Preventive Care - Key Activity 9

KEY ACTIVITY #9:

Partner with Patients to Discuss Cancer Screening During Patient Visits

 

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

Overview

This activity provides guidance on how the practice’s care team will use patient visits scheduled for other reasons as an opportunity to discuss any needed colorectal, breast and/or cervical cancer screening and provide education, including choice of testing, where feasible, to patients.

Numerous studies[1] [2] have demonstrated that having a clinician discuss the need for cancer screening directly with a patient is among the most effective and efficient strategies to support fulfillment of screening recommendations for colorectal, breast and/or cervical cancer. Developing skills to enable these critical conversations will increase the likelihood of success. In addition, patient education, discussing the benefits and risks of cancer screening, and offering a choice of testing modalities, where feasible, have all demonstrated improvement in cancer screening rates.[3] Discussions about cancer screening should also address concerns the patient has about engaging in screening activities so that these can be taken into consideration and addressed.

The approach to this discussion cannot be one-size-fits-all and needs to be tailored to the needs, preferences, culture, and likely barriers to screening of each patient. This activity provides guidance for better tailoring the conversation for several historically vulnerable populations. This should include the care team asking the patient about their concerns regarding the screening and about barriers or concerns in accessing the screening, many of which are related to social needs. Clinicians should explain the risks and benefits of the test and have relevant educational materials available.

It is important that data fields and workflows are configured to accurately capture preventive care declination to understand and manage this common challenge. Patient outreach and engagement technologies can assist the care team in assessing hesitancy, as well as delivering education. These technologies can be programmed to deliver scripted responsive interactions that can extend the ability of the care team to spend time addressing concerns and questions. Care dashboards and quality reports can be utilized with data analytics to identify trends that might suggest population-level strategies. Additionally, care should be exercised to understand population differences that might be contributing to patient declination. The use of data stratified by health-related social needs and other equity markers is encouraged to identify barriers to screening. Clinical templates and/or prompts in the EHR and care coordination applications can guide provider and care team discussions.

As outlined elsewhere, use of patient-facing technology can be utilized to augment direct discussion through education. Increasingly, these applications can be utilized in interactive ways and may be implemented in ways to provide options to engage the care team.

Action steps and roles

1. Use pre-visit planning and/or huddles to initiate this process.

Suggested team member(s) responsible: Primary care provider (PCP) and medical assistant (MA) for each panel.

This process starts during daily pre-visit planning and huddles by identifying which patients will need a reminder about the need for cancer screening(s) and the plan for having this conversation during the patient visit, including who will initiate the conversation and when. Patients who are eligible for screening tests should be flagged so that the PCP recognizes the need for guidance and recommendation. For more information, see Key Activity 8: Refine and Implement a Pre-Visit Planning Process and PHMI Care Teams and Workforce Guide Resource 4: Daily Huddles Overview and Process.

 

2. During the patient visit, discuss the need for colorectal, breast and/or cervical cancer screening and the importance of the screening(s) with the patient.

Suggested team member(s) responsible: Designated care team member, based on pre-visit planning.

The designated care team member should initiate the conversation about the need for screening. Based on the patient's age, risk factors, and medical history, the care team member should explain the importance of cancer screening. Effective communication strategies include:

  • Asking open-ended questions about the patient's health, well-being and health goals.
  • Listening attentively to patient questions or reservations and providing accurate, empathic answers.
  • Promoting shared decision-making with the patient.

This should be done in the preferred language of the patient, using interpretation services as needed. Use or adapt existing curricula, scripts, patient materials, visuals and/or videos to help patients understand the importance of cancer screening. See the resources for this activity below.

 

3. As needed, discuss the benefits and potential risks of colorectal cancer, breast cancer and/or cervical cancer screening with the patient.

Suggested team member(s) responsible: Designated care team member, based on pre-visit planning.

Use or adapt existing curricula, scripts, patient materials, visuals and/or videos to help patients understand the benefits and potential risks of cancer screening. This can include any differences in benefits or risks for the choice of screening modalities appropriate for them.

See the resources for this activity section below.

 

4. Discuss the choice of screening modalities with the patient when this is an option, and allow patients to select their preferred method.

Suggested team member(s) responsible: Designated care team member, based on pre-visit planning.

Offering patients a choice in healthcare screening methods, where choices exist, can increase the rate of screening completion. For example, patients are less likely to undergo colorectal cancer screening if the primary care practitioner only recommends colonoscopy, but screening rates increase when the provider offers the option of at-home fecal testing. Offering patients a choice allows them to address barriers to care, such as transportation, time limitations, or fear of anesthesia. Offering options places the patient in a position of authority over their own care.

