KEY ACTIVITY #3:

Use Care Gap Reports or Registries to Identify All Patients Due for Cancer Screening

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; implement condition-specific registries; address social needs.

Overview

This key activity provides detailed guidance on how to develop and use a continuously updated list of all patients eligible for recommended screenings through a care gap report or registry. Please note that this activity focuses on specific cancer screenings, but many other preventive and maintenance services are needed to provide comprehensive preventive care. See the Pre-Visit Planning: Leveraging the Team to Identify and Address Gaps in Care resource for a more complete list.

Care gaps are gaps between the recommended care that a patient should receive according to clinical guidelines and the care a patient has actually received.

Most EHRs already have a module that identifies what services are due for each patient (see examples below). It is important that clinicians address these services and document efforts to communicate with patients about the screening recommendations, barriers that may affect the patient’s ability to undergo the screening, choices for screening available to the patient, and other relevant information in the EHR. Some patients may have elected to pursue screening through another provider. For example, a person may have obtained a mammogram through an outside provider. Efforts should be made to enter the date of screening into the practice’s EHR and to obtain the results of the screening and enter that information into the EHR through an electronically accessed report or scanning the report.

FIGURE 3, FIGURE 4, FIGURE 5: EXAMPLES OF INDIVIDUALS WITH CANCER SCREENING CARE GAPS 

FIGURE 6 AND FIGURE 7: EXAMPLES OF A CARE GAP REPORT.

FIGURE 8 AND FIGURE 9: EXAMPLES OF CARE GAP REPORTS FOR A POPULATION FOR COLORECTAL CANCER SCREENING.

Rather than put the responsibility on the individual care team member for searching through charts or remembering which patients need further preventive care or follow-up, this activity provides guidance for how the practice can efficiently leverage electronic health records (EHRs) for all its patients.

Action steps and roles

1. Plan the care gap report.

Suggested team member(s) responsible: Panel manager or data analyst. If it is not clear how the report can be produced, this step may involve one or more people from the practice who work on the EHR and, possibly, the EHR vendor.

For adults with preventive care needs, use guidance from your cancer screening protocols to build care gap reports for all patients eligible and due for colorectal cancer, breast cancer and cervical cancer screening. Identify the inclusion criteria for each report, such as age, any exclusion criteria, and factors that make someone high-risk. You can build reports across different risk states, such as identifying those with a higher risk for colorectal cancer because of their family history of colorectal cancer, a personal history of inflammatory bowel disease, or a personal history of colorectal polyps.

Generating a report within the EHR is more complicated for colorectal cancer screening because multiple testing options are available to patients, and each test has its own frequency recommendation. It is less complicated for breast and cervical cancer.

For colorectal cancer screening, it is essential to know the type of test last performed to determine the retesting schedule. For example, those who have had a fecal immunochemical test (FIT) test for colorectal cancer are recommended to screen annually, while those who underwent colonoscopy are placed on a 10-year schedule, provided that the test results were negative. In all cases, your cancer screening protocols and the care gap report should be updated to capture the latest recommended frequency for rescreening (see Key Activity 2: Develop or Update the Practice’s Cancer Screening Protocols).

2. Build the report.

Suggested team member(s) responsible: Data analyst.

Determine whether the EHR has an existing report or one that can be modified to fit the inclusion and exclusion criteria. You should talk to staff who are familiar with the electronic record; in some cases, it may be necessary to consult with the EHR vendor to confirm this information and how to run the report.

The care gap format should include:

• Criteria for inclusion and exclusion in the report.
• The overall compliance rate for the care gap being measured.
• All patients eligible for the screening and their addresses and phone numbers.
• The last date the test was performed, if known or if applicable, the previous results, and the type of test used.
• Preferred method of communication (e.g., phone, email, text).

Reports should be able to display and/or disaggregate the data based on:

• Race, ethnicity and language (REAL) as well as sexual orientation and gender identity (SOGI).
• Any known social or behavioral needs.
• Communication preferences or other preferences that would inform the screening modalities offered, such as documented declination of prior screenings.
• Data on any other characteristic, including insurance data, that could pose a barrier to completing screening.

3. Standardize the data format.

Suggested team member(s) responsible: Panel manager or data analyst.

Standardizing the data format and where and how it is entered is critical to ensuring accuracy in the report.

Document how each data element must be entered into the EHR to populate the fields needed for reporting. In some cases, data on completion of screening must be entered by hand (e.g., when the test is performed by a lab that does not communicate with the EHR). Doing this will require a decision on the part of the practice as a whole and may require staff training and reinforcement on an ongoing basis. Where issues or apparent confusion are identified, regular discussion at team huddles or staff meetings will help in maintaining a standard approach.

Tip: Assign responsibility for the initial review of the reports to confirm data integrity.

4. Develop workflows to support improved patient screening completion rates.

Suggested team member(s) responsible: Panel manager and care team.

At the patient level, ensure that the care gap report can be used for or linked with reminders or alerts for clinicians, as well as for sending reminders to adults who need to come into the practice for recommended cancer screening.

Depending on communication preferences that have been expressed by patients, the patient care gap report may be exported to an automated reminder system that can trigger reminders by phone, text, email, or postal mail. Several studies and case studies have indicated that personal calls are more effective, so in the absence of a known patient preference, practices should consider personal calls as a strong option.

For adults with preventive care needs, cancer screening reminders can get particularly complicated. See Key Activity 7: Create and Use Clinician Reminders.

In addition, as part of the practice’s pre-planning process, patient care gaps should be reviewed and flagged as part of the daily huddle. See Key Activity 8: Refine and Implement a Pre-Visit Planning Process for more details.

5. Develop a process for review of gaps at the population level.

Suggested team member(s) responsible: Panel manager.

Set a report frequency to review care gap reports at regular care team meetings or huddles to develop a plan for improvement at the population level. This may include an outreach campaign to build community awareness of the value of screenings and the availability of easily accessed screening services.

6. Monitor the care gap report for accuracy and completeness.

Suggested team member(s) responsible: Panel manager or data analyst.

It is critical to have bidirectional feedback with the practice’s care team about any real or potential errors in the care gap report, such as:

• Errors in how the data is entered compared to what is required under the new standardized data format.
• Patients who are eligible for and due for screening who are missing from the report.
• Patients who have recently been screened who are still listed as due for a screening.

