1. This presentation was supported by Cooperative Agreement Numbers U48-DP001909, U48-DP001946, U48-DP001924, U48-DP001934, U48-DP001938(03), U48-DP001944, U48-DP001936, U48-DP001949-02, U48–DP001911, & U48-DP001903 from the Centers for Disease Control and Prevention. The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Shin-Ping Tu, MD, MPH ; Maria Fernandez, PhD, Vicki Young, PhD on behalf of the CPCRN FQHC Workgroup Investigators Emory UniversityUniversity of California Los Angeles University of ColoradoUniversity of South Carolina University of Texas HoustonUniversity of Washington Washington University at St. Louis Denver October 4, 2013 The Cancer Prevention and Control Research Network: Federally Qualified Health Centers Workgroup

2. CPCRN CHC Survey Align with CHCs’ missions Guided by real world health policy & health care delivery landscapes Health Care Reform Meaningful Use of EHR Patient-Centered Medical Home National Association of Community Health Centers (NACHC) Primary Care Associations Community Health Centers (CHCs)

3. CPCRN CHC Survey 3 Frameworks Patient Centered Medical Home (PCMH) Practice Change and Development (PCD) Model Consolidated Framework for Implementation Research (CFIR) Sections A -Clinician Staff Questionnaire (Transformed’s NDP) 23 item Practice Adaptive Reserve (PAR) Scale B - Primary CRC screening modality recommended at clinic C -4 Community Guide EBIs to increase CRC screening: Provider reminders, Patient reminders One-on-one education, Provider assessment and feedback EBI specific CFIR items D - 8 CRC screening best practices - NCQA PCMH standards How often performed best practices in past month E -Age, gender, race and ethnicity, languages spoken, number of hours/wk and years worked at clinic

4. CPCRN CHC Survey Convenience sample of CHC clinics from 7 states Completed May 30, 2013 327 providers, nurses, MAs, QI/operations staff Primary CRC Screening Test promoted in CHCs FrequencyPercent % Colonoscopy9229.11 Fecal Occult Blood Test (FOBT) - at home14445.57 Fecal Immunochemical Test (FIT) - at home7423.42 Sigmoidoscopy10.32 None51.58 Total316100 Missing Frequencies =11

5. Clinic Characteristics Survey - Content Patients served Uninsured, below poverty level, LEP, race/ethnicity Number of encounters Staffing - FTEs & shortages EHR Ease to generate information & accuracy of data PCMH best practices 8 Community Guide EBAs Provider reminder implementation Pressures, incentives, alignment with QI Feedback on CRC screening CDC funding of CRC screening program CRC screening reporting to outside organization Scores well – additional income/reimbursements/other rewards

6. CHC Clinic Characteristics Number of CHC Clinics (% Total) Number patients served in 2012 <5,000 5,000-20,000 >20,000-30,000 >30,000 17 (36%) 22 (47%) 3 (6%) 5 (11%) Number of clinics in CHC 1-2 3-5 6-10 >10 19 (38%) 18 (36%) 7 (14%) 6 (12%) Percent of patients uninsured <20% 20-50% >50-70% >70% 6 (13%) 21 (47%) 10 (21%) Percent of patients with limited English proficiency <10% 10-40% >40-60% >60% 18 (38%) 11 (23%) 8 (17%) 10 (21%) Respondents - CEO (6); CMO/Med Director (8); CNO/Nursing Director (3); COO/Clinic Operations Director (3); QI Director/Manager (11); Others (19)

7. CHC Staffing Shortages

8. Practice Change and Development Model Miller et al. Primary Care Practice Development: A Relationship-Centered Approach. Ann Fam Med 2010;8(Suppl 1):s68-s79.

9. Practice Change and Development Model Capability for Development Practice core Adaptive reserve Attentiveness to local environment

10. Robust Practice Core consistent performance & delivery of reliable primary care Miller et al. Primary Care Practice Development: A Relationship-Centered Approach. Ann Fam Med 2010;8(Suppl 1):s68-s79.

11. Practice Adaptive Reserve enhances resilience & facilitates adaptation and development Miller et al. Primary Care Practice Development: A Relationship-Centered Approach. Ann Fam Med 2010;8(Suppl 1):s68-s79.

12. Practice Adaptive Reserve Scores by State Scores are scaled so as to range from 0.00 to 1.00; 1.00 = perfect score of agreement StateNMeanSDMinQ1Q2Q3Max California280.600.230.020.460.650.780.96 Colorado520.660.180.260.520.660.781.00 Georgia250.710.190.240.630.730.831.00 Missouri40.650.060.580.610.650.690.73 S. Carolina190.680.170.210.600.650.771.00 Texas790.660.180.070.540.700.790.98 Washington890.660.150.210.570.680.750.95 Combined2960.660.180.020.550.670.771.00 National Demonstration Project - Highly-motivated practices w/ significant capability for change Mean baseline PAR score 0.69 (s.d. 0.35) Post intervention PAR score increased to 0.74

