1. Finding non-traditional allies for CRC screening Gloria D. Coronado, PhD Beverly B. Green, MD, MPH Policy- makers Community Partners Clinic staffPatients

2. Key messages  Multi-stakeholder teams can be effective;  Know your audience --- evidence can help engage, inform action, and manage expectations. Policy- makers Community Partners Clinic staffPatients

3.  2014 Oregon 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 and have polyps removed will not be charged co-pays and deductibles.  2015 Oregon passed legislation that prohibits insurance companies from imposing 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. Policy- makers

4. Possible partnerRole Community organizations that provide colonoscopy to uninsured Fund colonoscopies for uninsured patients GI providersProvide colonoscopy services (sometimes donated) Medicaid health plansOffer clinic incentives, patient outreach Advocacy organizationsRaise patient awareness, advocate for legislation Breast, Cervical and Colon Health Programs (CDC) Fund fecal testing/ colonoscopy for uninsured Community Partners

5. ExampleRole Clinic leadershipPromote buy-in; assign staffing, dedicate resources ProviderPromote CRC screening Medical AssistantDiscuss CRC screening with patients; place standing orders, show videos Patient Care/ Referral Coordinator Coordinate referrals; contact patients Front office staffRespond to patient inquiries; track returned tests EMR site specialistGenerate patient registries and tracking reports Outreach staffDeliver reminders, live/auto-calls, text messages Clinic staff

6. Know your audience  Example 1: Concerns about obtaining colonoscopy for the uninsured.  “…I hear a lot of frustration from doctors that want to have their patient have the colonoscopy and it’s just not happening. It’s really an expensive exam…” (Nurse Practitioner)  “Even if you have insurance … it takes about nine months for a routine colonoscopy in this community. Usually, to get a colonoscopy with any speed, you need some reason.” (Medical director) Clinic staff

7. Needed colonoscopies Anticipated Eligible Patients, CRC Screening, and Needed Follow-up FQHC N Total patients aged 50-74 (2012) N Eligible* (75%) N reachable (80%) N obtain FIT (35%) N need colonoscopy (4.5-9%) Clinic 19757315852059 – 18 Clinic 214391,07986330214 – 28 Clinic 36725044031416 -- 12 *based on OCHIN data from 1/1/2012 – 12/31/2012 Clinic staff

8. Colonoscopy screening FIT-based screening FIT reduces colon cancer mortality Number Needed to Scope to find an advanced adenoma*: Colonoscopy screening scenario: 47.4 FIT-based screening scenario: 8.3 *For females aged 50 - 59 Clinic staff

9. 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 Clinic staff

10. Newly insured Financially challenged Insured procrastinator / rationalizer African American Hispanic 2015 Communications Guidebook, American Cancer Society Patients

11. Patient reasons for non-response Coronado et al. Translational Behavioral Medicine 2015

12. Pilot findings from Virginia Garcia Patients

13. Conclusion  Multiple stakeholders can/ should be involved in implementing a CRC screening program. Important to identify internal and external partners.  Understanding and addressing stakeholders’ concerns can build buy-in, expand impact, and help manage expectations. Policy- makers Community Partners Clinic staffPatients

14. Acknowledgments Funding source: NIH Common Fund [UH2AT007782 and 4UH3CA188640-02] and Kaiser Permanente Community Benefit  STOP CRC Research Team;  OCHIN;  Participating Clinics  STOP CRC Advisory Board