Errors should be investigated through a chart review. If errors in the report specifications are discovered, the care gap report or process for producing the report should be modified. If the issue is incorrect documentation, staff training and reinforcement of documentation standards will be required.

Additional consideration for sustainability: Ensure there is an internal process for updating the criteria included in the EHR for care gap reports as clinical guidelines change.

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

Conderino S, Bendik S, Richards TB, Pulgarin C, Chan PY, Townsend J, Lim S, Roberts TR, Thorpe LE. The use of electronic health records to inform cancer surveillance efforts: a scoping review and test of indicators for public health surveillance of cancer prevention and control. BMC Med Inform Decis Mak. 2022 Apr 6;22(1):91. doi: 10.1186/s12911-022-01831-8. PMID: 35387655; PMCID: PMC8985310.

Sequist TD, Zaslavsky AM, Marshall R, Fletcher RH, Ayanian JZ. Patient and physician reminders to promote colorectal cancer screening: a randomized controlled trial. Arch Intern Med. 2009 Feb 23;169(4):364-71.

KEY ACTIVITY #4:

Use a Systematic Approach to Address Inequities within the Population of Focus

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; implement condition-specific registries; proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination; behavioral health integration; address social needs.

Overview

This activity provides guidance for a systematic, evidence-based approach for identifying and then reducing inequities for adults with preventive care needs. It focuses on the first primary driver in PHMI’s equity framework: Reduce inequities for populations of focus.

FIGURE 10: PHMI DRIVER DIAGRAM

Action steps and roles

1. Build the data infrastructure needed to accurately collect REAL, SOGI, social needs and other demographic data.

Suggested team member(s) responsible: Data analyst.

• Race, ethnicity and language (REAL).
• Sexual orientation and gender identity (SOGI).

The PHMI Data Quality and Reporting Guide provides guidance and several resources for collecting this information. According to this guide, the initial step in addressing disparities is to collect high-quality data that fosters a holistic view of patient characteristics and needs. This entails incorporating REAL data, demographic data (age, SOGI, geography) and social needs data. By collecting and monitoring this information, healthcare practices can gain valuable insights into disparities in access, continuity and health outcomes. Steps two to four below provide more information on this process.

Collecting REAL information allows for practices to identify and measure disparities in care while also ensuring that practices are able to interact successfully with patients. This is done by understanding patients’ unique culture and language preferences.^[6] KHA Quality has a toolbox that assists with REAL data collection.

The Uniform Data System (UDS) Health Center Data Reporting Requirements (2023 Manual) provides detailed guidance on REAL and SOGI. While UDS does not currently require that practices report on the preferred language of each patient, practices should make an effort to identify and record each patient’s preferred language due to UDS reporting still requiring for languages other than English to be reported.

Accurate data collection requires appropriate fields and options in the EHR and other employed technologies, as well as appropriate human workflows in collecting the data. Staff responsible for data collection should be continuously trained and assessed for best practices in data collection, including promotion of patient self-report.

In addition, practices should work to ensure that patients understand the importance and use of this information to help them feel comfortable and support its collection. High rates of “undetermined” or “declined” responses in these fields may be indicative of the need to attend to these staff training needs.

Collecting this data is important, especially to obtain a complete picture of health for patients who identify as transgender. There are certain risks and condition indicators that are gender-specific, which impact how providers provide care to a patient. This should also be taken into account for cancer screenings for patients who have transitioned but carry the risk of certain cancers based upon their gender at birth and degree of transitioning (e.g., a transgender male who still has a cervix may still be at risk for cervical cancer). By understanding the needs of patients more fully, providers can make more informed decisions for the best treatment of their patients. The World Professional Association for Transgender Health (WPATH) has provided further guidance regarding standards of care related to gender diversity.

2. Use the practice’s electronic health record (EHR) and/or population health management tool to understand inequitable health outcomes at your practice by stratifying your data.

Suggested team member(s) responsible: Data analyst.

This includes reviewing your care gap report or care registry and being able to stratify all of the following:

• Core measures for the population of focus.
• Supplemental measures for the population of focus.
• Process measures for the population of focus.

Stratify this data by:

• Race, ethnicity and language (REAL).
• Sexual orientation and gender identity (SOGI).
• Other factors that can help identify subpopulations in need of focused intervention to reduce an equity gap (e.g., immigrants, people experiencing homelessness, literacy levels, etc.).

Figure 11: Example of data stratified by race and ethnicity.

This is not a one-time event, but rather a continuous process (see step 13 below) and should be done in tandem with step three below.

Each practice should define the frequency of review and use of their registry to stratify data for adult preventive care. In early use, the stratified data will support the identification of areas of inequity and allow for prioritization of interventions.

See also Key Activity 3: Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Care

3. Screen patients for social needs.

Suggested team member(s) responsible: Care team.

Key Activity 14: Use Social Needs Screening to Inform Patient Treatment Plans provides guidance on screening patients for health-related social needs and how the information can begin to be used to inform patient treatment plans, including referral to community-based services.

This is not a one-time event, but rather a continuous process and should be done in tandem with step two above.

4. Analyze the stratified data from steps two and three to identify patterns in inequitable outcomes within the population of focus.

Suggested team member(s) responsible: Data analyst

This includes:

• Using data tools to visualize and understand disparities across different populations or subpopulations.
  • Data over time (using run charts).
• Exploring trends, patterns and significant differences to understand which demographic groups will require a focused effort to close equity gaps.

This is not a one-time event, but rather a continuous process (see step 13 below) and should be done in tandem with step two (above) and step four (below).

Periodic review of the stratified data allows for the recognition of gap closures and the emergence of new disparities.

5. Conduct a root cause analysis for each population or demographic group that the practice does not yet have equitable outcomes for.

Suggested team member(s) responsible: Multidisciplinary team.

Select root cause analysis approaches that work best for the equity gap you are closing:

• Engage and gather information from patients affected by the health outcome in your root cause analysis (see step six).
• Brainstorming.
• Systems thinking (understanding how interconnected social, economic, cultural and healthcare access factors may be impacting the health outcome).
• Tools that rank root causes by their impact and the feasibility of addressing them (e.g., prioritization matrix and/or an impact effort matrix)
• Visual mapping of root causes and effects (e.g., fishbone diagram).
• Perform focused investigations into selected root causes and gather qualitative data through interviews, surveys or focus groups with the subpopulation of focus.

Present the findings to a broader group of stakeholders, including affected community members, to validate the identified root causes and gain additional insights. Incorporate their feedback and refine the analysis, as needed.

