1. Therese Chan Tack, DO MPH Therese.ChanTack@ucsf.edu Improving Colorectal Cancer Screening among PRIME population in Primary Care

2. 2 Problem Statement Colorectal cancer (CRC) is the 3rd most commonly diagnosed cancer and 2nd highest cause of cancer-related deaths in the US. Only 65% of Americans are adequately screened despite CRC being highly treatable with early detection. At UCSF Primary Care (UCPC), baseline CRC screening rates were lower than more established care sites. Moreover, ~30% of our patients are Medi-Cal PRIME eligible. These patients on average have higher medical complexity / co-morbidities, and reduced access to preventative medical care. Objectives  Achieve HEDIS 90th percentile for CRC screening (Medi-Cal 2020 PRIME program goal).  Improve patient awareness, engagement and shared decision-making.  Create a sustainable, interdisciplinary team approach to population management team.

3. Improving Colorectal Cancer Screening among PRIME population in Primary Care 3 Settings and Participants  2 clinics: 10 triads of physicians, medical assistants (MA), practice coordinators (PC); 3 nurse practitioners (NP), 1 panel manager (PM).  Criteria: 50-75 years old, eligible per healthcare maintenance (HCM) banner. Approaches  Scaled outreach: EHR bulk messages / letters / calls. PM addition. FIT kit / colonoscopy reminders.  Personalized 1:1 follow ups to address patient specific concerns. HCM banner notifications. NP expansion. Techniques  EHR data analysis: Identify patients’ screening preferences. Collate CRC data sources. Create specific messaging templates (letters, order sets, forms).  Quarterly workflow gap analysis.  Flow charts / state transition diagrams: Clarify task ownership.  Task specific tools / training: team training on screening guidelines.

4. Improving Colorectal Cancer Screening among PRIME population in Primary Care 4 Figure 1: Work Flows and State Transitions Figure 2: State Transitions and Task-Owner Assignment

5. Improving Colorectal Cancer Screening among PRIME population in Primary Care 5 Figure 3: All Population Colorectal Cancer Screening Rates Clinic 1 Clinic 2

6. Improving Colorectal Cancer Screening among PRIME population in Primary Care 6 Figure 5: PRIME Population Colorectal Cancer Compliance Funnel Figure 4: PRIME Population Colorectal Cancer Screening Rates Our proven process design has sustained and exceeded HEDIS target. Our project showed almost 50:50 split between FIT and Colonoscopy as screening preferences.

7. Improving Colorectal Cancer Screening among PRIME population in Primary Care 7 Results  Overall population (PRIME + rest):  Clinic 1, CRC screening rate increased: 41.9%  63.1%.  Clinic 2, CRC screening rate increased: 56.4%  64.4%.  PRIME population:  UCPC achieved the FY2017 HEDIS CRC screening metric (65%).  1327 PRIME patients attained CRC screening completion (70.7%). Ripple Effects  Applied our proven process design to other preventative care metrics.  PRIME patients breast cancer screening increased: 68.7%  76.3%.  PRIME patients cervical cancer screening increased: 64%  77.3%.

8. Improving Colorectal Cancer Screening among PRIME population in Primary Care 8 Lessons Learned  Parallel scaled outreach and personalized follow up sustainably improves care quality with higher team / patient satisfaction.  EHR serves as an effective avenue for population level outreach with its repository of patient screening preferences.  Staff screening guidelines education improves patient communication / decision making.  Clear task ownership assignments, tools standardization creates consistency in staff’s care delivery. Next Steps  Use Panel Manager platform to target intermediate state bottlenecks.  Segment patient populations into highest need.  Incorporate CRC screening nuances (Colo-guard, sigmoidoscopy, CT).  Coordinate screening efforts at community health fairs, FIT drop off (monthly), FIT-Flu clinics (seasonal).

9. Acknowledgements: N. Jones MA, C. Kivlahan MD MSPH, M. Martin MD, N. Yang, UCPC Care teams at China Basin and Laurel Village, Office of Population Health, D. Sengupta.