See the resources for this activity section below

 

5. Discuss which screening is covered and any out-of-pocket costs for cancer screening with the patient.

Suggested team member(s) responsible: Designated care team member, based on pre-visit planning.

Helping ensure that the recommended screening(s) are covered or low-cost may involve working with the patient’s health insurer, if one exists, modifying the timing of the screening, and other strategies. For patients who are not on Medi-Cal, this may require exploration with the insurer to verify coverage. Use or adapt existing curricula, scripts, patient materials, visuals and/or videos to help patients understand what is covered and what the out-of-pocket costs are related to colorectal cancer screening. See the resources for this activity section below.

 

6. As needed, discuss barriers to screening with the patient.

Suggested team member(s) responsible: Designated care team member, based on pre-visit planning.

Many patients have barriers to screening. To help reduce barriers (e.g., transportation, mobility, instructions in their preferred language, etc.), have an open discussion with each patient to understand the barrier(s) and co-develop potential ways to address each barrier with the patient. After the discussion, document the barriers and any strategies to address them in the EHR.

The Community Guide, endorsed by the American Academy of Family Physicians (AAFP), discusses specific interventions that can address structural barriers to breast, colon and cervical cancer screening.

 

7. Use quality improvement (QI) methods to test and refine all changes before bringing them to full scale at the practice.

Suggested team member(s) responsible: Panel manager and QI lead or their designee.

Whenever trying a new or adapted script, educational resource, or process, use plan-do-study-act (PDSA) cycles. We recommend starting with small-scale tests (e.g., test with one patient or for one afternoon). Study the results of the test and then refine the process, script or educational resource, as needed, as you test again. Continue increasing the scale of your tests as you see them achieving better results under a wider range of conditions.

While this may appear like it would slow down the full implementation of the change, by working out the inevitable kinks in the process before taking it to full scale, the practice will actually save time, resources, and frustration, while making the process better for patients. Testing and refining also can eliminate the costly workarounds that occur when a policy or system doesn’t fit well into the system or workflow it is being placed into. Generally, start as small as feasible – think “ones” – (e.g., one clinician, one hour, one patient, etc.) and become larger as your degree of belief in the intervention grows.

Selected resource on quality improvement (QI):

 

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

Suggested team member(s) responsible: Panel manager and QI lead or their designee.

To help ensure this activity is meeting the needs of patients and is consistently feasible for the care team, it is important to have both formal and informal feedback loops.

For patients, feedback loops might include:

  • Patient satisfaction surveys (or similar).
  • Follow-up calls with a subset of patients to understand what went well and what could be improved.
  • Patient focus groups.
  • Having the practice’s patient advisory board (or similar) provide feedback.

For the care team, feedback loops might include:

  • Existing or new staff satisfaction and feedback mechanisms.
  • Regularly scheduled meetings and calls to get staff feedback on processes, methods and tools.

See also the Key Activity 10: Use Culturally Appropriate Educational Materials for Cancer Screening and Key Activity 11: Provide or Arrange for Cancer Screening for guidance on providing screening to patients who express interest in this.

Implementation tips

  • Always try to test each action or substep on a very small scale to work out kinks and challenges before scaling up the action or substep. This will save time and frustration.
  • Consider how your existing technology can be leveraged to automate or partially automate the steps in this activity (e.g., EHR, automated survey mailers, email platforms, etc.).
  • Combining clinician counseling and patient education materials improves patient likelihood of follow-through.
  • 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

Alberti LR, Garcia DP, Coelho DL, De Lima DC, Petroianu A. How to improve colon cancer screening rates. World J Gastrointest Oncol. 2015 Dec 15;7(12):484-91.

Dalton AF, Golin CE, Morris C, et al. Effect of a Patient Decision Aid on Preferences for Colorectal Cancer Screening Among Older Adults: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open. 2022;5(12):e2244982. doi:10.1001/jamanetworkopen.2022.44982.

Endnotes

  1. Alberti LR, Garcia DPC, Coelho DL, Lima DCAD, Petroianu A. How to improve colon cancer screening rates. World Journal of Gastrointestinal Oncology [Internet]. 2015;7(12):484. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4678395/ 
  2. Baron RC, Melillo S, Rimer BK, Coates RJ, Kerner J, Habarta N, et al. Intervention to Increase Recommendation and Delivery of Screening for Breast, Cervical, and Colorectal Cancers by Healthcare Providers. American Journal of Preventive Medicine. 2010 Jan;38(1):110–7. 
  3. Peterson EB, Ostroff JS, DuHamel KN, D'Agostino TA, Hernandez M, Canzona MR, Bylund CL. Impact of provider-patient communication on cancer screening adherence: A systematic review. Prev Med. 2016 Dec;93:96-105.