6. Partner with patients to develop additional insights that will help you develop successful strategies.

Suggested team member(s) responsible: Care team and people with lived experience (e.g., patients who are representative of the population(s) of focus).

Using one or more human-centered design methods such as focus groups, 7- Stories, Journey mapping, etc. (see links to these methods below), work with members of each population of focus to better understand their:

• Assets, needs and preferences, as they relate to adult prevention recommendations.
• Cultural beliefs, including traditional healing practices that may impact their understanding of or willingness to engage in certain adult prevention practices.
• Beliefs and level of trust in healthcare generally and in the topic of focus specifically (e.g., cancer screening, immunizations, behavioral health, etc.)
• Barriers to accessing care, including health insurance, transportation, childcare, housing access and other social factors.
• Barriers to remaining engaged in care, including the above-noted barriers, and including cultural beliefs, trust, and concerns about follow-up requirements.
• Trusted sources of information and communication mechanisms and preferences for this population.
• Ideas for improving health outcomes as they relate to the uptake of preventive care.

The patients you partner with for this and other steps in this activity may be part of a formal or informal patient group and/or identified and engaged specifically for this equity work.

7. Identify key activities that address or partially address the identified equity gaps.

Suggested team member(s) responsible: Care team

Based upon the insights your practice has developed for a population of focus and your root cause analysis, determine which of the key activities could address or partially address the equity gap.

Most of the key activities either explicitly address an equity challenge or can be adapted to better address an equity challenge. Examples of key activities that can be adapted to reduce identified equity gaps include but are not limited to:

• Key Activity 6: Conduct Proactive Outreach to Patients Due for Screening.
• Key Activity 13: Coordinate Care.
• Key Activity 14: Use Social Needs Screening to Inform Patient Treatment Plans.
• Key Activity 15: Strengthen Community Partnerships.
• Key Activity 16: Continue to Develop Referral Relationships and Pathways.

8. Develop new strategies and ideas to address the identified equity gaps.

Suggested team member(s) responsible: Care team and people with lived experience.

If one or more of your root causes cannot be addressed fully through key activities, use one or more human-centered design methods (see resources below), to develop ideas to improve health outcomes and reduce inequities among adults with preventive care needs.

Developing these ideas is best done with representatives of the population of focus, as they have expertise and experience that may be missing from the practice’s care team. Compensating these patients and community members for time spent on improvement activities is a best practice. During this brainstorm, you are developing ideas without immediate judgment of the ideas in an effort to generate dozens of potentially viable ideas.

Selected resources on human-centered design and co-design:

• Center for Care Innovations (CCI) Human-Centered Design Curriculum.
• IDEO’s Field Guide to Human-Centered Design.
• IDEO’s Design Kit: Methods.

9. Determine which strategies to test first.

Suggested team member(s) responsible: Care team and people with lived experience.

Steps seven and eight above help your practice identify existing key activities and generate new ideas. Your practice likely doesn’t have the bandwidth to test all of them, at least not at the same time, so now is the time to prioritize a few to begin testing.

There are many ways to prioritize ideas. The Institute for Healthcare Improvement (IHI) often recommends a prioritization matrix and/or an impact effort matrix.

If you have organized your key activities and new ideas into themes or categories, you may choose to work on one category or select one to two ideas per category to work on.

The number of key activities and/or new ideas that you prioritize for testing first should be based on the team’s bandwidth to engage in testing. So, it is critical to determine the bandwidth for the team(s) who will be doing the testing so that you can determine how many ideas to test first.

10. Use quality improvement (QI) methods to begin testing your prioritized key activities and new ideas for and with the population of focus.

Suggested team member(s) responsible: Care team and people with lived experience.

Nearly all of the key activities and all of your new ideas will require some degree of adaptation for use within your practice and to be culturally relevant and appropriate to your population(s) of focus.

Use plan-do-study-act (PDSA) cycles as feasible, generally starting as small as possible – think “ones” (e.g., one clinician, one hour, one patient, etc.) – and become larger as your degree of belief in the intervention grows.

Whenever testing an activity or new idea, we recommend that the practice:

• Use plan-do-study-act (PDSA) cycles to test your ideas and bring them to scale. See more information on PDSAs below in the tips and resources section.
• Generally, start with smaller scale tests (e.g., test with one patient, for one afternoon, in a mailing to 10 patients, etc.). Use Figure 12: How Big Should My Test Be?, in the tips and resources section to help you decide what size test is most appropriate.

Develop or refine your learning and measurement system for the ideas you are testing. A simple, yet robust learning and measurement system will help you know if your ideas are having their intended effect, if they are having unintended secondary effects (e.g., staff burnout), and how the overall implementation process is going. Consider the following:

• What core measures, supplemental measures and/or process measures is this intervention designed to improve equity for?
• What are or will be the first or early indications that the intervention or idea is working?
• How will you know how the implementation itself is going from a patient perspective, a staff perspective, and a management perspective?
• What are some balancing measures to monitor for the implementation itself and for the time and resources spent on implementation?
• Study the successes and challenges of the test. When feasible, this should include getting feedback from patients directly after testing a new idea with them and incorporating their feedback into your next test.
• Refining the idea, as needed, based on the test.
• Then testing again, increasing on the scale of the test as these tests result in few challenges and better results.

By working out the inevitable kinks in the idea you are testing before taking it to full scale, the practice will make the idea work better for patients and be less frustrating to the care team. Testing and refining also can eliminate the workarounds that occur when a process or approach doesn’t fit well into the system or workflow it is being placed into.

Select resources on quality improvement (QI):

• Institute for Healthcare Improvement (IHI) QI Essentials Tool Kit.
  • Cause and effect diagrams.
  • Driver diagrams.
  • Failure modes and effects analysis.
  • Flowcharts.
  • Histograms.
  • Pareto charts.
  • PDSA worksheets.
  • Project planning forms.
  • Run charts.
  • Scatter diagrams.
• IHI’s Videos on the Model for Improvement (Part one and Part two).
• Rapid Experiments to Improve Healthcare Delivery.
• CCI’s ABC's of QI via CCI Academy.

11. Implement – meaning, bring to full scale and sustain – those practices that have proven effective.

Suggested team member(s) responsible: Care team

Once an idea has been well tested and shown to be effective on a small scale, it is time for your practice to hardwire the idea, approach or practice into your daily work. Consider using the MOCHA Implementation Planning Worksheet to think through:

• Measurement.
• Ownership.
• Communication, including training.
• Hardwiring the practice.
• Assessment of workload.

