American Cancer Society CI Report – Interim

What has been most instrumental to your progress?

Enhanced coordination across ND/SD state borders has been instrumental. Based on the priorities & geography of key partners, we’ve approached them jointly where appropriate. For example, ND and SD ACS staff worked with the Primary Care Association (PCA) covering both states to engage all Federally Qualified Health Centers (FQHC’s) in the Dakotas in calculating their number of uninsured patients needing colonoscopy per year. We now have a defined need for donated colonoscopies across both states and are working with partners to display this on a GIS map. Our states have also collectively met with the largest hospital system and are in the process of exploring a regional ask for donated colonoscopy with this system’s executive leadership. In addition, we have coordinated educational offerings across both states, including sponsoring the keynote speaker at the bi-state PCA conference and coordinating a regional webinar series on colorectal cancer (CRC) screening evidence-based interventions (EBIs), patient navigation, and donated care arrangements. We have also formed a small learning community among ND and SD ACS staff, where we reflect jointly on project progress and lessons learned

In ND, a community assessment showed screening barriers with cost, transportation and language. Discussions with Indian Health Service (IHS) units revealed that cost is not the main barrier to screening for their patients, yet other barriers persist. These findings elevated care coordination to become a central strategy. ACS worked with Valley Community Health Centers (VCHC) to set screening goals and provide technical assistance to support implementation, including 3 staff trainings. ACS convened VCHC and their colonoscopy referral site, Altru Health, to clarify the current referral process and build mutual understanding of one another’s facilities and existing community resources. A process map was developed to visually outline the referral process and gaps. Adaptations to the process were implemented, including translation of colonoscopy prep instructions into 2 additional languages. VCHC achieved a 10% CRC screening increase and co-presented with Altru at the ND CRC Roundtable in Fall 2018. FQHC’s, IHS clinics, and their colonoscopy referral sites were grouped by medical neighborhood at the statewide meeting and developed action plans within their own communities.

In South Dakota, we have completed a CRC screening statewide community assessment with over fifty stakeholder participants that included phone interviews and an online survey. Our evaluation consultant has put together a final report that illustrates the need for specialty care for uninsured FQHC patients. We have begun to share findings with key stakeholders and will share more formally at our stakeholder meeting in early 2019. One of the meetings we’ve had so far included leadership from Avera Health System. Avera is one of the largest health systems in the state and has many rural clinics nearby FQHC locations. After sharing some of the high-level assessment findings, we were able to get a broad commitment from them to provide for donated colonoscopies for uninsured FQHC patients. We expect to have additional meetings with them in the coming months to work out specifics. We’ve held a number of provider and nurse online and in-person CRC screening trainings at Horizon Health Care. When the grant period started, Horizon had a baseline screening rate of 41% and their most recent report shows an increase of 49%.

Key lessons learned

One of our key lessons learned was the importance of being flexible and adaptable throughout the project. Links of Care was a national pilot which had been conducted in 3 communities across the country prior to this project. While colonoscopies in the Dakotas are largely performed by providers employed within large hospitals, the original Links of Care pilots were located in communities where private practice providers perform colonoscopy. We knew the Links model would need to be adapted to a hospital-based landscape, and it has taken time and patience to identify the best approach in each state (and we continue to learn and adapt). In ND, care coordination emerged as a necessary first step to fulfill the capacity of existing assistance programs before pursuing donated care. In SD, ACS staff listened to their partner Horizon and expanded the project scope to include all FQHC’s in the state based on Horizon’s extensive statewide presence. The SD team also chose to postpone a statewide stakeholder meeting in order to ensure that the right decisions makers are present for the discussion. This flexibility has been key during this first project year.

Through this project, we have gained a new appreciation for the influence and role that ACS can play in convening key healthcare partners around a common cause. As we are not providers, payers, or regulators of healthcare, our team can effectively act as a third-party neutral convener. While facilities often work in silos and focus on their own healthcare system, ACS brings a comprehensive view to CRC screening and can help bridge connection between clinic and hospital systems with shared patients. While partners are often willing to engage in these conversations and want the best for their patients, we’ve found that it may require an outside organization to initiate and facilitate that discussion between facilities. Through this process, ACS can be a driving force in elevating CRC screening as a priority, enhancing the coordination of care across health systems, and introducing key resources and best practices to aid the facilities in implementation. We have learned that there is immense value to the role of a third-party, neutral convener and connector in enhancing coordination and collaboration among key healthcare partners.

