CommunityHealthBecause No One Should Go Without

Healthcare

Cancer Screening Quality Improvement

in a Free Clinic Setting

MissionServing those without essential health

care

Vision: Delivering healthier communities

About Us

Founded in 1993, CommunityHealth is the largest volunteer-based health center in the nation.

We provide free medical and dental care, prescription medications, mental health services and health

education classes to low-income, uninsured residents of Chicago and the surrounding metropolitan area

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LocationsLederman Family Health Center

2611 W. Chicago Ave.Chicago, IL 60622

Englewood Health Center641 W. 63rd St.

Chicago, IL 60621

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Our Patients• Adults who have no health insurance and live at

or below 250% of the Federal Poverty Level ($60,625 for a family of four)

• Fall through the cracks of our health care system, despite the reforms of the Affordable Care Act

• Many are also:

• From working households that do not qualify for Medicaid and can’t afford to purchase insurance

• Living with – or at risk for – chronic conditions like diabetes and hypertension

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Our Services• In 2014, we provided over 21,000 medical and dental

visits to more than 11,000 patients

• Primary Care• Specialty Care• Lab Work• Medications• Dental Care

• Health Education• Social Services/Mental Health

• No fee is ever charged for any services. 6

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Overview1. What are the recommendations?2. What resources do we have access to?3. How are we doing right now? – Benchmarks4. What are the challenges/limitations?5. How can we make improvements? – process

mapping, targeted QI6. How do we measure success?

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Breast Cancer Screening

• Breast cancer is the second leading cause of cancer death in women, second only to lung cancer.

• Survival rates with early detection are high.

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What are the recommendations?

ACS = Yearly mammograms at age 45-55, every other year thereafter. ACOG = Yearly mammograms beginning at age 40.

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USPSTF = Biennial Screening mammography for women 50-74 years.

http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-acs-recshttp://www.acog.org/About-ACOG/News-Room/Practice-Advisories/ACOG-Practice-Advisory-on-Breast-Cancer-Screening http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast-cancer-screening

What are our resources? • IBCCP – Illinois Breast and Cervical Cancer

Program Live in Illinois No insurance 35-64 years of age

• Current Partnerships:Saint Mary of Elizabeth (IBCCP) Northwestern MemorialMercy Hospital (IBCCP) Swedish Covenant

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What are our limitations and challenges?

• Patient education/health literacy• Language barrier• Transportation• Scheduling • Fear of being billed for services• Patient follow up / Return to Clinic• Limited funding through IBCCP Partners

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How are we doing? What benchmarks should we use for comparison?

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2014 Avg

1st Qtr 2015

2nd Qtr 2015 Uninsured2 Medicaid1 Medicare

HMO1Medicare

PPO1

Breast Cancer

48% 46% 45% 39% 52% 70% 68%

1 The National Committee for Quality Assurance (2013). Continuous Improvement and Expansion of Quality Measurement: The State of our Health Care Quality 2013. www.ncqa.org/Portals/0/Newsroom/SOHC/2013/SOHC-web_version_report.pdf2 National Center for Health Statistics (2011). 2010 National Health Interview Survey public use data release. US Department of Health and Human Services, CDC, National Center for Health Statistics. ftp://ftp.cdc.gov/pub/health_statistics/nchs/dataset_documentation/nhis/2010/srvydesc.pdf (cancer data)

How can we improve?

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Breast Cancer Screening Assessment Questions Responses1. Who is responsible for identifying patients dues for screening? How are patients identified (registry)? Does the capacity exist to pull report if not doing so currently?

The provider or nurse is responsible for identifying patients due for screening. Volunteer reviews upcoming appointments, and add notes to chart for nurses regarding patient screening. There is a quality manager tracker in the EMR system.

Opportunity #1: Monthly pulling a report for all patients ages 50-75 who are due or overdue for screening.

2. How are patients reached with screening reminder? appointment reminders? recall/overdue reminders? Who is responsible to execute?