Sometimes, implementation may require that you update your protocol and/or policies and procedures for the populations of focus.

12. Once you have tested, refined and scaled up the initially prioritized ideas, begin testing other ideas.

Suggested team member(s) responsible: Care team and people with lived experience.

Consider revisiting the ideas that were developed previously but not were not initially prioritized for implementation. You might also move through the testing steps above to develop and prioritize new ideas or adapt ideas to better serve additional subpopulations of focus.

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

Suggested team member(s) responsible: Care team.

To help ensure that your practice’s ideas are meeting the needs of patients and their families, helping to reduce identified equity gaps and increase the feasibility and sustainability of your practices, it is important to have both formal and informal feedback loops.

For patients, feedback loops could be created using many of the human-centered design tools used to design your improvement activity (e.g., surveys, interviews, focus groups).
Consider establishing a standing funded patient advisory board that is available to design, implement and evaluate all of your practice’s improvement activities.

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.

14. Continually analyze your data to determine if your efforts are closing equity gaps.

Suggested team member(s) responsible: Care team.

This includes regular (at least monthly) review of the stratified measures for all of the following:

• Core measures for the population of focus.
• Supplemental measures for the population of focus.
• Process measures for the population of focus.
• Social needs data.
• Any additional measures collected as part of your testing and refinement effort.

Share the data with patients to both show your work to decrease known equity gaps and to solicit ideas for closing them.

KEY ACTIVITY #5:

Develop and Implement Standing Orders

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction.

A standing order – a preapproved provider order to perform a specific intervention for any patient who meets the criteria for the order – is used when the step in the workflow specifically requires the order of a qualified provider. An important characteristic of a standing order is that all the patients who meet the criteria for the order receive the same treatment, thereby embedding equity into the clinical approach. Standing orders describe the action to be taken and identify who on the care team is authorized to complete the order. Standing orders are designed to enable care team members other than the primary care provider (PCP) to initiate specific clinical actions to provide timely screening and care, provided that specific criteria are met. Common standing orders include preventive measures such as immunizations, cancer screenings, and other screenings to be conducted ahead of the clinician’s time with the patient. While California does not require a provider order to obtain a screening mammography, the FDA requires that Nevertheless, health centers may provide their patients with a referral that specifies the name and address of the primary care clinician requesting the test.

To limit the potential for errors and ensure patient safety, standing orders should be carefully designed, regularly reviewed, and revised as necessary. They should be based on evidence-based recommendations and best practices, and they should have broad support from the medical director, practice manager, physicians, and other staff. In addition, they should outline the criteria for initiating, modifying or discontinuing a particular course of action or treatment for a patient^[7].

Action steps and roles

The steps below outline the actions required to create standing orders. They are adapted from the University of California, San Francisco (UCSF) Center for Excellence in Primary Care (CEPC).^[8]

1. Review and understand the latest clinical guidelines for the required standing order and your practice’s already established protocols.

Suggested team member(s) responsible: Quality improvement lead; panel manager, data analyst, medical director or equivalent.

The University of California, San Francisco’s Center for Excellence in Primary Care provides guidance on developing standing orders, along with examples of standing orders for several clinical conditions.

See the clinical practice guidelines section earlier in this guide.

• Note: Regardless of the specific guidelines being used by the practice, the care team should monitor the website containing these guidelines at least annually and/or upon notification of changes to ensure that the latest recommendations are being used by the practice.
• Note: Because California does not require provider orders for screening mammography but does suggest provider referral, the care team should consider whether and how they wish to initiate screening mammography orders. Assisting patients to schedule a mammography supports their ability to carry out the screening plan.

2. Translate the appropriate clinical guidelines into a standing order.

Suggested team member(s) responsible: Panel manager.

The standing order will follow the relevant clinical guidelines and be updated whenever clinical guidelines are updated. It will generally allow the following:

• Registered nurses (RNs) and/or medical assistants (MAs) with proper training may initiate the agreed upon standing order process when patients meet the agreed upon criteria for initiating screening, and do not have any clinical history that may require a clinician to address the concern.
• This may include initiating an order, initiating a referral, or notifying the PCP of the need for screening and/or testing.

In addition to the written standing order, the practice should develop a process map or update other documentation outlining how and when the standing order is to be implemented in the practice’s current workflows.

3. Obtain approval for standing orders from clinical leadership.

Suggested team member(s) responsible: Panel manager and medical director or equivalent.

For the standing order to be valid and in effect, it must be approved by clinical leadership at the practice, signed by a designated valid signatory (e.g., medical director or other physician), and dated, and it must include the effective date for the standing order. Practices should consider including an expiration date and flagging this date in their system to help ensure that the standing order is reviewed and updated regularly. As the clinical guidelines change or other components are updated, the standing order should be signed and dated again by the appropriate party with an effective date for the revision.

4. Train practice staff on how to use standing orders and include this training in clinical onboarding of new staff.

Suggested team member(s) responsible: Medical director or equivalent.

It is critical that practice staff, both those directly named in the standing order and other members of the care team, receive training on the use of this standing order. Such training should include a thorough review of the written standing order and ensure that practice staff understand all of its aspects, including the associated workflow and any additional materials related to the workflow, such as patient education or instructional materials that include nuances that the care team will need to understand.

Training should be provided on each standing order at least annually, retraining should be provided before the effective date on any revisions, and the training should be part of the orientation for all new members of the practice care team.

Based on feedback from the staff, the standing order can be refined to make the instructions clearer (e.g., during training several staff members were confused by a specific instruction, indicating that the instruction needed to be revised).

5. Institute mechanisms to ensure the proper use of the standing order and its effectiveness.

Suggested team member(s) responsible: Clinical director or equivalent or their designee.

It is important that practice team members understand the purpose, scope and limits of standing orders and be ready to implement them appropriately and within legal constraints of professional practice and of the state of California. In some cases, portions of the standing order will be carried out by professionals outside the practice (e.g., mammography center for breast cancer screening or surgical center for colonoscopy). In the case of these standing orders, it may be helpful for the practice to share the orders with the entity carrying out the order so that results are appropriately communicated to the practice in a timely fashion.

