Improving Colorectal Cancer Screening among PRIME population in Primary Care

1. Therese Chan Tack, DO MPH
Therese.ChanTack@ucsf.edu
Improving Colorectal Cancer
Screening among PRIME
population in Primary Care

2. Improving Colorectal Cancer Screening among PRIME population in Primary Care2
Problem Statement
Colorectal cancer (CRC) is the 3rd most commonly diagnosed cancer and 2nd
highest cause of cancer-related deaths in the US. Only 65% of Americans are
adequately screened despite CRC being highly treatable with early detection.
At UCSF Primary Care (UCPC), baseline CRC screening rates were lower
than more established care sites. Moreover, ~30% of our patients are Medi-Cal
PRIME eligible. These patients on average have higher medical complexity /
co-morbidities, and reduced access to preventative medical care.
Objectives
 Achieve HEDIS 90th percentile for CRC screening (Medi-Cal 2020 PRIME
program goal).
 Improve patient awareness, engagement and shared decision-making.
 Create a sustainable, interdisciplinary team approach to population
management team.

3. Improving Colorectal Cancer Screening among PRIME population in Primary Care3
Settings and Participants
 2 clinics: 10 triads of physicians, medical assistants (MA), practice coordinators
(PC); 3 nurse practitioners (NP), 1 panel manager (PM).
 Criteria: 50-75 years old, eligible per healthcare maintenance (HCM) banner.
Approaches
 Scaled outreach: EHR bulk messages / letters / calls. PM addition. FIT kit /
colonoscopy reminders.
 Personalized 1:1 follow ups to address patient specific concerns. HCM banner
notifications. NP expansion.
Techniques
 EHR data analysis: Identify patients’ screening preferences. Collate CRC data
sources. Create specific messaging templates (letters, order sets, forms).
 Quarterly workflow gap analysis.
 Flow charts / state transition diagrams: Clarify task ownership.
 Task specific tools / training: team training on screening guidelines.

4. Improving Colorectal Cancer Screening among PRIME population in Primary Care4
Figure 1: Work Flows and State Transitions
FROM TO SUGGESTED OWNER
(PRIMARY IN BOLD)
CRC ELIGIBLE PT CURRENT
PT NOT CURRENT
NP, PCP
PT CRC NOT CURRENT MYCHART DONE
PHONE DONE
PM, NP, PCP
PM, RN, MA
PT MYCHART DONE OR
PHONE DONE
FIT SENT
COLO ORDERED
PT DECLINED
PT UNREACHABLE
PM, MA
NP, PCP
RN > MA
RN > MA
PT FIT SENT PT FIT COMPLETE
PT FIT PENDING
NP, PCP
PM, MA
PT COLO ORDERED PT COLO COMPLETE
PT COLO PENDING
NP, PCP
PM, MA
Figure 2: State Transitions and Task-Owner Assignment

5. Improving Colorectal Cancer Screening among PRIME population in Primary Care5
Figure 3: All Population Colorectal Cancer Screening Rates
40.2%
42.2% 43.3% 41.9% 44.5%
45.1%
48.7%
54.4%
57.7% 59.4% 58.8%
60.8%
61.9%
63.1%
54.7%
56.0% 55.9% 56.4% 55.9% 55.8%
58.7% 58.9% 60.5%
61.4% 62.4%
64.3% 64.3%
64.4%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
7/1/16 8/1/16 9/1/16 10/1/1611/1/1612/1/16 1/1/17 2/1/17 3/1/17 4/1/17 5/1/17 6/1/17 7/1/17 8/1/17
NP Outreach
Expansion
Panel Manager
Addition
Project Start
Clinic 1
Clinic 2

6. Improving Colorectal Cancer Screening among PRIME population in Primary Care6
Figure 5: PRIME Population Colorectal Cancer Compliance Funnel
Figure 4: PRIME Population Colorectal Cancer Screening Rates
Identify CRC eligible population
EHR review
Filter population not CRC current
Per prior patient preferences
Bulk outreach
Schedule FIT,
Colonoscopy, Sig
CRC
current
Mychart, phone, in-person
Personalized follow up, Q&A
PRIME: 1877
Completed:
FIT: 650, Colo: 647, Sig: 30
Total: 1327 (70.7%)
Bulk MyChart:
~70%
Data cleansing
Our proven process
design has sustained and
exceeded HEDIS target.
Our project showed
almost 50:50 split between
FIT and Colonoscopy as
screening preferences.

7. Improving Colorectal Cancer Screening among PRIME population in Primary Care7
Results
 Overall population (PRIME + rest):
 Clinic 1, CRC screening rate increased: 41.9%  63.1%.
 Clinic 2, CRC screening rate increased: 56.4%  64.4%.
 PRIME population:
 UCPC achieved the FY2017 HEDIS CRC screening metric (65%).
 1327 PRIME patients attained CRC screening completion (70.7%).
Ripple Effects
 Applied our proven process design to other preventative care metrics.
 PRIME patients breast cancer screening increased: 68.7%  76.3%.
 PRIME patients cervical cancer screening increased: 64%  77.3%.

8. Improving Colorectal Cancer Screening among PRIME population in Primary Care8
Lessons Learned
 Parallel scaled outreach and personalized follow up sustainably improves care
quality with higher team / patient satisfaction.
 EHR serves as an effective avenue for population level outreach with its
repository of patient screening preferences.
 Staff screening guidelines education improves patient communication / decision
making.
 Clear task ownership assignments, tools standardization creates consistency in
staff’s care delivery.
Next Steps
 Use Panel Manager platform to target intermediate state bottlenecks.
 Segment patient populations into highest need.
 Incorporate CRC screening nuances (Colo-guard, sigmoidoscopy, CT).
 Coordinate screening efforts at community health fairs, FIT drop off (monthly),
FIT-Flu clinics (seasonal).

9. Acknowledgements: N. Jones MA, C. Kivlahan MD MSPH, M.
Martin MD, N. Yang, UCPC Care teams at China Basin and
Laurel Village, Office of Population Health, D. Sengupta.