The hospital sends reminder to patients of screening due. If the patient is due and comes into the clinic, they will be referred to the hospital for an annual follow up.

Opportunity #2: CommunityHealth sends screening reminders to all eligible patients who are due or overdue for screening

3. At visit check in, does front line staff remind patient of screening? How are new/walk in patients handled? Front line staff does not remind patients of screening (they may not know how to have this conversation with patients). New patients fill out form that shows they qualify for services and a health questionnaire. Front desk enters the info into the patient's chart. Often providers will wait for the second appointment to perform pap smear and breast exam/referral.

Opportunity #3: Utilize "Health Card Kits" at patient registration/check-in stations to prompt front office staff to remind patients of screening

Opportunity # 4: Create an office policy for screening to ensure that this recommendation is delivered to each and every age-appropriate patient. (This policy should be based on national screening guidelines, the realities of your practice, patient history and risk level, patient insurance coverage, and local medical resources)

4. Are patient records flagged to remind providers of need to recommend screening? Are EMR alerts turned on? Do staff routinely take action on the alerts?

Patient records aren't flagged, but providers do have a chart review and typically review the quality management tracker prior to the patient's appointment. Typically the PCP will follow up on all action items within the quality management tab.

5. Which staff member(s) is responsible for making the recommendation to get screened? The provider or nurse is responsible.

Opportunity #5: Provider Assessment and Feedback: Evaluation and sharing of provider performance in offering or delivering screening Confirmations accumulated over twodecades show that a recommendation from a doctor is the most powerful single factor in a patient’s decision about whether to obtain cancer screening. While other factors also have impact (including health beliefs, social influences, insurance, and access to care), for those who have a doctor, the doctor’s advice is the single most persuasive factor.

6. Do you use a breast cancer risk assessment? Who completes? Is family history taken? No, a breast cancer risk assessment is not used. Sometimes a provider will take family history, but typically no. A risk assessment will be calculated within the patient's results from the hospital after the first mammogram.

Opportunity #6: Update existing new patient registration form that includes family and patient history for breast and colorectal cancers.

7. What patient education occurs? Are patient education materials provided? The patient education that occurs is, at this juncture, more patient driven. If the patient is due for a mammogram, they get referred. We advise patients that they are being referred for a breast cancer screening. More educational materials are needed around the clinic to enforce education and why this screening is important.

Opportunity #7: LPN or MA to provide one-on-one education on the importance of breast cancer screening. Give patients small media (brochures, videos) that will reinforce these messages. According to the Community Guide one on one education and small media are effective evidenced based interventions for increasing breast cancer screening rates.

8. How is the mammogram ordered? Are there standing orders? The mammogram is ordered through EMR and a paper referral. Yes, there are standing orders.

9. How are patients reminded of their screening appointment? When does the reminder take place? Depending on the referral location, either the patient is called by the hospital (majority of cases), the clinical coordinator, or the nurse. The reminder is dependent on the hospital that the patient was referred to but is typically about one month or less leading up to the actual annual due date.

10. How do you verify if a patient completes their screening? How is the screening completion documented? Who documents? In EMR?

Patient screening completion is not verified, unless the hospital sends the results (most do outside of one hospital which only sends abnormal results), or the patient returns with the results. The hospital fax of the result is put directly into the patient chart, or it is uploaded by Sylvia.

11. How are patients informed of results (call, letter)? No findings? Positive finding? Who contacts? Within what time frame of processing?

The hospital sends a letter to the patient of results within less than a month of test with all types of results.

12. Are there formal referral relationships in place with specialists? Hospitals? (What are the institutions for which you have a formal relationship?) Different for insured vs. uninsured patients?

Yes, there are formal relationships in place. Community Health has relationships with the IBCCP at Mercy and Saint Mary Hospital. Relationships are also in place with Swedish, Erie Family Health Center (West Town), and Northwestern Hospitals. Community Health only serves uninsured patients.