It is possible that one or more aspects of the standing order will not work as planned. For example, the practice’s workflow may not fully support the standing order, the wording may be confusing to one or more staff members, or the standing order’s protocol may not be regularly followed exactly (e.g., staff are using workarounds). The practice should routinely check for these and other common challenges and revise and update the standing order, as needed, to ensure that it works for the practice and meets all applicable regulations and guidelines.

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.

Ishida K, Weiss E, Kee SA, Yingling CT. Increasing colorectal cancer screening orders using unlicensed assistive personnel. BMJ Open Qual. 2019 Jun 29;8(2):e000545.

Percefull J, Butler J. Improving mammography through effective screening, brief intervention, and referral to treatment at a rural health center. J Am Assoc Nurse Pract. 2020 Jan 16;33(4):324-330. doi: 10.1097/JXX.0000000000000356. PMID: 31972786.

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).

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:
  • California Department of Health Care Services: Every Woman Counts Reminder Cards for breast and cervical cancer.
  • The Community Guide Cancer Screening: Client Reminders - Colorectal Cancer.
  • The Community Guide Cancer Screening: Client Reminders - Breast Cancer.
• 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.

This resource provides recommendations and considerations to ensure comprehensive care for when patients decline colorectal cancer screening. Access the full resource.

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).

KEY ACTIVITY #7:

Create and Use Clinician Reminders

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

Overview

This activity provides guidance on how to develop, configure and use reminders in the electronic health record (EHR) so that clinicians are aware of which patients are eligible for and due for their colorectal cancer, breast cancer and/or cervical cancer screening based on the U.S. Preventive Services Task Force (USPSTF) guidelines. This activity calls for clinician reminders that flag patients at higher risk, as well as patients with likely barriers to screening (e.g., mobility issues, speaking a language other than English, etc.).

While many of the examples for this activity are for colorectal cancer screening, in most cases the same general steps apply to other adult cancer screenings. When the steps need to be customized for breast cancer or cervical cancer screening, we have included specific guidance.

Action steps and roles

1. Create a flag or alert in the patient record.

Suggested team member(s) responsible: Panel manager or data Analyst and practice staff responsible for the EHR.

At the patient level, ensure that the practice’s electronic health record (EHR) or population health management tool creates a flag or alert to notify the care team of gaps in care related to colorectal cancer, breast cancer and cervical cancer screening using the latest USPSTF recommendations for colorectal cancer and USPSTF or other recommendations for breast cancer and cervical cancer, in accordance with your practice’s cancer screening protocols (see Key Activity 2: Develop or Update the Practice’s Cancer Screening Protocols). These alerts enable the care team to maximize the identification of necessary preventive services related to patient visits.

See also the clinical practice guidelines section earlier in this guide.

This step may involve one or more people from the practice who work on the EHR, if it is not clear if or how the EHR can produce the colorectal cancer, breast cancer and cervical cancer screening care gap reports.

An example of what a patient-level care gap alert may look like is included in Figure 13.

FIGURE 13: EXAMPLE POPULATION CARE GAP REPORT ON BREAST, CERVICAL, AND COLORECTAL CANCER SCREENING

2. Configure the EHR alerts.

Suggested team member(s) responsible: Practice staff responsible for the EHR.

Collaborate with the person or team responsible for your EHR to set up automated alerts within the EHR system for patients due for colorectal cancer, breast cancer and/or cervical cancer screening.
Define reminder frequency. Determine the timing and frequency of reminders (e.g., annually, biennially) based on clinical guidelines and patient risk factors.
Work with the care team and the person or team responsible for your EHR to help ensure that the automated alerts are not lost due to the flood of alerts they receive, are provided at the appropriate time, and are in a place or on a screen that is intuitive to the care team.
If possible, the alert also flags those at greater risk (see the USPSTF guidelines) and/or those who likely have barriers to getting screened.

3. Make clinician reminders a part of the pre-visit planning process.

Suggested team member(s) responsible: Panel manager.

Work with the clinician and care team to develop ways to ensure these reminders are part of the pre-visit planning process. See Key Activity 8: Refine and Implement a Pre-Visit Planning Process.

4. Ensure reminders are updated continuously.

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

So that the clinician reminders remain accurate (e.g., don’t show a patient needing a cancer screening that they just had), it is important to ensure a process for updating the EHR records. At a minimum, this should include:

• The person(s) responsible for doing this.
• Whether the needed screening was discussed with the patient (yes/no).
• If the screening was discussed and the patient’s response (e.g., yes, maybe, no, not at this time).
• The follow-up needed based on this conversation, including the results of any screening.

5. Provide ongoing training on creating and using clinician reminders.

Suggested team member(s) responsible: Panel manager and practice staff responsible for the EHR.

Ensure that all members of the care team receive ongoing training on each of the four steps above. This training can be incorporated into huddles and should be part of the orientation for new staff. At a minimum, it should include ensuring that care team members:

• Know of the reminders and what they mean.
• Understand where, how and when they will receive them. This should include showing each clinician in the EHR itself and ensuring that this flag or alert is turned on, as well as visual reminders easily accessible to clinicians.
• Understand the process for updating the EHR to ensure that the reminders are accurate.

6. Monitor clinician reminders for accuracy and completeness.

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

It is critical to have a feedback loop with the practice’s care team about any real or potential errors in clinician reminders. This might include patients who are eligible for and due for screening for whom a reminder or flag does not appear or patients who have recently been screened for whom the reminder or flag continues to appear. The reminders process should be modified as needed whenever errors are discovered.

FIGURE 14: EXAMPLE OF A CLINICIAN REMINDER

KEY ACTIVITY #8:

Refine and Implement a Pre-Visit Planning Process

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction; care coordination; address social needs.

Overview

This activity provides guidance for how the care team can effectively and efficiently embed cancer screenings into the practice’s pre-visit planning process (PVP). Pre-visit planning is typically driven by the medical assistant with help from other care team members and includes steps taken:

• At the end of the current visit to ensure the patient understands any actions they need to take and to schedule any follow-up.
• Prior to a scheduled appointment, scrub the chart and identify any pre-visit tasks per the pre-visit checklist.
• The day of an appointment, during the daily huddle and before the patient sees the PCP.

Action steps and roles

1. Assess the current state of the pre-visit planning (PVP) process across your practice.

Suggested team member(s) responsible: Implementation team or QI team.

