1. 80% by 2018 Forum: Increasing CRC Screening Rates 80% by 2018 Forum: Increasing CRC Screening Rates Implementing a Quality Screening Navigation Program Implementing a Quality Screening Navigation Program Lynn Butterly, MD Lynn Butterly, MD Director, Colorectal Cancer Screening Director, Colorectal Cancer Screening Dartmouth Hitchcock Medical Center Dartmouth Hitchcock Medical Center PI and Medical Director, NH CRC Screening Program PI and Medical Director, NH CRC Screening Program

2. Rationale for Patient Navigation in CRC Screening Rationale for Patient Navigation in CRC Screening Colorectal cancer (CRC) is the second most common cause of death from cancer in the U.S. Colorectal cancer (CRC) is the second most common cause of death from cancer in the U.S. CRC can be prevented through screening, in addition to early detection to prolong survival CRC can be prevented through screening, in addition to early detection to prolong survival Despite compelling evidence for CRC screening those rates remain low, particularly for low income individuals and racial and ethnic minorities Despite compelling evidence for CRC screening those rates remain low, particularly for low income individuals and racial and ethnic minorities

3. NHCRCSP Patient Navigation NHCRCSP Patient Navigation NHCRCSP provided free colonoscopies to low income, uninsured and under-insured NH residents for six years NHCRCSP provided free colonoscopies to low income, uninsured and under-insured NH residents for six years Patient Navigation has proven highly effective for adherence, provision of high-quality screening, and appropriate and timely follow-up Patient Navigation has proven highly effective for adherence, provision of high-quality screening, and appropriate and timely follow-up Program was statewide, so telephonic navigation was provided by two nurse Patient Navigators Program was statewide, so telephonic navigation was provided by two nurse Patient Navigators

4. NHCRCSP Patient Navigation NHCRCSP Patient Navigation Colonoscopy screening navigation included: Colonoscopy screening navigation included: –Patients are medically appropriate and cleared for test –Understanding of test including travel and appt details –Details of preparation –Results and recommended follow-up –Communication with and between providers –Barriers identified and addressed throughout the process

5. Patient Navigators address client barriers including: Patient Navigators address client barriers including: - lack of knowledge, fear - lack of knowledge, fear - language - language - transportation, location of endoscopy site, ride home - transportation, location of endoscopy site, ride home - practical issues: no permanent home, limited phone - practical issues: no permanent home, limited phone - obtaining and taking test preparation - obtaining and taking test preparation - cultural or social issues - cultural or social issues - test results and recommended follow-up from provider - test results and recommended follow-up from provider - compliance with subsequent follow-up - compliance with subsequent follow-up Barriers to Colonoscopy Barriers to Colonoscopy

6. Details of NHCRCSP Navigation Details of NHCRCSP Navigation Defined series of calls per patient Defined series of calls per patient Comprehensive data collection Comprehensive data collection Review with Medical Director Review with Medical Director Assessment of patient satisfaction Assessment of patient satisfaction Evaluation of outcomes for patients, endoscopy sites, and for the program Evaluation of outcomes for patients, endoscopy sites, and for the program Ensuring appropriate follow up Ensuring appropriate follow up

7. NHCRCSP Outcomes NHCRCSP Outcomes Two no-shows for ~ 2000 colonoscopies Two no-shows for ~ 2000 colonoscopies Only 1% of clients had an inadequate colonoscopy preparation. Only 1% of clients had an inadequate colonoscopy preparation. 100% of clients received follow up recommendations from their endoscopist following their colonoscopy 100% of clients received follow up recommendations from their endoscopist following their colonoscopy

8. NHCRCSP Navigation Outcomes: Ensuring Quality Patient navigation not only improves colorectal cancer screening rates Patient navigation not only improves colorectal cancer screening rates but – of critical importance – but – of critical importance – navigation can improve the quality of colorectal cancer screening navigation can improve the quality of colorectal cancer screening Quality is essential for effective and cost- effective colorectal cancer screening Quality is essential for effective and cost- effective colorectal cancer screening

9. Patient Navigation Topics Patient Navigation Topics Does your program need a navigator(s)? Does your program need a navigator(s)? How to select a navigator How to select a navigator Organize a navigation process Organize a navigation process How to approach patients How to approach patients Assessing and addressing barriers Assessing and addressing barriers Patient satisfaction (navigator and process) Patient satisfaction (navigator and process) Frequent data collection for outcomes evaluation and process improvement Frequent data collection for outcomes evaluation and process improvement

10. NHCRCSP Processes to Ensure Quality Medical Review: Pre-Procedure Review Medical Review: Pre-Procedure Review –Assess significance of symptoms (PNs with MD) Appropriate patients and fewer patient exclusions Appropriate patients and fewer patient exclusions –Determine appropriateness for current exam based on patient personal and family history –Provide useful information to endoscopy sites: Important medical factors addressed (need for anesthesia, anticoagulation issues, cultural issues) Important medical factors addressed (need for anesthesia, anticoagulation issues, cultural issues) –Ensure good bowel preparation