13. Who schedules follow up appointments for positive findings? The hospital sends a letter to the patient of results within less than a month of test. The nurses ensure the patient has been scheduled with the hospital for a follow up as well as the clinic to discuss positive results with the patient's PCP.

14. How are patients reminded of diagnostic screening? When (# of days)? The hospital reminds patient of diagnostic screenings; typical follow up is about one week but dependent on the facility. If a patient has a 6 month follow up, the women's health nurse places another referral at 6 months so the patient can return to the same facility for the diagnostic screening follow up.

15. How do you verify if patient completes a diagnostic screening? Laura tracks the patient to verify that they received diagnostic screening.

16. Who communicates diagnostic results to patient? Phone or letter? Within what timeframe? The Hospital or Laura communicates diagnostic results with the patient. Often times, the results are sent to the patient directly or if possible, advised to the patient immediately following the diagnostic procedure. If the hospital cannot call the patient with results, Laura will call the patient to advise and recommend follow up.

17. How are diagnostic results communicated back to clinic? Are they captured in EMR? Is it a data field that can be collectively pulled in a report?

The hospital sends the report to the clinic and it is scanned directly into the EMR system. Laura reports on all results monthly including diagnostic findings.

18. Who refers/schedules appointments with specialists if cancer found? The hospital typically schedules appointments with oncology if cancer is found.

19. If cancer is found, who confirms that patient has appropriate continued medical care? The hospital coordinates continued medical care along with followup from CommunityHealth.

20. How is patient's ongoing care communicated between systems? Frequency? Sometimes there is no communication between the systems, as the patient is considered a patient of the hospital after cancer diagnosis.

21. Is there a survivorship care plan put in place in conjunction with the oncology team? Is there any data on % of patient population that are survivors?

There is no survivorship care plan in place as the patient is typically seen by the hospital after cancer diagnosis. Currently about 1% of patient population with a history of cancer.

Opportunity # 8 E-survivorship e-learning series for Primary Care Providers

How can we improve? Process Mapping Opportunities:

1. Monthly report for all patients ages 50-75 who are due for screening – reminders to providers in Reason for Visit section of EMR

2. Screening reminders to all eligible patients who are due for screening3. Utilize “Health Card Kits” as patient registration/check-in stations to prompt front

office staff to remind patients of screening4. Create an office policy for screening to ensure that this recommendation is

delivered to each and every age-appropriate patient – nursing standing orders5. Provider Assessment and Feedback: Evaluation and sharing of provider

performance – Leaderboards, Provider Huddles, and individual provider quality management reports

6. Update existing new patient registration form that includes family and patient history for breast and colorectal cancers – already done

7. MA or RN to provide one-on-one education on the importance of breast cancer screening, including small media to reinforce education as needed – intensive “high touch” model of patient outreach and follow-up

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Quality Measures Reminders in the EMR

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Leader Boards

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Individual Provider Quality Management Reports

How do we measure success?

1 The National Committee for Quality Assurance (2013). Continuous Improvement and Expansion of Quality Measurement: The State of our Health Care Quality 2013. www.ncqa.org/Portals/0/Newsroom/SOHC/2013/SOHC-web_version_report.pdf2 National Center for Health Statistics (2011). 2010 National Health Interview Survey public use data release. US Department of Health and Human Services, CDC, National Center for Health Statistics. ftp://ftp.cdc.gov/pub/health_statistics/nchs/dataset_documentation/nhis/2010/srvydesc.pdf (cancer data) 19

1st Qtr 2015

2nd Qtr 2015

3rd Qtr 2015 Nov 2015 Uninsured2 Medicaid1

Breast Cancer 46% 45% 48% 50% 39% 52%

Colorectal Cancer Screening

Colorectal cancer incidence and mortality disproportionately effect minority populations.

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What are the recommendations?Starting at 50 and continuing through age 75.

ACS - Tests that detect polyps and cancer (flex sig or colonoscopy) are preferred if available and patient is willing to have them.

