The Community Cancer Screening Program (CCSP), operated by the Cancer Coalition of South Georgia, aims to increase cancer screening among low-income, underinsured, and uninsured patients aged 50–64 who access federally qualified community health centers in rural settings. The intervention’s approach is based on the patient navigation framework, which accounts for the cultural, socioeconomic, and other factors that create patient-, provider-, and system-level barriers to cancer screening and lead to cancer health disparities.
Questions and Answers
The Community Cancer Screening Program is designed for use in primary care settings, and is not recommended for adaptation in other community-based settings. The chart-auditing function of the program was designed for use in primary care settings with established electronic health record systems; however, it can be adapted for paper-based medical record systems, as well. While the Cancer Coalition employs professional navigators who are extensively trained to serve in this role, they are not licensed health professionals. However, the program can easily be coordinated by a nurse or nurse practitioner. Up to six contacts are usually needed to schedule a patient for colonoscopy screening, to coach him or her to ensure adequate preparation, and to conduct appointment reminder calls. Thus, it is important that the person who is responsible for navigating patients have adequate time to effectively perform these duties.
To effectively implement the program, one must have in place a well-trained navigator and the necessary resources to cover the costs of screening, follow-up testing, and treatment for the uninsured. Assembling a team of providers who are willing to provide care for the uninsured is the greatest challenge in implementing a colonoscopy-based screening program. It is helpful to have a physician champion or a high level hospital administrator assist you in gaining the necessary support of gastroenterologists and endoscopy centers, pathologists, surgeons and other specialists who are prepared to serve patients who may not be able to pay for care. Set expectations by providing assessment data to these stakeholders on the number of uninsured as well as insured patients expected to be referred for services. Also, it is important to share information on program costs for each stakeholder in language that is meaningful to them. For example, hospital administrators are concerned with return on investment. Therefore, point out what percentage of colonoscopy patients will have high-risk adenomatous polyps removed (in our experience about 30%), thus preventing many colorectal cancers from occurring, saving healthcare costs downstream. Among gastroenterologists, communicate costs and time estimates in terms that demonstrate a shared, and thus manageable, burden of care. For example, if you expect to screen 200 uninsured patients a year and have five gastroenterologists interested in participating in the program, ask that each of them perform 3 or 4 colonoscopies per month in-kind or at reduced costs (200 divided by 12 divided by 5 = 3.33). If your program will serve both insured and uninsured patients, discuss the potential impact of your outreach and promotion efforts on increasing screening among all patients, thus offsetting the costs of screening the uninsured.
Evaluation is an important part of the CCSP! To successfully implement this program, you’ll want to think about process evaluation, provider assessment and feedback, and tracking CRC screening rates.
Process evaluation: Your program should establish a master patient database to track where patients are in the process, including demographic data, date of last colorectal cancer screening (if any), personal or family risks, screening referral date, screening date, screening results, and recall schedule. The Cancer Coalition uses an Excel spreadsheet to track this information. You can use your database, along with the Quality Assurance Checklist for Colonoscopy Screening Navigation available from the Cancer Coalition, to make sure that the program is delivered as intended.
Provider assessment and feedback: Provider assessment and feedback is one of the core elements of the CCSP. You can read more about this evidence-based strategy on the Community Guide website. According to the Community Guide:
Provider assessment and feedback interventions both evaluate provider performance in delivering or offering screening to clients (assessment) and present providers with information about their performance in providing screening services (feedback).
In order to conduct this core element of the CCSP, you will need to have a system in place for assessing provider performance. You can use your master patient database to summarize weekly or monthly totals for CRC referrals and the number of completed screenings, abnormal polyps, and CRC diagnoses. In some practices, you may be able to use the EHR to generate reports about CRC referral and screening rates. Whatever your assessment method, you should plan ahead for how you will assess provider performance and how you will give feedback to providers about that performance. You can also use the feedback reports as part of your program evaluation.
Tracking CRC screening rates: Although not strictly necessary to deliver the CCSP, we strongly recommend that you track CRC screening and referral rates over time at participating clinics. This data will be useful in demonstrating to stakeholders the potential impact of the program. To do this well, you will need to establish a baseline screening rate. Tracking CRC screening rates over time will help you and your providers see the difference that the CCSP is making and may help you identify sites where the program isn’t working as well as expected. Without this information, it may be difficult to keep providers engaged, justify the resources needed for the program, or expand to new sites. Tracking clinic-wide CRC screening rates can also be a valuable part of your provider assessment and feedback program.
