Preventive Care - Key Activity 6

KEY ACTIVITY #6:

Conduct Proactive Outreach to Patients Due for Screening

 

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; proactive patient outreach and engagement.

Overview

This activity provides guidance on how practices can develop and use patient reminders to increase the percentage of patients who attend preventive care visits and complete recommended preventive care measures. This includes guidance on both the communication methods (e.g., phone, text, email, postal mail) and tailoring the content of the reminders to meet the needs of your practice’s patients. Conducting proactive outreach can ensure patients know about their recommended cancer screening and are able to access all recommended cancer screenings. Proactive outreach involves identifying and understanding subpopulations who may benefit from outreach, implementing reminders and touches for those populations, and cultivating a trusting and engaging environment.
This should include developing distinct strategies for three populations:

  1. Patients who are regularly seen by the practice for other health-related reasons (active patients).
  2. Patients who have been seen by the practice in the past but not over the last 12 months (inactive patients).
  3. People who are on the practice’s panel but have not been seen by the practice (empaneled, but not yet seen patients).

Proactive outreach is one way a practice can help to detect precancerous and cancerous conditions early. Culturally appropriate proactive outreach enhances early detection of colorectal, breast and cervical cancer. This improves survival rates and enhances patients' quality of life. Proactive outreach helps patients access all the recommended cancer screenings in accordance with your practice’s cancer screening guidelines, which can identify precancerous conditions and provide an opportunity for your practice to intervene before cancer develops.

This approach supports patients and families and boosts participation in preventive care. Numerous studies have demonstrated the effectiveness of culturally tailored patient reminders in helping ensure patients receive recommended cancer screenings.[1][2][3][4]

Practices can focus on equity by using data to identify which populations, subpopulations or groups the current outreach and education efforts don't reach. See the PHMI Data Quality and Reporting Guide the for more information.

Co-designing outreach strategies with community partners and current patients promotes cultural humility and sensitivity. Tailored outreach with personalized reminders addresses diverse needs, reducing inequities in access to care for chronic conditions.

Patient reminders should be tailored to the needs, preferences, culture, and likely barriers to screening of each patient and use their preferred method of communication, when feasible. This activity provides guidance for better tailoring reminders for several historically marginalized populations.

Unmet social needs (e.g., income insecurity, lack of transportation, and health illiteracy) can result in lower cancer screening rates. Proactive outreach, coupled with awareness of health-related social needs, can connect patients to community resources and build trust in the care team.

Which patients are eligible can be found in your practice’s care gap reports for colorectal cancer screening, breast cancer screening and cervical cancer screening. See Key Activity 3: Use Care Gap Reports or Registries to Identify All Patients Due for Cancer Screening for more details.

For high-risk patients or patients with complex health and social needs, consider care management as a more intensive approach for facilitating ongoing communication and coordination. Patient reminders should include information about common barriers to screening and how your practice can address them and, as your patient reminder system becomes more mature, can include more tailored messages for patients with known social needs.

This activity relies on similar capabilities as care gap management, utilizing population views and registries to track adult preventive healthcare gaps against screening guidelines. These registries can be utilized to generate outreach lists for appointment schedulers and/or care managers and other care team members who might be tasked with contacting patients due for services. Many EHRs are capable of storing next-appointment-data, which can also be used to generate lists and may link to automated appointment outreach workflows. Patient-facing outreach and engagement technologies can be utilized to deliver appointment reminders and for patient self-scheduling. Care managers might use care management applications to track and prompt adult preventive health needs, as well as wellness visits.

Other relevant HIT capabilities to support this activity include care guidelines, clinical decision-making support, including patient-facing clinical decision support, care dashboards, and reports. Some health centers may focus extra resources on adult patients identified as high-risk through risk stratification algorithms.

See Appendix E: Guidance on Technological Interventions.

Action steps and roles

1. Start by understanding your practice’s current reminder processes, content, methods and effectiveness (if any).

Suggested team member(s) responsible: Panel manager, data analyst or EHR data manager and multidisciplinary team for cancer screening.

