1. Colorectal Cancer Screening: 2014 Change in methodology from previous years. 2011 and 2013: administrative (claims) data only, rate per 1,000 mm. 2014: hybrid (administrative data + medical record review), percentage. 2014 data are not comparable to earlier years. Benchmark established by Committee, based on high performing FQHCs in Oregon. Oregon QHOC - July 2015

2. Colorectal Cancer Screening: Comparative data Oregon QHOC - July 2015

4. Next steps OHA will publish 2015 chart review guidance document this summer. Metrics & Scoring Committee to determine if colorectal cancer screening will continue as incentive measure in 2016 in their July meeting. If continuing as incentive measure, Committee will revisit benchmark for 2016. Oregon QHOC - July 2015

5. Key messages – Consider your screening approach – Understand your population – Make continual improvements – Assure follow-up care

6. Colorectal Cancer statistics for Oregon Stage of CRC detection* CRC screening disparity* *Source: Oregon State Cancer Registry *Source: Behavioral Risk Factor Surveillance Survey

7. Free FIT vs. Free colonoscopy program Study included uninsured patients aged 54-64 at the John Peter Smith Health Network, a safety net health system. Randomized patients into 3 groups: – Free FIT (n = 1593) – Free colonoscopy (n = 479) – Usual care (n = 3898) Gupta et al. JAMAIM 2013

8. Mailed FIT programs are effective Type of clinic interventionEffect sizeN studies Direct mailed fecal tests 5.8% - 24%4 Telephone reminders NS – 6.1%3 Decision support tool NS2 Patient navigation9.5% - 18.8% 6 Flu FIT16.3%1

9. Legislative update 2014 OR passed legislation that requires insurance companies to treat to colonoscopy as a screening colonoscopy, even if polyps are removed. This means that patients who go in for a screening colonoscopy will not be surprised by co-pays and deductibles. 2015 OR passed legislation that requires insurance companies to not impose patient co-pays or deductibles for follow-up colonoscopies when a FIT test is positive. This means to there is no financial barrier to follow-up colonoscopy for insured patients.

10. Questions? Gloria D. Coronado, PhD Kaiser Permanente Center for Health Research Gloria.d.coronado@kpchr.org

11. Colorectal Cancer (CRC) Screening – Promising Practices in Implementing Evidence-based Interventions Facilitator: Melinda M. Davis, PhD Director of Community Engaged Research, Oregon Rural Practice-based Research Network (ORPRN) Research Assistant Professor, Department of Family Medicine QHOC Meeting * July 13, 2015 * Salem, OR

12. Colorectal Cancer (CRC) Screening – Promising Practices in Implementing Evidence-based Interventions Facilitator: Melinda M. Davis, PhD Director of Community Engaged Research, Oregon Rural Practice-based Research Network (ORPRN) Research Assistant Professor, Department of Family Medicine QHOC Meeting * July 13, 2015 * Salem, OR

13. Panelists Tran Miers, RN – Clinical Programs Director – Virginia Garcia Memorial Health Center Daisuke Yamashita, MD – Medical Director – OHSU Family Medicine at South Waterfront – Assistant Professor OHSU Department of Family Medicine Coco Yackley – Operations Manager – Columbia Gorge Health Council (Pacific Source Columbia Gorge CCO) Kevin Heidrick, PA – Regional Medical Director, Associate Medical Director for Utilization Management – Yakima Valley Farmworkers

14. Session Overview Quick Orientation – Test options, screening targets – Evidence-base – Now what? Panel Q&A Discussion (40 min) Small Group Activity (20 min) Large Group Debrief (10 min) Next Steps (5 min)

15. QUICK ORIENTATION

16. CRC Screening Options The US Preventive Services Task Force (USPSTF) recommends regular CRC screening between 50- 75 using: High-sensitivity fecal occult blood test (FOBT) annually Flexible sigmoidoscopy every five years with FOBT every three years. Colonoscopy every 10 years

17. CRC Screening Targets Oregon Health Authority: – 47.0% for 2015, TBD for 2016! National Colorectal Roundtable – Coalition of 70+ public, private, and voluntary organization – Led by American Cancer Society and Centers for Disease Control and Prevention – Goal: Increase the use of CRC screening tests among the population for whom screening is recommended.