ACG - Colonoscopy preferred, but recognize that colonoscopy is not available in every setting due to economic limitations and not all eligible persons are willing to undergo colonoscopy. In these cases, patients should be offered an alternative prevention test (flex sig) or a cancer detection test (fecal immunochemical test).

USPSTF - Because several screening strategies have similar efficacy, efforts to reduce colon cancer deaths should focus on strategies that maximize the number of individuals who get screening of some type.

www.cancer.org/cancer/colonandrectumcancer/moreinformation/colonandrectumcancerearlydetection/colorectal-cancer-early-detection-acs-recommendationsgi.org/guideline/colorectal-cancer-screening/www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/colorectal-cancer-screening 21

What resources do we have?• Total patients age 50-75 (seen in past year) = 1,624• Total colonoscopies per year = 200 available• Total flex sigs = 100-200 per year (vol dependent)• Fecal Immunochemical tests = 1000 available (new in

2014, previously FOBT)

Limitations:• Patient willingness to do scope• Providers able/willing to do flex sigs

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Original Approach to Screening• Started in 2006• Average Risk = FOBT + flex sig• High Risk = colonoscopy

• Result = hundreds of patients on waitlist for well over a year and many patients resistant to colon cancer screening.

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How are we doing - 2013?Benchmarking

Year end 2013

Uninsured nationally2

Commercial HMO1

Commercial PPO1

Medicare HMO1

Medicare PPO1

Screening rate 47% 21% 63% 56% 62% 58%

1 The National Committee for Quality Assurance (2013). Continuous Improvement and Expansion of Quality Measurement: The State of our Health Care Quality 2013. www.ncqa.org/Portals/0/Newsroom/SOHC/2013/SOHC-web_version_report.pdf2 National Center for Health Statistics (2011). 2010 National Health Interview Survey public use data release. US Department of Health and Human Services, CDC, National Center for Health Statistics. ftp://ftp.cdc.gov/pub/health_statistics/nchs/dataset_documentation/nhis/2010/srvydesc.pdf (cancer data)

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Tiered approach to maximize resources

• Average risk patient = Fecal Immunochemical Test (FIT)

• High risk patient = colonoscopy– Family history of colon cancer – Previous colonoscopy with tubular adenoma or carcinoma– Positive FIT screen

• Flex sig used for diagnostic evaluation of low risk patients with anorectal symptoms or chronic diarrhea

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What else is needed to improve?A test is only useful if patients receive it, understand it, and complete it.

Strategies:• Intensive provider education – scheduled huddles• Quality Measures reminders in EMR• Staff education – how to instruct patients on test• Nursing standing orders• Intensive outreach following test kit distribution = 75% return rate!• Paid postage for mailing test back to clinic• Targeted campaigns – FluFIT

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Measuring Success

1 The National Committee for Quality Assurance (2013). Continuous Improvement and Expansion of Quality Measurement: The State of our Health Care Quality 2013. www.ncqa.org/Portals/0/Newsroom/SOHC/2013/SOHC-web_version_report.pdf2 National Center for Health Statistics (2011). 2010 National Health Interview Survey public use data release. US Department of Health and Human Services, CDC, National Center for Health Statistics. ftp://ftp.cdc.gov/pub/health_statistics/nchs/dataset_documentation/nhis/2010/srvydesc.pdf (cancer data) 29

Year end 2013 Year end 2014 Year to date 2015

Screening rate 47% 49% 54%

Year to date 2015

Uninsured nationally2

Commercial HMO1

Commercial PPO1

Medicare HMO1

Medicare PPO1

Screening rate 54% 21% 63% 56% 62% 58%

Summary

• Select recommendations keeping in mind what is realistic given resources available.

• Maximize screening resources via institutional and corporate partnerships.

• Use benchmarks to gauge current performance.• Utilize process mapping to identify limitations and

challenges and develop targeted QI• Think outside the box.• Measure success!!

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Questions?

Laura Sheffner, MSN, RN Emily Hendel, MSN, CNPlsheffner@communityhealth.org ehendel@communityhealth.org(773) 969-5926 (773) 969-5941

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