Adults with Preventive Care Needs Guide

According to the U.S. Centers for Disease Control and Prevention (CDC), in 2020^[1] colorectal cancer, female breast cancer and cervical cancer resulted in over 98,000 deaths in the U.S. and over 10,000 deaths in California.

One of our more powerful tools in the fight against these three cancers is having all patients complete all the U.S. Preventive Services Task Force’s (USPSTF) recommended screenings. Despite the known benefits of screening, screening rates for these three cancers are suboptimal.^[2]

*The USPSTF is currently in the process of updating these guidelines, and clinical teams should review progress in order to incorporate current guidance.

Developing, implementing and continually improving a multifaceted and culturally relevant cancer screening protocol that includes all patients is critically important for a range of reasons:

• It helps avoid missed or delayed diagnosis, which is devastating to patients and their family and caregivers.
• A culturally relevant screening program can help to address inequities in access and outcomes by tailoring outreach and education to the populations served by your practice.
• It helps practices adhere to the most current cancer screening guidelines.

The work to ensure that all adults receive all recommended cancer screenings is a continuous effort and we still have much to learn. This document uses existing evidence, bright spots and examples from the field to offer practical guidance on improving the effectiveness of your cancer screening protocols, keeping in mind that it will be adapted to your practice’s unique context.  

Key activities in this guide are organized into three categories: 

• Foundational activities: Activities that all practices should implement as part of their cancer screening protocol.
• Going deeper activities: More advanced activities that build off the key activities and that help to ensure your practice can achieve equitable improvement in your cancer screening rates.
• On the horizon activities: Additional activities, including ideas worthy of testing that include the latest ideas and thinking on cancer screening.

Where to Start: While we recommend following the sequence of the key activities in this guide, the activities can be used individually or adapted to fit your practice’s priorities. 

Trying it Out then Making it Habit: For each activity, we provide guidance on how to plan, try, and implement the activity along with links to other resources, technology considerations and examples. Consider trying different versions of the action steps and roles with a smaller group before fully implementing at your practice. 

Maintaining Progress: Ongoing review and continual improvement are important for your practice to maintain your progress in population health management and help you stay nimble in adapting to changing patient demographics, new clinical best practices, new payment policies, workforce changes and other changes at your practice. For many activities we have also provided tips for periodically reviewing and making improvements to key workflows even after initially implementing the change 

If you implement the Foundational Activities in this guide, your practice should be able to achieve the following objectives: 

1. Engage patients served by your practice to validate any of your proposed process improvements and to propose alternative methods to improve quality in your focus area.
2. Analyze core quality measures to identify inequities and improvement opportunities for colorectal, breast and cervical screening rates.
3. Use evidence-based clinical guidelines, identify when and where it is necessary to update, or develop new protocol(s) for colorectal, breast and cervical screening.
4. Create an outreach protocol to reach and engage all attributed patients.
5. Create a health-related social needs screening process that informs patients’ treatment plans.
6. Assess current health information technology (HIT) capabilities and develop a plan for ongoing improvement in data utilization, care team workflows, and efficiency.

This guide also includes sections on measurement, equity, social health, behavioral health integration and an appendix including helpful tools and resources. We have included information about California Medi-Cal covered benefits and services that were up-to-date at the time of publishing, but benefits and billing guidance change over time. Nothing in this guide should be considered formal guidance, and anyone using this guide should check with the appropriate authorities on benefits and billing guidance. 

This is a living document and will change based on continued learning on this topic and may include additional activities, examples, resources and sections in the future. 

Additional Information can be found in Getting Started: Introduction to the PHMI Implementation Guides, and Aligning PHM Principles with Community Health Clinic Strategic Planning.

Improving the health of a population impacts everyone in a practice. Critical roles needed to engage in the work outlined in this guide and support practice change include:

• Quality improvement leadership, like a director of quality improvement (QI), to support cultural changes.
• Coaches or practice facilitators who are partnered with teams to help identify areas for improvement and support change through change management strategies.

PHMI’s approach emphasizes four foundational areas for PHM: a reimagined care team, empanelment, the business case, and data quality and reporting (DQ&R). These areas provide the foundation for the sustainable delivery of person-centered, population-based care and improving outcomes for a population of focus; see Building the Foundations for Population Health Management: Talking Points for Engagement for a concise overview and talking points for why these areas are important.

In addition, practices can reference specific Building the Foundations key activities to go deeper into specific challenges related to advancing equity, social health, behavioral health integration, and access and outreach for their population of focus:

Equity

• Business Case Guide: Advancing Equity Through Your Business Case
• Empanelment Guide: Advancing Equity Through Empanelment
• Data Quality and Report Guide: Advancing Equity Through Data Quality and Reporting
• Care Teams and Access Guide: Advancing Equity Through Care Teams and Workforce
• In this guide: Key Activity 4: Use a Systematic Approach to Address Inequities within the Population of Focus and Key Activity 16: Strengthen a Culture of Equity

Social Health

• Care Teams and Workforce Guide: Key Activity 1: Develop and test a core team structure
• In this guide: Key Activity 8: Use Social Needs Screening to Inform Patient Treatment Plans

Behavioral Health

• People with Behavioral Health Conditions Guide
• Care Teams and Workforce Guide: Key Activity 1: Develop and test a core team structure and Key Activity 2: Identify gaps in staffing and decide how to address them

Access and Outreach

• Empanelment Guide: Going Deeper: Connecting Empanelment with Patient-Centered Access
• Care Teams and Workforce Guide: Key Activity 2: Identify Gaps in Staffing and Decide How to Address Them
• In this guide: Key Activity 6: Conduct Proactive Outreach to Patients Due for Screening