Beautiful, rural Mendocino County is home to a diverse population of families, service industry workers, loggers, fishermen, and a growing Hispanic community. The area also faces significant challenges with substance abuse, high rates of fentanyl-related deaths, and homelessness. Amidst these challenges, PHMI cohort member Mendocino Coast Clinics (MCC) is working on a new patient engagement strategy to reach its region’s most vulnerable people and improve cancer screening rates.
The need for a more tailored approach to screening surfaced when MCC analyzed its colon cancer screening rates and realized that people experiencing homelessness were more likely to die from cancers that are manageable with proper screening.
“The systems we have in place make it almost impossible for homeless individuals to get these screenings,” says Jeremie Foley, Director of Operations at MCC. As Foley explains, current screenings require insurance, a prescription, and a stable address to receive and return test kits. They also require a clean, safe space to use the restroom, which is often not available to people experiencing homelessness.
To address these barriers, the team realized they needed to directly engage with the population and meet them where they are. Through population surveys and interviews and by collaborating with community partners, MCC developed and continues to refine its strategy to provide the necessary supports and resources for screenings.
Key insights from implementing their strategy are highlighted below.
Enlist the Support of Trusted Community Partners
Early on, MCC enlisted the support of the Mendocino Coast Hospitality Center, a local hub for homeless individuals to receive meals, temporary housing, street medicine, social support, and therapy. Feedback was gathered in-person at the Hospitality Center, supported by a street medicine provider who had already established trust with the homeless community and the Center staff.
Key insight: Enlisting the help of trusted community members who have established connections within the community is essential for successful patient engagement - encouraging openness among participants, leading to more honest and insightful feedback and better responses to outreach efforts.
Ask Broad Questions
To gain insights from the unique perspectives of patients or potential patients, the team asked broad, open-ended questions. They first wanted to gain a general sense of the barriers a person experiencing homelessness might face in seeking medical care, and then focused on barriers to screening for colorectal cancer. Questions included:
- What is your experience trying to get medical help when you're sick?
- Have you had a colorectal screening before, or when was the last one?
- Are you interested in getting a colorectal screening?
- What would make it easier or harder to get screened?
- What might motivate you to get screened (e.g., gift card, food)?
- Where would be the easiest place for you to take the test?
- Do you need access to a bathroom, privacy, and safety to complete the test?
- What haven’t I asked?
Key insight: It's important to not only ask predefined questions but also to leave room for open-ended ones. Checking assumptions in the questions asked can avoid responses that are limited to what might seem obvious to the provider. This also allows for more meaningful and productive feedback, with patients being able to express their true needs and concerns.
Use Insights to Guide Implementation
Participants shared a range of concerns about the screening process. Some expressed skepticism about the test, with concerns about privacy and handling the process, such as, "I don’t want the man to have my DNA," or "I’m not going to poop in a box for anyone." Practical issues also surfaced, like confusion over the test kit’s instructions. Some participants abandoned the test because the process seemed too complicated. Others indicated that incentives like food or gift cards would motivate them to complete the test, with $50 being the preferred amount.
Based on additional feedback, the promotional materials MCC developed were redesigned to make the process clearer and more accessible. Signs were simplified with lower literacy levels and more straightforward language.
Then, MCC used these insights for planning and implementation. To encourage participation, they distributed posters in various community locations such as food banks and churches. The event itself, which attracted 22 participants, consisted of a special breakfast with an elaborate spread of foods like smoked salmon to elevate the occasion. During the event, a video was shown explaining the screening process, and patient advocates were available to help individuals—19 in total—sign up for the colorectal cancer screening kits. Trained staff at the Hospitality Center were on hand to distribute the kits and provide instructions.
Key insights: The discovery phase can help create inclusive, culturally sensitive experiences and better reach populations of interest. Providing a safe and welcoming space, along with ongoing support from patient advocates for challenging or potentially confusing processes, can further remove barriers to participation.
Ask for Continuous Feedback and Adjust as Needed
The event revealed that participants wanted immediate results—many expected to drop off their sample and receive their $50 gift card immediately. While most participants had Medi-Cal, the program faced challenges. A significant portion of the participants could not be located afterward, and many did not return to complete the screening. Only one participant returned the kit. Based on this feedback, MCC plans to set a deadline for participation, provide more immediate follow-up, and have street medicine staff available once a week to emphasize the urgency of completing the process.
Key insights: Though the initial screening initiative didn't yield the desired results, the experience provided valuable insights. MCC learned the importance of involving the population not only in the planning phase but also in the ongoing process, including asking for feedback on what felt right and what didn’t. They found that understanding why people do or don't participate in health screenings, and gaining perspective on their motivations, is crucial. The process has highlighted the need for ongoing communication and adjustments to better meet the population's needs.
Looking Ahead
The MCC team plans to apply these lessons to future health initiatives with a more inclusive approach that involves the population throughout. For instance, during their new “Pap-athon” initiative to encourage pap smears, they ask “Why did you decide to participate?” rather than only focusing on barriers to participation. They also intend to continue refining their strategy, recognizing that change may come gradually with repeated nudges. Additionally, they are hopeful that upcoming developments, like a new blood test for colorectal cancer screening, could resolve many of the current barriers and make it easier to reach marginalized populations.
Ultimately, this approach to engagement can be applied across different patient populations to improve outcomes and better tailor health initiatives.
As a participant in PHMI, MCC receives grant funding, in-person and virtual peer learning opportunities, one-on-one technical assistance, coaching, and subject matter expertise on population health management, health information technology, equity, and social health.
MCC’s PHMI Population of Focus is Adults with Preventive Care Needs, with a specific focus on cancer screening.