11. NHCRCSP Processes to Ensure Quality Data Review: Post-Procedure review Data Review: Post-Procedure review –Patient past history of adenoma or CRC –Patient family history –Completeness of exam (to cecum) –Quality of prep –Withdrawal time –Polyp pathology: type, number, size, location –Completeness of polypectomy –Follow-up recommendations –Notification of patient about results and follow-up

12. NHCRCSP Processes to Ensure Quality Additional Patient Navigation Processes Additional Patient Navigation Processes –Referral to Quit Line, BCCP, medical home –Referral of ineligible patients to other resources –Communication with endoscopy site contacts to clarify history, findings, follow-up, or patient questions –Through Data Review, observe (confirm via database) provider practice patterns needing to be addressed (for example: % fair preps, incomplete polypectomies, short withdrawal time, missing or inappropriate follow- up recommendations that do not follow Guidelines) (for example: % fair preps, incomplete polypectomies, short withdrawal time, missing or inappropriate follow- up recommendations that do not follow Guidelines)

13. Research Review of Navigation for Colorectal Cancer Screening 3 Randomized Controlled Trials for CRC 3 Randomized Controlled Trials for CRC Additional Research: RCT Evidence for Telephonic Patient Navigation Additional Research: RCT Evidence for Telephonic Patient Navigation Formal CDC evaluation of the NHCRCSP navigation program is currently underway Formal CDC evaluation of the NHCRCSP navigation program is currently underway

14. RCT of Patient Navigation in Colorectal Cancer Screening Targeted low-income minorities Targeted low-income minorities 21 average-risk patients referred by PCP 21 average-risk patients referred by PCP Plus or minus navigation for colonoscopy Plus or minus navigation for colonoscopy Of 13 PN +: 54% had colo; of 8 PN - : 13% Of 13 PN +: 54% had colo; of 8 PN - : 13% Conclusion: PN improves compliance with screening Conclusion: PN improves compliance with screening Christie J, Itzkowitz S, Lihau-Nkanza I et. al. A Randomized Controlled Trial Using Patient Navigation to Increase Colonoscopy Screening among Low-Income Minorities. Christie J, Itzkowitz S, Lihau-Nkanza I et. al. A Randomized Controlled Trial Using Patient Navigation to Increase Colonoscopy Screening among Low-Income Minorities. J Natl Med Assoc. 2008; 100: 278-284 J Natl Med Assoc. 2008; 100: 278-284

15. RCT of Patient Navigation in Colorectal Cancer Screening Culturally tailored intervention to increase CRC screening for low-income, non-English speaking patients Culturally tailored intervention to increase CRC screening for low-income, non-English speaking patients Single urban community health center Single urban community health center 1223 patients: PN (409) vs. usual care (814) 1223 patients: PN (409) vs. usual care (814) Colonoscopy completion: Colonoscopy completion: –21% of navigated vs. 10% of usual care patients Conclusion: statistically significant (p=<0.001) difference Conclusion: statistically significant (p=<0.001) difference Percac-Lima S, Grant RW, Green AR, et. al. A Culturally Tailored Navigator Program for Colorectal Cancer Screening in a Community Health Center: A Randomized, Controlled Trial Percac-Lima S, Grant RW, Green AR, et. al. A Culturally Tailored Navigator Program for Colorectal Cancer Screening in a Community Health Center: A Randomized, Controlled Trial J Gen Intern Med 2009; 24: 211-217 J Gen Intern Med 2009; 24: 211-217

16. RCT of Patient Navigation in Colorectal Cancer Screening 465 patients from 4 CHCs and 2 public hospital clinics 465 patients from 4 CHCs and 2 public hospital clinics Randomly assigned to navigation or usual care Randomly assigned to navigation or usual care PN: language-concordant telephone contacts PN: language-concordant telephone contacts CRC screening: 33.6% with PN vs. 20% without PN CRC screening: 33.6% with PN vs. 20% without PN Navigation was particularly helpful for black or non-English speaking patients and may be useful in reducing disparities Navigation was particularly helpful for black or non-English speaking patients and may be useful in reducing disparities Lasser KE, Murillo J, Lisboa S, et al. Colorectal Cancer Screening Among Ethnically Diverse, Low-Income Patients. A Randomized Controlled Trial Arch Intern Med 2011; 171 (10): 906-912

17. Evidence for Telephonic Navigation Telephone Outreach to Increase Colon Cancer Screening in Medicaid Managed Care Organizations: A Randomized Controlled Trial Telephone Outreach to Increase Colon Cancer Screening in Medicaid Managed Care Organizations: A Randomized Controlled Trial Conclusion: Telephone outreach by MMCO staff increased CRC screening over usual care Conclusion: Telephone outreach by MMCO staff increased CRC screening over usual care Dietrich AJ, Tobin JN, Robinson CM et al. Dietrich AJ, Tobin JN, Robinson CM et al. Annals of Family Medicine 2013; 11: 335-343 Annals of Family Medicine 2013; 11: 335-343

18. NHCRCSP Navigation NHCRCSP Navigation Patient Satisfaction Patient Satisfaction

19. Conclusion Conclusion Patient Navigation is an extremely effective method of increasing compliance with colorectal cancer screening while simultaneously ensuring screening quality. Patient Navigation is an extremely effective method of increasing compliance with colorectal cancer screening while simultaneously ensuring screening quality.