More specifically, determine:

  • What reminders, if any, your practice sends out to patients who are eligible and due for colorectal, breast and cervical cancer screening.
  • What is the content and languages your practice uses to send cancer screening reminders to patients (if applicable) for initial screening and follow-up.
  • How and what communication methods does your practice use, including automated methods.
  • How often (e.g., with what frequency) does your practice send out reminders?
  • What types of reminders does your practice send including mailed reminders, postcards, letters, and electronic reminders (e.g., text, email, phone, and EHR portal).
  • What tailored content, if any, does your practice have for specific tests and specific populations (e.g., Black women, Native Americans, immigrants, patients who are uninsured or underinsured, etc.)

 

2. Understand the patient population eligible for colorectal cancer, breast cancer and cervical cancer screening at your practice.

Suggested team member(s) responsible: Panel manager.

This information can be found in your practice’s care gap reports for colorectal cancer screening, breast cancer screening and cervical cancer screening. See Key Activity 3: Use Care Gap Reports or Registries to identify All Patients Due for Cancer Screening for more details.

The care gap report should include the overall screening rate for colorectal cancer, breast cancer and cervical cancer and address the following:

  • To apply an equity lens, screening rates should be disaggregated by:
    • Race, ethnicity and language (REAL), sexual orientation and gender identity (SOGI) and similar data.
    • Any known patient needs and preferences that would inform the screening modalities offered.
    • Insurance status.
    • Data on any other characteristics, including social needs, that could pose a barrier to completing screening.

 

3. Use data to determine the populations of focus for your reminders.

Suggested team member(s) responsible: Panel manager and multidisciplinary team for cancer screening.

  • If your practice does not currently send reminders to patients for cancer screening, you may either elect to develop a broad reminder strategy in which every patient eligible and due for a cancer screening receives the same general reminder using the preferred communication method and/or tailored reminder strategy with customized messages and methods for one or more populations of focus (e.g. populations with low screening rates).
  • If your practice currently sends any reminders to patients for colorectal cancer, breast cancer and/or cervical cancer screening, you can use data on the current effectiveness of this effort to decide whether you want to improve your broad reminder strategy for all patients eligible and due for screenings and/or develop or improve more tailored reminder strategy with customized messages and methods for one or more populations of focus.
  • Most patients can benefit from reminders in their preferred language. We have provided links to general reminder materials in step four below.
  • Start with frequent no-show or missed appointment patients and seek to understand their root causes, which may be related to health-related social needs or health literacy issues. Ask your care teams to identify patients they consider high-risk patients who have been lost to care.
  • Some populations will require more customized culturally relevant reminders to increase their rates of recommended cancer screenings. We provide guidance and examples for developing reminders for specific populations of focus, in step five below.

 

4. Develop, refine and implement your practice’s general reminder strategy.

Suggested team member(s) responsible: Multidisciplinary team for cancer screening, administrative staff, IT staff.

Substeps for implementing your general reminder strategy include:

  •  Determine the content for the initial reminder and any planned follow-up reminders. For the initial reminder, we strongly recommend incorporating patient-specific information, such as name, recommended screening and due date to personalize your practice’s reminders.
  • Follow-up reminders should include additional content to explain the importance of getting screened now and may address the availability of support services to address barriers to screening. For example, common barriers to accepting colonoscopy include the time required to complete the test and transportation to a surgical center where the test is performed. A common barrier to cervical cancer screening is fear of the exam to procure the test. Subsequent messages may address such common barriers and offer assistance to overcome them.
  • Strong sources of guidance and/or sample reminders for cancer screening include:
  • Tailor the method of delivery, the frequency of message delivery, and the message to subpopulations based on their access to and use of technology, language, ethnic background, and other sociocultural elements and based on patient and community feedback.
  • Determine the communication method for reminders. This should include:
    • Segmenting the list of patients to receive a reminder by the patient’s preferred communication method, if known. For patients for whom the preferred communication is not known, consider using an automated reminder based on the contact information you have for the patient.
    • Using methods that your practice has the resources and bandwidth to sustain, including any automated reminders that your practice can provide.
    • Potentially using one method for the initial reminder and different methods for follow-up reminders. Follow-up reminders may include more personal methods, such as phone calls from your care team.
  • Schedule reminder delivery. This includes setting up automated reminders and follow-up reminders for patients who do not respond to initial reminders. Scheduling the reminders nearing a due date and follow-up reminders immediately following a due date may improve the effectiveness of the reminders. Depending on the bandwidth of your administrative team, this might include nonautomated phone calls as follow-up reminders to a subset of patients (e.g., patients at higher risk of cancer). Subsequent messages may need more tailored information that addresses common barriers to fulfillment of the recommendation, such as addressing transportation needs, addressing fears of screening, etc.
  • Send out the reminders. Send out the reminders using the agreed upon content, communication method(s) and scheduled frequency. Studies have shown that women preferred receiving text messages about mammography on a regular basis.
  • If the EHR allows, document the communication of the patient reminder, date and technique.
  • Monitor delivery and responses. This includes:
    • Monitor delivery rates, including bounce-backs and reminders flagged as undeliverable or similar. Attempt to find updated contact information for any reminder that couldn’t be delivered and update the EHR and/or contacts database with the new information.
    • Track responses. Depending on the method(s) used, this might include tracking:
      • Open rates (the reminder was opened).
      • Responses (the patient responded to the reminder, regardless of outcome).
      • Responses that result in initiating a cancer screening.
      • Responses that result in completing a cancer screening.
    • Track which methods yield better response rates for each of the above. Your practice can use this to improve (see step nine below).