• This step begins by working to understand how the process currently works based on your practice’s performance on core and supplemental measures.
• Compile existing paperwork and process documentation into one place and talk to medical assistants and other members of the care team to understand their questions and challenges around the pre-visit planning process.
• Consider making current-state process maps that communicate the major steps in the PVP process and acknowledge pain points or kinks in the process. Pain points are places where the process isn’t working well for patients, staff or specific subpopulations or demographic groups for which your data analysis has revealed equity gaps. In addition, pay attention to places where staff are creating workarounds to the process. The presence of workarounds indicates that the process might need further clarification or refinement to support the care team to reliably implement it.
• Your team may find it helpful to compile process maps for both the high-level pre-visit planning, as detailed in figure 6.1 of the PHMI Care Teams and Workforce Guide Resource 6: Workflow Examples, in addition to more detailed documentation for specific clinical workflows. Understand which clinical workflows and care gaps are currently addressed through the PVP process and work to understand what gets in the way of the team reliably addressing these care gaps.

FIGURE 16: EXAMPLE WORKFLOW FOR PRE-VISIT PLANNING (PVP).

2. Identify where to update the PVP process to address care gaps more consistently and reliably.

Suggested team member(s) responsible: Implementation team or QI team; may include the data manager to assist with identifying patients through EHRs.

Examine where you can further incorporate or streamline your practice’s clinical protocols and standing orders into PVP, including via the PVP checklist, daily huddles and other key clinical workflows.

This may include the following discussion points:

• Who will initiate the discussion with the patient based on the needs (e.g., primary language) and preferences of the patient.
• How and when they will plan to have the discussion during the visit.
• How they will be prepared to address any barriers.
• Educational materials available for use that are relevant to the patient.

Clinical guidelines and care gaps: Consider which preventive and maintenance services could be addressed more reliably using PVP and include those in your EHR’s care gap module. The Pre-Visit Planning: Leveraging the Team to Identify and Address Gaps in Care resource provides a more complete list of preventive services for adults and children.

PVP checklist: A generic PVP checklist is to be completed by the MA or LVN at least one to three days before the appointment is provided in Figure 17. Most EHRs will have a health maintenance module that identifies what preventive care is due, but a printed or digital checklist provides a starting point for ensuring key steps aren’t missed.

FIGURE 17: PVP PLANNING CHECKLIST ITEMS TO ADD FOR ADULT PREVENTION

FIGURE 18: EXAMPLE CHART SCRUB PROCESS FOR OPEN ORDERS.

Putting it all together: Leveraging team-based approaches to address screening for cervical, colorectal and breast cancer

Pre-visit planning checklists may be created by the multidisciplinary team, authorized by the medical team, and carried out by relevant health center staff. The list below provides examples of possible actions that care team members can take to support providers and to advance population health management for both in-person visits or outreach attempts to identify and address gaps for cervical, colorectal and breast cancer screening.

For breast, cervical and colorectal cancer, MAs or nurses (or others on the team) can:

• Advise the patient they are due for the screening.
• Provide patient education on the benefits of completing the screening.
• Outline screening options for the patient.
• Enter orders into the EHR in accordance with standing orders (see Key Activity 5: Develop and Implement Standing Orders).
• Assist or refer patient to ensure insurance or other program coverage and to advise of any potential out-of-pocket costs.
• Schedule patient, if possible. If not, provide information to the patient to schedule and set a reminder to call patient to ensure they were able to get scheduled.
• If a patient declines, document accordingly, including why the patient declines, and notify the provider to have further discussions and to document that the patient declines after informed consent.

Daily huddles: Design or redesign the team’s daily huddle so the care team can review prioritized action items for the list of patients scheduled to come and any further follow-up for patients seen in the previous days. For more information, see PHMI Care Teams and Workforce Guide Resource 4: Daily Huddles Overview and Process.

The Centers for Excellence in Primary Care resource on Healthy Huddles includes tools, a video, and examples around how pre-visit planning flows into the daily huddle process, including a “Healthy Huddles” warm-up, which can help MAs prepare for huddles.

Patients requiring special considerations: Ensure that the PVP includes a process to flag for the care team:

• Patients requiring special attention, such as those with chronic conditions, complex needs or recent hospitalizations.
• Patients who need extended time or additional services during their visit (e.g., translation services, mobility assistance, screenings).

Detailed clinical workflows: Clinical workflows should be updated to describe at which step in PVP or the patient visit a care team member will address a specific gap in care with the patient.

Planning forward for care after the visit: Effective PVP includes scheduling pre-visit labs and other diagnostics at the end of the current visit and coordinating care and referrals for services not available at the practice (see Key Activity 13: Coordinate Care). Confirm the patient understands the purpose of any follow-up care.

The American Medical Association (AMA) has an online guide for implementing pre-visit planning, which includes forms, templates and other resources.

3. Test planned changes to the PVP workflows and support care teams in implementing the workflow.

Suggested team member(s) responsible: Implementation team or QI team.

Test and refine important changes to the PVP process with one or two care teams before rolling out the change more broadly at the practice.

Implementing the change includes updating documentation and creating a staff training schedule or training refresher for staff to sustain workflow changes. For example, train MAs every six months on the PVP. If they have difficulty, have them retake training with a different highly effective MA and monitor closely until competency in the task is reached.

4. Establish a process to review and update PVP workflow.

Suggested team member(s) responsible: Care team with quality improvement manager.

Identify staff responsible for reviewing and updating the PVP process at least annually to incorporate the latest clinical guidelines and check for any workarounds that have developed.

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.

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):

• Institute for Healthcare Improvement (IHI) QI Essentials Toolkit.
• IHI’s Videos on the Model for Improvement (Part one and Part two).
• Rapid Experiments to Improve Healthcare Delivery.
• CCI’s ABC's of QI via CCI Academy.

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.

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.

KEY ACTIVITY #10:

Use Culturally Appropriate Educational Materials for Cancer Screening

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

Overview

This activity provides guidance on how practices can curate and use existing educational materials to increase the rate of patients who complete recommended colorectal cancer, breast cancer and cervical cancer screening.

Action steps and roles

1. Understand the patient population(s) at your practice eligible for screening.

The first step is to understand the patient population eligible for colorectal cancer, breast cancer and cervical cancer screening at your practice.

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

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 6: Conduct Proactive Outreach to Patients Due for Screening for more details.

2. Compile, curate, evaluate and adapt existing educational materials.

Suggested team member(s) responsible: Multidisciplinary team, MA, nurses, health educators.

Based on your patient population, compile, curate, evaluate and adapt your practice’s existing educational material for colorectal cancer, breast cancer and cervical cancer screening.

