic screening is a client-centered, holistic approach to care that has the potential to increase service utilization and improve clinic efficiency. This is the first time systematic screening has been tested in the US, providing a unique opportunity for South-to-North diffusion to improve health outcomes and ultimately address U.S. health disparities. Effective practices from the global south have the potential to significantly contribute to improving health outcomes in U.S. settings facing similar constraints.
Kimberly, Felicia, Rosa
Systematic Screening: Applying lessons learned from an international best practice to a rural U.S. setting
Systematic Screening: Applying lessonslearned from an international best practice to a rural U.S. setting Felicia Batts, Miranda Beckman, Irit Sinai Kimberly Aumack-Yee, Rebecka Lundgren
South-to-North diffusionIs systematic screening feasible and effective inunderserved populations in the US ?
Integrate family planning Increase use of FP services Increase use of STI screening & treatment Increase diabetic screening & diabetes care counseling Improve clinic efficiency by increasing the number of services provided in a single visit
Why Diabetes & Family Planning?disparities Diabetes Obesity Unintended pregnancy
Screening Process • Affixes patient encounter labelFront desk • Asks screening questions, documents responses Medical Assistant • Calculates BMI • Reviews completed checklist • Provides indicated service(s) and marks when Clinician completed • Refers for health education and lab tests • Provides education/counseling or lab testHealth Ed/ • Marks if service was provided Lab • Schedules future visitsFront office • Files completed checklist
Study Design YEAR 1 YEAR 2 YEAR 3 Intervention Formative Endline and Fidelity Research Research Research• Client exit interview • Client chart audit • Client exit• Provider/staff in- • Client shadowing interviews depth interview • Provider/staff in-• Client in-depth depth interview interview • Client chart audit• Client chart audit • Service statistics • Cost effectiveness analysis
Results: Baseline Exit Interviews (n=1003) 48% of patients desired additional services Patients 24% received additional expressed services interest in: Top reasons for not obtaining nutrition (30%) these services diabetes (23%) Didn’t tell their provider (10%) birth control Not aware could request (9%) (20%) Planned to make appt. in future (8%)
Assessing Intervention FidelityShadowed 22 Patients:From initial patient intake toexit 4 Intervention Sites Patterson= 6 patients Hanshaw=5 North Merced=7 Modesto Women’s=4 Observational Checklists to Document Performance Front office staff Back office staff (Medical assistants) Clinician providers 17 women 5 men
Shadowing Results: Staff Performance Front Office Staff: Very good compliance, 100% administered SST Areas for improvement: Thank patient for visit and schedule referrals Back Office Staff: Good compliance, 100% completed SST Areas for improvement: Ask sensitive questions regarding family planning and STI services Clinician Providers: 91% (20/22) reviewed the SST Areas for improvement: Review the SST for optimizing the visit by increasing the number of needed services, offer indicated additional services (or refer) within the time constraints of an office visit
Shadowing Results:Opportunities for Additional Services Additional Services Missed Opportunities for Provided Additional Services18 Family planning=516 STI services = 314 Diabetes services= 21210 Weight management= 0 8 6 BMI Values 4 82% (18/22) of patients had BMI ≥25 2 64% (14/22) had one or more risk factors 0 for diabetes BMI as a trigger for weight management counseling and diabetes counseling and testing
Results: In-Depth Interviews with Staff (n=26) Tool is an attractive, user friendly, learning aid: But staff unsure whether it is for their own use or to share with patients. “People like looking at the pictures when I am explaining it. They are curious about BMI because they are overweight and can create goals.” Facilitates difficult conversations: BMI chart provides legitimacy. Weight identified as a sensitive issue. “It gives me more permission to cross that threshold.” Continued implementation was a challenge. “At the beginning I felt like it went pretty well, but toward the end it wasn’t getting filled out. It kind of faded away.”
Staff Perceptions of Benefits andChallengesBenefits Challenges Sensitizes Patient volume patients to their Confidential space needs Additional work Lets patients Repeat patients know they can Difficulty request multiple scheduling services additional services Helps clinicians understand
What next? Complete analysis Consider the effectiveness , feasibility and value of systematic screening to GVHC If results are favorable, fine-tune strategy Test revised approach and begin phased scale-up Disseminate results
Challenges and Considerations Complexity of How can integration implementation be improved? Transition to EMRs Better integration? Maintaining Including prompts in motivation EMRs? Competing demands New role for MAs
Client-centered, holistic approach Improve clinic efficiency Increase service utilization South-to-North diffusion Reduce U.S. health disparities