 

5. Develop, refine and implement tailored reminders and outreach strategies for populations of focus.

Suggested team member(s) responsible: Multidisciplinary team for cancer screening or their designees.

  • Use your care gap reports and stratified data to identify populations or groups for whom your practice has lower screening rates and who might benefit from tailored strategies.
    These populations vary but often include:

    • Patients of color.
    • Patients for whom English is not their primary language.
    • Immigrants and refugees.
    • Patients with no insurance.
    • Patients with behavioral health needs.
    • Patients experiencing homelessness or housing instability.
    • Patients with physical or developmental disabilities.
    • Patients with lower literacy levels.
    • Other historically marginalized populations.
  • Determine which of the three populations you have the bandwidth to develop tailored strategies for, beginning with one population one, if needed):
    • Patients who are regularly seen by the practice for other health-related reasons (active patients).
    • Patients who have been seen by the practice in the past but not over the last 12 months (inactive patients).
    • People who are on the practice’s panel but have not been seen by the practice (empaneled but not yet seen patients).
    • Gather insights from the population of focus to better understand their needs and preferences regarding reminders and reminder methods. If you have existing messaging available, have members of the population of focus provide feedback on this including, what works, if anything; what was confusing, if anything; and what they think would need to be improved upon, if anything
    • Use these insights to develop new ideas for reminders or to refine existing reminders for this population. Ideally, this ideation is done with representatives of the population of focus, as they have expertise and experience that may be missing from the practice’s care team. This might include having members of the population of focus:
      • Develop the reminder message content. Having experts review to ensure compliance with clinical guidelines.
      • Design or refine the layout for written messages.
      • Send the message from a trusted member of their community rather than your practice.
      • Change the timing of the reminder or follow-ups to the reminder.
      • Change the reminder method or experiment with new methods.
  • Using the insights and ideas you have developed, finalize the content for the reminders and implement the revisions. For the initial reminder, we strongly recommend incorporating patient-specific information, such as name, recommended screening, and due date to personalize your practice’s reminders. Follow-up reminders might include additional strategies to explain the importance of getting screened now.
  • Use touches that provide alternatives to the traditional office visit. Assess what types of interaction or care can be provided outside this setting and collaborate with patients as part of initial care planning to understand their preferences for communication and care team interactions. Examples include:
    • Nursing visits (virtual).
    • Pharmacy visits.
    • Digital communication through emails, texts and patient portals.
    • Newsletters focused on a specific condition.
    • Social media that includes discussion groups relative to the conditions of focus.
    • Home visits for high-risk, historically marginalized or mobility-challenged patients.
    • Other technological solutions, such as apps focused on patient conditions, which provide a vehicle for ongoing engagement.

 

6. Develop a follow-up system to proactively reach and engage patients who have not responded to reminders.

Suggested team member(s) responsible: Care team.

