American Cancer Society CI Report – Final

What has been most instrumenta to your progress?

One of the most critical components of our work has been the strategic engagement of our two largest health systems in the innovation process. Sanford Health and Avera Health have colonoscopy referral sites for many FQHCs in the Dakotas, making them essential partners in solving the problem of cost barriers to colonoscopy for uninsured FQHC patients. These partners have helped us understand that the traditional Links of Care model (securing a set number of donated colonoscopies per year for FQHC patients) does not translate well to a large health system, despite the model’s previous success with private gastroenterology practices. By listening to the health systems’ feedback, our attention has turned toward understanding the underutilization of existing resources as well as the need for organizational and public policy to address this problem. These health systems partnered with ACS to improve internal processes to increase utilization of their existing financial assistance policy. ACS convened health systems with FQHC and state health department partners to facilitate improved navigation into these assistance programs.

In both states, convening key healthcare stakeholders has been instrumental in guiding our innovation approach and adding to our understanding of the many complexities in CRC screening access. At the SD stakeholder meeting, a key take-away was the need to better understand why existing hospital financial assistance policies are not meeting the needs of FQHC patients. The role of public policy also arose in two ways: 1.) Stakeholders reiterated the need to pass Medicaid Expansion in SD, and 2.) The SD Department of Health added CRC screening dollars to its 2020 state budget request, based on recommendations from meeting participants. At the ND stakeholder meeting, the need to better understand insurance coverage, coding, & billing for CRC screening was a key theme. The importance of preserving Medicaid Expansion was also expressed by stakeholders. These meetings contributed to the ND Insurance Commissioner issuing a memo to all insurers clarifying federal guidelines for screening coverage, and also sparked discussions with the ND Department of Health about how to enhance access to the state screening program

Continuing to coach and support our FQHC partners has been important. In May 2019, ACS used the Bush capacity dollars to provide patient navigation training to all FQHCs across the Dakotas, in partnership with the primary care association. Patient navigation is a critical component in increasing CRC screening with underserved populations. ACS has continued to work with the FQHC in Grand Forks in expanding their medical neighborhood, and today a broad partnership among the FQHC, hospital, public housing, public health, homeless shelter, and low-cost pharmacy is forming which will bring increased coordination to CRC screening for FQHC patients in Grand Forks. In SD, ACS has worked closely with Horizon Health Care, an FQHC which has seen an 8% improvement in screening completion since the project start. Interventions have included a mailed stool test pilot and an increased focus on navigating patients through hospital charity care resources. These activities have served as a catalyst for hospital systems to develop a better process for their charity care programs.

Key lessons learned

The first key lesson we learned was the importance of having internal champions across multiple levels of a partner organization. ACS frequently partners with health systems at a local level, however in this project our initial strategy was to secure executive-level support and buy-in. In order to successfully develop executive-level champions for partnership, we learned that it is critical to first engage some of our trusted local hospital staff champions. While we still believe that executive-level support is crucial, we now recognize the important role that ground-level hospital staff can have in helping us secure leadership support. Health systems are complex systems, and executives are overseeing such a wide range of health issues that they may not be well-versed in the jargon and technical details of something as specific as colorectal cancer screening. These passionate ground-level staff have deep insights into their organizations and can advise us in how to best frame our message in a way that resonates with high-level leaders. They can also be key in ensuring accountability and follow-up after high-level partnership discussions.

The second key lesson we learned about our work is that problems are often more complex than they seem on the surface. We have learned to lean into this complexity and appreciate the learning that can come when that is embraced. The traditional Links of Care model has not translated well to the large health system partnership. While this could be interpreted as a failure, what we’ve gained through this realization is a much deeper understanding of the complexities surrounding CRC screening access. We have felt a bit like detectives at times, peeling back the layers to understand how the healthcare system fits together across multiple facilities and how CRC screening is impacted by broader context including public policy, organizational policy and workflow, insurance coverage, quality measures, and more. We’ve used the Bush capacity dollars to train all of our regional cancer control staff in hospital community benefit requirements to inform future strategy. Our ability to look at this problem comprehensively has paved the way for new possible solutions which may ultimately prove more effective with large health systems

Reflections on the community innovation process

While all of these elements have been important, we feel that being collaborative has been the most important. By collaborating with our largest hospital systems and shifting our strategy based on their feedback and structure, we have now seen this project move towards being a true joint effort. The hospital system dedicated staff time to this partnership and has committed to regular meetings to continue implementing the project. They are approaching this as an internal initiative and have executive level support for the project. This integration of the project into their workplans shows shared ownership between ACS and the hospital system, as well as shared decision making as we pursue an innovation together.

Other key elements of Community Innovation

Flexibility has been another key element in our process. As referenced throughout this report, we’ve needed to demonstrate the flexibility to shift strategies based on new information and feedback from partners. This flexibility has allowed us to continue moving forward toward our ultimate goal rather than getting stuck on one specific approach.

Progress toward an innovation

There are three areas we’ve gained clarity around: Data, the need for care coordination, and leveraging partner resources for solutions. Prior to the grant period, we knew anecdotally that uninsured FQHC patients in the Dakotas had cost barriers to accessing colonoscopy. Since that time, we’ve worked with FQHCs across both states to identify a numerical need for uninsured colonoscopies and have shared GIS maps displaying this need with key partners. Our partners have also brought much clarity to this problem through their engagement in the process. Hospital systems pointed to their existing financial assistance programs as the solution, but local FQHCs helped identify that patients are not easily accessing these programs. Hospital systems then helped identify that their own staff internally may not always be aware of the programs or eligibility, and there are not good processes in place for navigating patients into these programs. As this project unfolded it became less about developing new resources to solve the problem and more about enhancing access into underutilized existing resources through stakeholder engagement and process improvements.

What it will take to reach an innovation?

What’s next?

Our conversations with the health systems around accessing colorectal cancer screening have sparked larger quality improvement partnership where we are exploring additional projects including lung, breast and cervical cancer. We have reoccurring meetings with the health systems to work on shared priorities and improve access to cancer screenings.

If you could do it all over again…

If we could go back to the start of the project and give ourselves one piece of advice, it would be this: Be patient with the innovation process and welcome the twists and turns that come with true innovation. This is a marathon, not a sprint, and it is important to keep focused on the ultimate end goal, which is reducing disparities in colorectal cancer. At the start of this project, our focus was solely on securing a set number of donated colonoscopies per year for uninsured patients. It would have seemed more convenient to move quickly towards this goal, but by slowing down and listening to our partners, we have gradually moved toward a solution that may be more effective in the long run. By focusing on improvement processes for navigation into hospital financial assistance programs, this project could potentially have a ripple effect of impacting healthcare access far beyond CRC screening. Our ability to shift strategy has required a great degree of patience and a commitment to inclusive, collaborative innovation.

One last thought

Our organization continues to be committed to reducing disparities around colorectal cancer screening. We are committed to continuing to see this work be successful by following up with health systems in terms of their financial programs, continuing to convene partners, and addressing some of the more complex solutions such as payment practices and policy.