13. PCMH CRC Screening Best Practices (%) NeverRarelyOccasionallyUsuallyAlways Daily huddles, huddle sheets or checklists to go over scheduled patients who need CRC screening. 175 (59.1)8 (2.7)16 (5.4)54 (18.3)43 (14.5) Standing CRC screening orders or orders prepared by nurses/medical assistants then signed by providers. 167 (56.4)3 (1.0)17 (5.7)62 (21.0)47 (15.9) Tracking of patients who had CRC screening orders.140 (47.3)20 (6.8)22 (7.4)59 (19.9)55 (18.6) Tracking of patients who completed CRC screening tests. 129 (43.6)15 (5.1)23 (7.8)64 (21.6)65 (21.9) Tracking of abnormal CRC screening tests.104 (35.1)12 (4.0)13 (4.4)68 (23.0)99 (33.5) Referrals for diagnostic work-up of abnormal CRC screening tests. 57 (19.3)6 (2.0)23 (7.8)66 (22.3)144 (48.6) Tracking of diagnostic work-up completed by patients with abnormal CRC screening tests. 96 (32.4)9 (3.1)21 (7.1)69 (23.3)101 (34.1) Referrals to specialists for patients with abnormal colonoscopies. 52 (17.5)10 (3.4)26 (8.8)55 (18.6)153 (51.7)

14. PAR and PCMH Best Practices Score Respondent reported performing PCMH best practices “usually” or “always”

15. Adjusted Regression Analysis PCMH Best Practices and PAR PARPCMH Best Practices (0-32) Mean95% CI 0.08 – 1.0020.6817.51, 23.86 0.60 - <0.8015.8413.31, 18.36 0.00 - <0.6012.679.90, 15.44 PCMH Best Practices Mean Composite Score (0-32) Adjusted for state, age, job type, years worked at the clinic, hours worked each week Differences b/t PCMH BP Mean Composite Scores all statistically significant: 0.08 - 1.00 vs. 0.06 - <0.80 (p = 0.0013) 0.08 - 1.00 vs. 0.00 - <0.60 (p = <0.0001) 0.06 - <0.80 vs. 0.00 - <0.60 (p = 0.0155)

16. Adjusted Logistic Regression Frequency of PCMH Best Practices and PAR Scores PARFrequency of PCMH Best Practices (6-8 vs. 0-5) OR95% CI 0.08 – 1.005.492.31,13.06 0.60 - <0.802.231.11,4.47 0.00 - <0.60Referent PCMH Best Practices Dichotomized Score (6-8 vs. 0-5) Respondent reported performing PCMH best practices “usually” or “always” Adjusted for state, age, job type, years worked at the clinic, hours worked each week

17. Electronic Health Record Adoption N=50

18. Electronic Health Record Functionality CHC clinics that use EHR data to (a)-(d) CHC clinics that use EHR & can EASILY (a)-(d) Number (%) (n=43 to 45) Number (%) (n=37 or 30) (a) Create list of patient panels by provider 37 (84%)30 (81%) (b) Identify patients due or overdue for CRC screening 37 (82%)21 (57%) (c) Send reminders to patients when they are due for CRC screening 30 (70%)8 (27%) (d) Estimate CRC screening rates 37 (82%)23 (62%)

19. Electronic Health Record Accuracy *Primary source for reports or patient care decision **Need a secondary audit or cross check with additional documentation ***Would not use for reports or patient care decision

20. Summary In 3 months since survey concluded, we have identified: Partner CHCs have significant staffing shortages Positive associations of PAR with PCMH CRC screening best practices Room to go to fully and systematically implement Community Guide EBIs at participating clinics Associations of PAR and 10 CFIR constructs with implementation of Provider Reminders Limitations of EHR data

21. FQHC Survey Subgroup: Manuscripts MANUSCRIPT FOCUS LEAD SITE U CoEmoryUCLAUSCUT-HUWWU CFIR Measures/ Survey development*UTHxxxxXxx Survey results – Practice Adaptive Reserve (PAR)/PCMH Best Practices UWxxxxxXx Survey results – EHR/?PCMH Best PracticesUWxxxxxXx Survey results – Practice Adaptive Reserve/PCMH BP/Clinic characteristics ?UW Survey results – CG EBAs/Practice Adaptive Reserve TBD Survey results – CG EBA/CFIR measuresUTH/UCoXxxxXxx Survey results – CG generic EBAs/CFIR measures EmoryxXxxxxx ? Survey results – CG EBAs/Clinic Characteristics TBD Agreement b/t staff reports and clinic contact of CG EBAs/ PCMH Best Practices TBD

22. Acknowledgements Special thanks to: CPCRN FQHC Workgroup Team Alan Kuniyuki MS, Letoynia Coombs PhD Allison Cole, MD, MPH Jim Hotz MD Kathleen Clark CHC contacts Survey respondents Contact Information: shinping@uw.edushinping@uw.edu This work was also supported by National Cancer Institute grants R21 CA 136460 and R01 CA124397