Segment your population. This action step should develop distinct strategies for three populations:

  • Patients who are regularly seen by the practice for other health-related reasons (active patients).
  • Patients who have been seen by the practice in the past but not over the last 12 months (inactive patients).
  • People who are on the practice’s panel but have not been seen by the practice (empaneled but not yet seen patients).

Use the practice’s EHR or other tools to track patients who have not responded to reminders.

  • Assign a member of the implementation team to track results of patient notification for cancer screening efforts and identify those who are eligible but have not responded within two months.
  • Create a subregistry of those who have not yet responded to the recommendations.
  • Determine if the patient is active (being seen by the practice), inactive (has been seen by the practice in the past but not in the past 12 months), or has never been seen (patient is on the panel but has never come into the practice).

Identify and attempt to correct errors in contact information.

  • The designated care team member reviews the registry of those who have not responded and attempts to identify possible sources of error(s) (e.g., patient is no longer at the address, patient no longer has the phone number, etc.) and correct these errors.
  • In cases where the practice is able to find updated contact information for a patient, the practice will resend the reminder to the patient.

Develop more focused outreach to patients for whom the practice appears to have correct contact information, but who have not responded to the general reminder(s). Since your practice’s bandwidth is limited, you might consider starting with your active patients, moving on to inactive patients once you are seeing success with your active patients, and tackling your not-yet-seen patients once you are seeing success with your inactive patients.

  • For the practice’s active patients:
    • The designated team member determines whether the patient has an upcoming appointment (within the next two months) at the practice for another reason.
    • If so, the team member creates an alert in the patient record to notify the clinical team and provider about the patient’s eligibility for cancer screening (see Key Activity 9: Partner with Patients to Discuss Cancer Screening During Patient Visits).
    • If the patient does not have an upcoming appointment, work with the care team to identify alternate methods to outreach to the patient, such as a community health worker (CHW) visit, cell phone text message, etc.
    • If contact with the patient is achieved, discuss recommended screening with the patient, identify potential barriers, and work with the patient and team to offer strategies to address barriers (e.g., transportation or at-home sample procurement, such as fecal-based testing.)
  • For the practice’s inactive patients:
    • Start by determining if there are any other reasons to schedule a patient visit (e.g., annual visit, high blood pressure, diabetes, etc.).
    • If there are other are other reasons for scheduling a visit, attempt to contact the patient to schedule the visit due to the reasons identified and, if they are willing to schedule a visit, create an alert in the patient record to notify the clinical team and provider about the patient’s eligibility for cancer screening (see Key Activity 9: Partner with Patients to Discuss Cancer Screening During Patient Visits).
    • If there are no other obvious reasons for scheduling a visit, work with the care team to identify alternate methods to outreach to the patient, such as a CHW visit, cell phone text message, etc.
    • If contact with the patient is achieved, discuss recommended screening with the patient, identify potential barriers, and work with the patient and team to offer strategies to address barriers (e.g., transportation or at-home sample procurement, such as fecal-based testing.)
  • For people who are on the practice’s panel but have not been seen by the practice (empaneled, but not yet seen patients):
    • Work with the care team to develop a customized message for the person to consider coming into the practice for care, and identify alternate methods to outreach to the patient, such as a CHW visit, cell phone text message, etc.
    • If contact with the patient is achieved, discuss recommended screening with the patient, identify potential barriers, and work with the patient and team to offer strategies to address barriers (e.g., transportation or at-home sample procurement, such as fecal-based testing.)

For going deeper in this area, consider Key Activity 15: Strengthening Community Partnerships to provide outreach to others outside of your patient population. Community partners can support outreach and health literacy efforts, participate in co-design by providing insight around a particular patient population, and provide resources and support for patients. See also Key Activity 10: Use Culturally Appropriate Educational Materials for Cancer Screening.

 

7. Track the effectiveness of your reminder and outreach strategy.

Suggested team member(s) responsible: Quality improvement lead or their designee.

For the overall population of patients due for cancer screening, as well as the subpopulations your practice is focusing on, regularly (at least quarterly) use the data from your care gap reports to determine if your strategies are increasing the percentage of patients who are having all recommended screenings while reducing inequities in screening rates.

 

8. Put in place formal and informal feedback loops with patients and the care team.

Suggested team member(s) responsible: Multidisciplinary team for cancer screening or their designees.