Assess the materials to determine if they address population needs and are understandable by the patient populations for your practice. Review reliable sources for educational materials that have been developed and tested by reputable sources.

See the Resources section of this Activity for reputable sources of educational materials.

It may be useful to categorize the educational materials by topic, by the intended primary user (e.g., provider guides for patients, patient self-use) and by type of material.

• Materials for patients to use to educate themselves should contain the following information:
  • The importance of screening.
  • Type of screening tests, if options exist, such as in colorectal cancer screening, and how the test is done. Materials may also focus on a single type of test.
  • Frequency of screening.
  • The benefits and potential risks of screening.
  • Likelihood of out-of-pocket costs.
  • Common misperceptions on cancer screening.
• Materials may be organized by type:
  • Printed materials, including photo novellas and graphic materials.
  • Materials for mail-based outreach and education.
  • Materials for social media-based outreach and education.
  • Web-based materials, including downloadable materials.
  • Video-based materials.
  • Other materials.

3. Tailor your approach using culturally appropriate materials, messages and messengers.

It is useful to remind the team of the common elements and approaches involved in tailoring educational content and messaging for any population of focus. This includes:

Language and tone:

• Developing materials in language(s) spoken by the population of focus.
• Using simple language free from medical jargon. Ensure readability and comprehension of material for all education levels.
• Ensuring that the tone is empathic, respectful and culturally sensitive.
• Using familiar concepts for the population of focus, including incorporating familiar symbols, metaphors and analogies that resonate with their culture(s).

Use of visuals: Use images, familiar symbols, graphics, illustrations, video and/or other visual media that are culturally relevant to the population of focus.

Incorporate storytelling:

• Use personal stories from members of the population of focus who have undergone screenings to emphasize the benefits.
• Share success stories of community members who have undergone screenings to encourage others.

Identify the most appropriate messengers and mechanisms: This includes asking and answering the following questions:

• Who are the best people or groups to get the message across? Who can speak to our subpopulations in their primary language? Should we partner with others for this?
• What communication mechanisms are most appropriate for the population of focus?
• Are there culturally significant events or holidays to convey the message of prevention and care?
• Where should we distribute these materials (e.g., practice waiting areas, community events, local organizations trusted by the population of focus, etc.)?

Accuracy and alignment with clinical guidelines: This involves having changes to materials reviewed by experts to ensure the changes adhere to clinical guidelines.

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

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

To help ensure that educational materials are meeting 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 materials with the population of focus to gather feedback and ensure accuracy before testing.
• Getting feedback from patients directly after testing materials or a new approach with them, and incorporate 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) 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.

KEY ACTIVITY #11:

Provide or Arrange for Cancer Screening

 
This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction; care coordination.

Overview

This activity provides guidance for setting up a cancer screening test for colorectal cancer, breast cancer and/or cervical cancer for any patient eligible and due for screening who agrees to complete the recommended screening. This includes patients who agree to get screened during a patient visit, in response to a screening reminder, or in response to an outreach activity. This includes guidance on the following screening methods:

• Screening at the practice.
• Providing screening materials during the visit to take at home.
• Providing screening modalities outside of the practice (e.g., mailed FIT, self-referred mammogram, or setting up an appointment for colonoscopy).
• Utilizing community linkages for screening (e.g., providing patients with contact to a mammography center or an outpatient surgical center for colonoscopy or sigmoidoscopy).

Action steps and roles

1. Plan for the cancer screening.

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

Planning and preparation are covered in the following key activities:

• Key Activity 2: Develop or Update the Practice’s Cancer Screening Protocols.
• Key Activity 3: Use Care Gap Reports or Registries to Identify All Patients Due for Cancer Screening.
• Key Activity 5: Develop and Implement Standing Orders.
• Key Activity 8: Refine and Implement a Pre-Visit Planning Process.
• Key Activity 9: Partner with Patients to Discuss Cancer Screening During Patient Visits.

2. Provide or arrange for the selected cancer screening.

Suggested team member(s) responsible: Designated care team member, based upon the test and the practice’s standing orders.

This is always based on your practice’s clinical practice guidelines and cancer screening protocols (See Key Activity 2: Develop or Update the Practice’s Cancer Screening Protocols).

• Based upon the screening indicated and the option selected by the patient, if choices are available, the appropriate care team member will implement the practice’s cancer screening protocol and standing orders.
• If the selected screening test can be done during the visit, the clinician will implement the screening process, such as a Pap smear or fecal testing.
• If the selected screening procedure is to be conducted by the patient at home using a self-collected sample (e.g., FIT kit), the clinician will explain and demonstrate the proper collection techniques and the process to return the specimen for testing.
• If the screening requires further appointments (e.g., mammogram, colonoscopy, Pap Smear), the medical assistant or appropriate care team member may schedule the patient in the practice or initiate the referral, per protocol, and schedule the necessary follow-up appointments or provide referrals using preestablished community linkages.
• If the screening test requires laboratory analysis (e.g., Pap smear, fecal testing), the clinician will explain when the patient can expect to receive the results and what to do next.

3. Document the screening.

Suggested team member(s) responsible: Medical assistant.

The medical assistant documents the cancer screening test(s) selected, including test type(s), date(s), and any relevant notes, in the patient's electronic health record (EHR).

FIGURE 19: EXAMPLE OF SCREENING DOCUMENTATION

4. Conduct ongoing quality assurance of the cancer screening process.

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

The QI lead or their designee(s) should develop and implement a process to review a subset of records each month to ensure that this practice is in compliance with the practice’s cancer screening protocols, standing orders and any other of the practice’s relevant policies and procedures. In cases where policies and procedures are not being followed, the QI lead should initiate corrective action.