The most accurate way to assess CRC screening rates in most clinics is likely with a chart audit (included as a pdf at the bottom of this page). A chart audit involves pulling a number of charts for individuals eligible for CRC screening and reviewing each chart to determine the individual’s CRC screening status. This is what we did for the CCSP evaluation, and you can use our chart abstraction form as a tool for your own chart audit. (Note that the dates on this form apply to our study and will need to be changed to your own review period.) The ACS publication How to Increase Colorectal Cancer Screening Rates in Practice has more information on conducting a chart audit. It is important to distinguish patients at increased risk for colorectal cancer (e.g., history of adenomatous polyps or colorectal cancer—see section 2 of the CCSP chart abstraction form) from those at average risk and exclude increased risk patients from your baseline. This is because screening colonoscopy is appropriate every 10 years for those at average risk; however, those at increased risk, including those with symptoms, are more likely to be referred for surveillance colonoscopy at more frequent intervals or diagnostic colonoscopy. Including those patients will inaccurately inflate your “screening” baseline.
Some practices are already tracking CRC screening rates as part of UDS (Uniform Data System) or PQRS (Physician Quality Reporting System) reporting, and you may be able to access this information.
Some EHR systems have the ability to generate reports of CRC screening rates; however, for these reports to be accurate, information about colonoscopy screening for the past 10 years must be entered in the EHR as “structured data.” This means that the data has been entered in a way that the system can identify it in the database. While things like a physician’s note or a scanned copy of the colonoscopy results may work fine for a physician reading the EHR to provide individual care to her patient, they will probably not be captured in an automatic EHR report. You may also be able to get CRC screening rates from billing data, if the records contain primary care billing information, lab test and endoscopy procedures. The CDC publication Increasing Quality Colorectal Cancer Screening: An Action Guide for Working with Health Systems has more information about using EHR systems and billing data to assess CRC screening rates.
Kimberly’s research continues to focus on improving the health of marginalized populations. Her currently funded work maintains her longstanding interest in developing and evaluating culturally-sensitive interventions to improve public commitment to organ and tissue donation. She is principal investigator of a web-based donation education intervention targeting African Americans (WEb ACTS: About Choices in Transplantation and Sharing) and a large community-based study designed to encourage registration on the Georgia state donor registry among African Americans (Project Giving ACTS). Both studies seek to help participants move past long held religious and cultural barriers to organ and tissue donation.
In partnership with the Emory Prevention Research Center, Denise is conducting formative research for Healthy Homes for Cancer Survivors. This intervention will be designed to help rural and African American cancer survivors and their families create healthy home environments that support lifestyle behaviors to reduce cancer risk and improve quality of life.
For more information regarding these researchers, their biosketches are below:
Dr. Kimberly Jacob Arriola
Kimberly Jacob Arriola, Ph.D., MPH – Dr. Arriola is the Rollins School of Public Health (RSPH) Associate Dean for Academic Affairs and a Professor of Behavioral Sciences and Health Education in the RSPH of Emory University. She earned a MA in 1996 and a PhD in 1998 from Northeastern University (both in Social Psychology), and she earned a MPH in 2001 from Emory University (in Epidemiology). All of her work focuses on improving the health of marginalized populations and communities of color. Some of her research interests include HIV/AIDS among correctional populations, organ and tissue donation among African Americans, and breast cancer education and treatment support for underserved women in Atlanta. For example, for the past 12 years she has served as principal investigator of an NIH-funded project that seeks to develop and test a culturally-sensitive organ and tissue donation intervention for African American adults. Additionally, she has served as co-investigator for two national multi-site studies that seek to evaluate new services for HIV-infected jail and prison inmates transitioning from the facility to the community. Dr. Arriola has published numerous journal articles and co-edited a book on the health of incarcerated women. Dr. Arriola also teaches Research Methods to Masters’ students and Health Promotion Interventions to doctoral students in her department.
Denise Ballard serves as vice president for Cancer Prevention and Control at the Cancer Coalition of South Georgia, a non-profit organization committed to reducing cancer deaths across a 32-county, mostly rural region. Having earned a M.Ed. from Wayne State University in 2002, with a major in instructional technology, she brings more than 25 years of experience in cancer control program planning and health communication, with an emphasis on reducing cancer disparities. She has designed and implemented numerous evidence-based programs to increase cancer screening among the uninsured, reduce cancer risks, and improve quality of life among cancer patients. She also has served as the community-based partner in a number of research studies conducted by Wayne State University, the University of Wisconsin, and Emory University. She has collaborated on studies that explored information dissemination among cancer patients, cancer treatment decision-making, and environmental change to promote healthy lifestyles, and co-authored several peer-reviewed journal articles. After joining the Cancer Coalition in 2005, Denise served as the South Georgia coordinator for the Emory Prevention Research Center’s obesity prevention research program, and before assuming her current role she served as director for the Cancer Coalition’s Center to Reduce Cancer Disparities. Prior to joining the Cancer Coalition, Denise served as Partnership Program manager for the Midwest Region of the National Cancer Institute’s Cancer Information Service at Wayne State University/Barbara Ann Karmanos Cancer Institute.