Reflections on inclusive, collaborative or resourceful problem-solving

An inclusive process has been key. Engaging key stakeholders has led to meaningful participation and valuable input for the community assessment. The assessment report has been helpful as we’ve begun to meet with large health systems about providing donated specialty care, and it will continue to be crucial as we gain momentum. We have also seen success from being inclusive with our PCA and our Department of Health. From our partnership with the PCA we have hosted statewide calls with a representative from each of the FQHC’s to identify their estimated colonoscopy need for uninsured patients. We are partnering with the Department of Health to display this information on a map. The data and maps will be extremely useful as we continue conversations with the large health systems. The inclusive element was also important to the success of the ND CRC Roundtable statewide meeting. By having the right people at the table from a variety of sectors we were able to develop actionable next steps for the group to work on. The meeting also included a CRC survivor speaker so stakeholders could hear directly from someone affected by the problem.

Other key elements of Community Innovation

Curiosity is a key element. We often feel like investigators working to understand the complexity of CRC screening and making sense of the ways in which many organizations play a role in some component of the screening process or access. This includes examining the existing data, which often sparks new questions. It has also meant identifying existing resources for colonoscopy coverage, as well as the remaining gaps and barriers. Having curiosity about the true barriers to CRC screening has lead us to better understand that while cost is a key barrier, care coordination is equally crucial to address. This recognition has helped us stay flexile and shift focus where needed. For instance, one partner in SD has secured donated colonoscopy but has not been successful in referring patients to the program. ACS is working with that partner to improve the referral process. In addition, we’ve stayed curious about the ways that donated colonoscopy may align with hospital systems’ existing priorities and community benefit requirements. As a fuller picture of the problem emerges, we find ourselves exploring strategies to bring more cohesion and integration across multiple facilities.

Understanding the problem

Our partnership with the bi-state PCA to assess the number of colonoscopy for their uninsured patients clarified the true need of the issue and created opportunity for larger health systems to take care of vulnerable patients. FQHC’s are the primary source of health care for many rural, low-income and hard to reach populations (such as the homeless and recent immigrants). CHCs have faced the challenges of being health care safety net and transformed to improve quality. CRC screening for this population requires coordination to offer initial screenings with primary care and if further testing is required follow-up services with specialty care providers. However, CHCs which are not connected to integrated delivery systems struggle to obtain specialty care for low-income patients and the uninsured. By calculating individual CHCs uninsured population over age 50 eligible for CRC screening and putting a number to the actual community need we will be able to make a business case to larger health systems to take on caring for these patients. The community assessment findings also gave us insight to the barriers that exist for FQHC patients.

If you could do it all over again…

If we could go back to the start of our grant period and give ourselves one piece of advice, it would be to get more comfortable with not knowing exactly how the project will evolve. We have learned the importance of staying curious and flexible in our plans and timeline. Throughout this first project year, we have slowly learned that access to CRC screening is a multi-faceted problem with many layers, and it requires flexibility and adaptability in solving on a local level. We’ve learned not to give ourselves arbitrary deadlines, but rather to adjust and respond to what we’re learning. We will work hard to carry this philosophy into the next project year.

One last thought

As we progressed in this project, we learned more about where the knowledge gaps are in our understanding of barriers to CRC screening, particularly with the American Indian population in both states. We were presented an opportunity to collaborate with Dr. Donald Warne, Associate Dean for Diversity, Equity, and Inclusion at the University of North Dakota School (UND) School of Medicine and Health Sciences. Dr. Warne expressed interest in supporting our work and assisting us as we advance through the community innovation model, with activities including executive engagement, chairing the ND CRC Roundtable, and health policy and health services research. As Dr. Warne is a national expert in American Indian health, we knew this was a great opportunity. This was not something we planned for in our original budget, but as we learned more about the problem of CRC screening access we knew this partnership opportunity could help us advance toward a well-informed community innovation. With permission from our Bush Foundation contact, we redirected $25,000 in our budget to support a sub-contract with UND. As a result, we will code less ACS staff time to the grant in Year 2.