To help ensure that educational materials meet the needs of patients and the processes involved are consistently feasible for the care team, it is important to have both formal and informal feedback loops.

  • For patients, feedback loops might include:
    • Sharing current reminders to gather feedback and incorporate that feedback into revised reminders.
    • Getting verbal feedback from patients directly after testing a new reminder or a new reminder strategy with them and incorporating their feedback into your next test.
    • Patient satisfaction surveys (or similar).
    • Follow-up calls with a subset of patients to understand what works well and what could be improved.
    • Patient focus groups.
    • Having the practice’s patient advisory board (or similar body) provide feedback.
  • For the care team, feedback loops might include:
    • Daily huddles.
    • Existing or new staff satisfaction and feedback mechanisms.
    • Regularly scheduled meetings and calls to get staff feedback on the cancer screening reminder systems.

 

9. Use quantitative and qualitative data (see steps six and seven above) to improve the effectiveness of reminders.

Suggested team member(s) responsible: Multidisciplinary team for cancer screening or their designees.

This ongoing work might include:

  • Refining the content of reminders, based upon feedback.
  • Modifying the communication method(s) used for reminders.
  • Further automating reminders.
  • Developing tailored reminder strategies for one or more populations of focus who have lower reminder response rates.
  • Using human-centered design methods to develop new ideas.
  • Using quality improvement strategies, methods and tools to improve areas of focus.

 

10. Cultivate a trusting and engaging environment where patients feel comfortable in accessing care.

Suggested team member(s) responsible: Care team.

  • Co-design outreach and engagement strategies with community partners and people using the practice’s services.
  • Train all staff in cultural humility, motivational interviewing skills, and the use of trauma-informed care.
  • Sponsor peer groups and group visits of similar patient segments of your population to foster peer engagement and support.
  • Sponsor support groups for caregivers of patients with chronic conditions.
  • Leverage your current patients and staff as potential trusted messengers to engage patient subgroups.

Implementation tips

  • Where there is a backlog of patients due to address a gap in care, consider a campaign where you bring patients in who are overdue for similar screenings, labs or vaccines.
  • Consider scheduling outreach to these patients on days when you might experience a lower volume of activity in order to level the demand on the care team.
  • Utilize multiple pathways to reach and engage patients.
  • Communicate where potential patients are most comfortable.
  • Regularly update outreach strategies based on community feedback and changing demographics.
  • See also Appendix D: Peer Examples and Stories from the Field to learn about how others are implementing this activity.

Evidence base for this activity

Denberg TD, Myers BA, Eckel RH, mcdermott MT, W. Perry Dickinson, Lin CT. A patient outreach program between visits improves diabetes care: a pilot study. International Journal for Quality in Health Care. 2009 Apr 1;21(2):130–6.

Ntiri SO, Swanson M, Klyushnenkova EN. Text Messaging as a Communication Modality to Promote Screening Mammography in Low-income African American Women. Journal of Medical Systems. 2022 Apr 13;46(5).

Subramanian S, Tangka FKL, Hoover S, DeGroff A. Integrated interventions and supporting activities to increase uptake of multiple cancer screenings: conceptual framework, determinants of implementation success, measurement challenges, and research priorities. Implementation Science Communications. 2022 Oct 5;3(1).

Endnotes

  1. Adams SA, Rohweder CL, Leeman J, Friedman DB, Gizlice Z, Vanderpool RC, et al. Use of Evidence-Based Interventions and Implementation Strategies to Increase Colorectal Cancer Screening in Federally Qualified Health Centers. Journal of Community Health. 2018 May 16;43(6):1044–52. 
  2. Power E, Miles A, von Wagner C, Robb K, Wardle J. Uptake of colorectal cancer screening: system, provider and individual factors and strategies to improve participation. Future Oncology. 2009 Nov;5(9):1371–88. 
  3. Subramanian S. Adherence with colorectal cancer screening guidelines: a review. Preventive Medicine. 2004 May;38(5):536–50. 
  4. Sequist TD, Zaslavsky AM, Marshall R, Fletcher RH, Ayanian JZ. Patient and Physician Reminders to Promote Colorectal Cancer Screening. Archives of Internal Medicine. 2009 Feb 23;169(4):364.