Virginity, Pain, and Confusion: Overcoming Barriers to Cancer Screening at Federally Qualified Health Centers -Nilani Downs and Chris Espersen

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Virginity, Pain, and Confusion Overcoming
Barriers to Cancer Screening at Federally
Qualified Health Centers-Nilani Downs and Chris
Espersen
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Pop Quiz

• A 66-year old female walks into your clinic for a
  physical, upon review of her chart you note that
  she has not had a pap test in over 10 years. Do
  you perform a pap test on her?
• Yes
• No

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Cervical Cancer

• The American Cancer Society estimates in 2014
• About 12,360 new cases of cervical cancer will be
  diagnosed
• About 4,020 women will die from cervical cancer
• However, 60-80 of women with advanced cervical
  cancer have not had a pap test in the past 5
  years
• More than 15 of cases of cervical cancer are
  found in women over 65. These cancers rarely
  occur in women who received regular screenings
  prior to 65.

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Breast Cancer

• The second most common cancer in the U.S. and the
  second deadliest in women
• In 2013
• More than 232,000 new cases
• Nearly 40,000 deaths
• Over 2 million Americans living with Breast
  Cancer
• Death rates have fallen steadily over the past 20
  years

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Colorectal Cancer

• Third most common cancer, 2nd deadliest
• In 2013
• 140,000 new cases
• Nearly 50,000 deaths
• Highest incidence and death rates in
• African American
• American Indian/Alaska Native
• 1.2 million individuals living with current or
  past CRC

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Pop Quiz

• What proportion of people who have never been
  screened have health insurance?

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ExampleWhos Not Screened
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Barriers to Screening at Iowa FQHCs

• Patient comfort
• Cultural beliefs
• Lack of education on screening
• Misunderstanding of the Pap Test
• Lack of reminder system
• Uninsured/underinsured
• Physician discomfort
• Lack of support for screening

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70-year old Spanish-speaking male patient with
multiple conditions including Diabetes, HTN, and
obesity. This patient is best described as one
who makes good use of resources. He is on the
ball. The patient frequently enlisted the help
of the Nurse Care Manager for help in getting his
prescriptions and diabetic supplies, including
diabetic shoes. In one instance the patient was
scheduled to see Iowa Orthopedics. The patient
was having problems with scheduling, so he
contacted the Nurse Care Manager. In another
instance, the provider felt that the patient was
doing well and he could discontinue Metformin.
The patient went to see his urologist for a
prostate problem was told he had sugar in his
urine. The patient promptly returned to the
clinic to request Metformin. The patient was
compliant in getting colonoscopy done and as of
April 2014, he was going to schedule his annual
diabetic eye exam with his own eye doctor. The
patient regularly follows-up with his urologist
for prostate issue and oncologist for past
history of pharyngeal cancer.
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Pt came in for appointment in tears, reporting
much anxiety and hopeless feelings. Recently had
a heart attack and reports that it was the first
time he really looked at his own mortality. Also
recently lost a brother to suicide. Spent approx
an hour with pt allowing him to vent and
utilizing MI skills to elicit some root causes to
his anxiety. One thing he was finally able to
share at the end of the visit was that he didnt
have enough money for food and didnt get his
check until the next week. We discussed ways to
help make that stretch and I offered him a food
box referral. You could actually see the relief
wash over his face and shoulders.
.
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Source Centers for Disease Control and
Prevention
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Disparity Data
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2013 Health Center Data
2011 2012 2013 2011 2013 Trend Change
Quality Care Indicators/Health Outcomes Perinatal Health Cervical Cancer Screening Quality Care Indicators/Health Outcomes Perinatal Health Cervical Cancer Screening Quality Care Indicators/Health Outcomes Perinatal Health Cervical Cancer Screening Quality Care Indicators/Health Outcomes Perinatal Health Cervical Cancer Screening Quality Care Indicators/Health Outcomes Perinatal Health Cervical Cancer Screening Quality Care Indicators/Health Outcomes Perinatal Health Cervical Cancer Screening
Iowa Data 49.9 49.9 47.2 50.4 0.9
National Data 57.8 57.8 57.2 57.8 0.1
Colorectal Cancer Screening Colorectal Cancer Screening Colorectal Cancer Screening Colorectal Cancer Screening Colorectal Cancer Screening Colorectal Cancer Screening
Iowa Data - - 20.1 29.7 -
National Data - - 30.2 32.6 -
Source HRSA Health Center Program Grantee Data Source HRSA Health Center Program Grantee Data Source HRSA Health Center Program Grantee Data Source HRSA Health Center Program Grantee Data Source HRSA Health Center Program Grantee Data Source HRSA Health Center Program Grantee Data
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Increasing Screening Rates
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This is a 58-year old female patient with mental
health and cardiovascular issues, tobacco use
obesity. The Nurse Care Manager initially saw
this patient in Feb. The patient was 5 4 and
weighed 201.4 lbs. (34.7 BMI). The patient was
seeing a cardiologist . She had mitral stenosis
and mitral regurgitation. The patient complained
she had no energy and did not want to do
anything. The patient required a mitral valve
replacement however, she needed to be smoke-free
for 2 months prior to the surgery. The patient
was smoking 10cigs/day at this time. The patient
was most concerned with smoking cessation so she
could have open heart surgery. The Nurse Care
Manager provided the patient with Healthwise
Handbook and went over sections on smoking
cessation and healthy weight. The patient was
happy the last time she was seen in April 2014.
Patient reported she was completely stopped
smoking. She no longer needed the nicotine patch
and had been smoke-free for over 2 months. The
pt. continues to see the cardiologist does not
add salt to her food and continues with weight
loss efforts.. Next goal will be to have the
patient agree to have a mammogram.
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Huddle Sheets
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Motivational Interviewing
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Recalls and Community Opportunities
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Barriers to Screening Opportunistic vs.
Organized Preventive Care