18. Evidence-based CRC Screening Interventions Findings synthesized from three systematic reviews (Holden et al 2010; Brouwers et al 2011; Sabatino et al 2012) LevelEffectiveMixed/Insufficient/Not Reported Patient Patient reminders (5-15%) One-on-one interactions (14.6-41.9%) Reducing structural barriers – e.g., mailing FOBT/FIT (14.6-41.9%) Small media Mass media Group education Reducing out-of-pocket expenses Client incentives Provider Assessment & feedback Provider reminders Provider incentives Health System or Community Improving referral patterns or introducing patient navigators (7-28.2%)

19. Not What, How?? “The research priority is to design and test interventions to increase screening and CRC screening discussions, building on the effective approaches identified…and tailored to specific population needs.” Holden et al (2010) Enhancing the Use and Quality of Colorectal Cancer Screening AHRQ Evidence Report/Technology Assessment

20. Panelists Tran Miers, RN – Clinical Programs Director – Virginia Garcia Memorial Health Center Daisuke Yamashita, MD – Medical Director – OHSU Family Medicine at South Waterfront – Assistant Professor OHSU Department of Family Medicine Coco Yackley – Operations Manager – Columbia Gorge Health Council (Pacific Source Columbia Gorge CCO) Kevin Heidrick, PA – Regional Medical Director, Associate Medical Director for Utilization Management – Yakima Valley Farmworkers

21. PANEL DISCUSSION

22. Question 1 Briefly describe your practice/CCO setting and your role within this context (particularly in relation to CRC screening improvement).

23. Question 2 What is your practice/CCO doing to improve colorectal cancer (CRC) screening? – Why did you choose to implement this intervention? – When did you start doing this work? How has your approach changed over time? – What resources have you used to implement this/these interventions? – Is it working?

24. Question 3 What is your ideal vision for improving CRC screening in your practice/CCO moving forward?

25. Question 4 What advice would you give other practices/CCOs that are working to improve CRC screening rates? – How would your advice differ for those actively implementing CRC screening interventions versus those considering the options?

26. THANK YOU PANELISTS!

27. Small Group Discussion Break into four small groups Discussion questions: – What is your practice/CCO currently doing to enhance CRC screening? – What CRC screening interventions did you hear about today that you might try in your practice/CCO?

28. Large Group Debrief Come back together! Report out by small group facilitators (1 min) Group comments, thoughts Final remarks – Gloria Coronado, PhD – Melinda Davis, PhD

29. Next Steps Next QHOC Meeting – Date: September 14 th, 2015 – Topic: Traditional Health Workers Before you leave: Please complete today’s session evaluation

30. OHSU FM AT SOUTH WATERFRONT PANEL MANAGEMENT Daisuke Yamashita MD

31. Panel ManagerMAClinician HM Room Pt, Review HM Pend orders Sign orders Perform orders Update HM modifiers EHR reminder placement/ Other specific reminders in the schedule Discuss HM Review Schedule Reach In

32. Panel ManagerClinicianNurse visitLab/Image/Consult Reach Out Review Pt’s Charts/reports Place appropriate Reminder Review and co- sign orders Contact Pt (My Chart, letter, phone) Clinic Visit (ie: Colon Cancer Screen shared decision) Place orders and sign Arrange Orders Nurse visit (Labs, immunizations) Tests/Consults (ie: mammogram, eye visit) Pt message regarding HM “Aha!” Identify All Appropriate gaps for each pts (all shots!)

33. Colorectal Cancer Screening Registry Quarterly Reports

34. Colorectal Cancer Screening Registry Quarterly Reports