• Most preventive care for adults in the U.S. is
  opportunistic, i.e. occurs incidentally during
  encounters with healthcare professionals
• Opportunistic care depends on a coincidence of
  encounters, circumstances, and interests between
  patient and provider
• This means some adults get some preventive care
  on some occasions and at some interval
• Few adults receive the full package, or even the
  majority of recommended preventive services

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Screening Toolkit

• The Guide outlines efficient ways for practices
  to get every eligible patient the colorectal
  cancer screening tests he or she needs
• Developed to introduce clinicians and staff to
  concepts tools included in the full toolkit
• To facilitate efforts of office-based clinicians
  to reduce disparities by applying screening
  guidelines on a universal basis to the
  age-appropriate population

http//nccrt.org/about/provider-education/crc-clin
ician-guide/
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Staff Involvement

• Key Point..the clinicians cant do it all!
• Time that patients spend with non-clinician
  staff is underutilized
• Standing orders can empower nurses, intake staff,
  etc. to distribute educational materials,
  schedule appointments for mammography, etc.
• Involve staff in meetings to discuss progress in
  achieving office goals for improving the delivery
  of preventive services

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Make a RecommendationRecognize Potential
Barriers to Screening

• In making recommendations we must be sensitive to
  and address
• Fear of cancer diagnosis
• Lack of understanding of need for asymptomatic
  screening
• Misconceptions about cancer causes and risks
• Embarrassment
• Concern over discomfort of screening tests
• Cultural issues
• Patient preferences

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Screening Policies Factors to Consider in Your
Office Policy

• Individual Risk Level (risk stratification)
• Medical resources (pap test providers)
• State and federal program policies and processes
  (BCCEDP)
• Patient Knowledge, Beliefs, Concerns
• Insurance (insured? deductible? copay?)
• Impact of Affordable Care Act on preventive
  services

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Reminder SystemsPhysician Patient Reminders

• Physician Reminders
• Chart Prompts
• Problem lists
• Screening schedules
• Integrated summaries
• Alerts Flags placed in chart
• Follow-Up Reminders
• Logs and Tracking
• Electronic Reminder Systems

• Patient Reminders
• Cues to Action
• Education

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Measure Practice ProgressTracking Practice
Progress

• Determine baseline screening rate
• Set realistic goals
• Chart audits or other tracking measures (i.e. EHR
  reports)
• Provide staff-specific feedback on performance
• Seek patient feedback
• Identify strengths and weaknesses, barriers,
  opportunities to improve efficiency
• Track progress and periodically reassess goals

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Resources
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Action Plan Toolkit Version

• Eight page guide introduces clinicians and staff
  to concepts and tools provided in the full
  Toolkit
• Contains links to the full Toolkit, tools and
  resources
• Not colorectal-specific
• Practical, action-oriented assistance that can be
  used in the office to improve screening rates for
  multiple cancer sites (colorectal, breast and
  cervical)

Available at http//nccrt.org/about/provider-educa
tion/crc-clinician-guide/
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Office Wall Chart
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Thank you!