Sample workflow for colorectal cancer screen using FIT test

1. Assure that the patient is eligible for fecal-based testing by referencing your organization’s screening protocols outlined in Key Activity 2: Develop or Update the Practice’s Cancer Screening Protocols.
2. Provide culturally and linguistically appropriate education materials and decision aides to the patient to ensure that they understand the benefits, risks and follow-up schedule for fecal-based testing (see Key Activity 10: Use Culturally Appropriate Education Materials for Cancer Screening). Best practices include:
   • Informing patients about the ability of different tests to detect colon cancer.
   • Noting the frequency of each test type.
   • Providing the patient with testing materials and instructions for the test of choice.
   • Highlighting the time frame to return the sample.
   • If the patient is available on site, review the sample procurement technique, return system and time frame with the patient while at the practice.
   • Using culturally and linguistically appropriate materials and providing graphic diagrams where possible.
3. If the patient is receiving the testing materials by mail, provide culturally and linguistically appropriate educational materials with an emphasis on graphic instructions and include information and materials for returning the test to the practice. Invite the patient to contact a specific person at the practice, if they have any questions.
4. Document the delivery of materials for testing in the EHR.
5. Process the sample or send the sample for processing within 24 hours of receipt and record the results in the EHR.
6. Document results and instructions in the EHR. Assure that the EHR cancer screening report notes the patient as having received a fecal-based test in order for the eligibility roster to be generated in accordance with the USPSTF testing frequency guidelines.
7. Contact the patient to inform them of the test results and the recommended follow-up (see Key Activity 12: Develop and Implement a Follow-Up System for Those Who Have Been Screened).
8. If the patient cannot be reached to communicate positive test results, the team should design and implement alternative methods to reach patients, such as deploying community health workers to attempt to reach the patient and/or sending written communications.

Sample workflow for use of a mobile Pap screening clinic

1. Front office staff contact the patient by phone or in person to establish an appointment for a Pap smear and affirm the patient’s knowledge that the appointment is for the mobile unit. The front office staff confirm the patient’s understanding of the date and location of the appointment and how the mobile unit can be identified.
2. Front office staff send the patient confirmation of the appointment by mail or text message with the date, time, and location and a reminder of the appearance of the mobile unit. They provide a number to call for questions or changes ahead of the appointment.
3. The front office staff or mobile unit staff confirm the patient’s availability by text message the day before the appointment.
4. At the mobile unit site, the clinical support personnel, such as an MA, greet the patient and invite the patient to enter the unit for pre-visit information gathering and confirmation of the appointment purpose and prepare the patient for the exam.
5. The clinician conducts the exam, secures a Pap Smear, and addresses other clinical needs of the patient.
6. The clinician and/or clinical support inform the patient of when the result is expected and how the patient will be informed of the result.

Evidence base for this activity

Williamson S, Patterson J, Crosby R, Johnson R, Sandhu H, Johnson S, et al. Communication of cancer screening results by letter, telephone or in person: A mixed methods systematic review of the effect on attendee anxiety, understanding and preferences. Preventive Medicine Reports. 2019 Mar;13:189–95.

Evidence base for this activity

• https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.01617
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7177185/

KEY ACTIVITY #18:

Strengthen a Culture of Equity

This activity builds off of your practice's approach to address inequities (see Key Activity 4: Use a Systematic Approach to Address Inequities within the Population of Focus) to provide strategies and in-depth resources that can help practices create or strengthen a culture of equity in your practice. The PHMI Equity Framework and Approach emphases that achieving long-term and sustainable improvements to health and racial equity for patients and the broader ecosystem requires a transformational shift at the organizational level. The following strategies can help practices strengthen a culture of equity:

• Demonstrate senior leadership ownership for and commitment to improving health equity.
• Understand and address internalized, personally mediated and institutionalized racism.
  • This should include ongoing learning and development activities on the full range of health equity topics (e.g., anti-bias, structural racism, race-based algorithms).
• Build organizational capacity to support efforts to improve health equity.
• Establish practices and policies to promote workforce diversity and provide culturally and linguistically appropriate care.
• Support policy efforts to eliminate inequities driven by social drivers of health.
  • This can take the form of joining advocacy efforts or participating in benefits created by recent policy reforms, such as connecting patients with CalAIM Community Supports or Enhanced Care Management. See Key Activity 14: Use Social Needs Screening to Inform Patient Treatment Plans for a discussion on social needs

KEY ACTIVITY #19:

Explore the Development of Self-Sampling Techniques for Human Papillomavirus (HPV) Screening

This activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; proactive patient outreach and engagement; pre-visit planning and care gap reduction; address social needs.

Overview

This activity offers guidance to practices exploring the development of self-sampling techniques that screen for the presence of human papillomavirus (HPV) as an alternative to a clinician-obtained Pap smear. Studies have demonstrated that self-sampling has the potential to increase participation of underscreened women. In the limited nations where it has been used, self-sampling for HPV has shown high levels of satisfaction among patients.1,6 In the United States, HIV self-testing has been demonstrated to decrease barriers to HIV screening and is supported by the CDC.2 Additionally, self-sampling for detection of chlamydia and gonorrhea has demonstrated both high performance and high patient acceptance. The National Cancer Institute is currently supporting a public-private partnership to bring together federal agencies, industry partners and professional societies to contribute evidence about the accuracy and clinical effectiveness of self-sampling based on HPV testing for cervical cancer screening. This partnership is called the Last Mile Initiative and is designed to evaluate the usability, acceptability and accuracy of multiple self-sampling device-assay combinations and is expected to inform future utility of self-sampling for HPV as an effective tool.

Self-sampling is not yet approved by the FDA in the United States, and it is unclear if or when self-sampling will be approved by the Health Resources and Services Administration (HRSA). However, given World Health Organization (WHO) support for self-sampling techniques and the expansion of technology, this is an option whose development is worth following.

Why this matters

Cervical cancer is a common disease caused by the human papillomavirus (HPV), and the presence of certain HPV subtypes on cervical cancer screening is understood to be a marker that may lead to cancer. Thus, screening for these precancerous cells can be lifesaving. Yet many eligible women do not undergo screening for cervical cancer due to barriers, such as transportation, time and fear of undergoing a pelvic exam. A new method of HPV testing can be performed on vaginal samples collected by the patient through self-sampling techniques. These techniques and materials are under evaluation in the United States and may prove to be effective tools for HPV detection among women at risk. In countries where self-sampling is used, the technique has demonstrated high levels of patient acceptance. A randomized controlled study of over 31,000 individuals enrolled in a U.S. healthcare system demonstrated that direct mail self-sampling increased fulfillment of cervical cancer screening by more than 14% among those who were due or overdue for cervical cancer screening.

Action steps and roles

Because HPV self-sampling techniques are not yet licensed by the FDA or approved by HRSA for use in federally qualified health centers (FQHCs), the technique is not available for health centers at this time. However, practices are encouraged to follow the development of these technologies and continue to evaluate them for possible use in patient populations. In the event self-sampling tools are approved by the FDA and approved for use in health centers, suggested action steps are provided.

To follow are potential steps for developing self-sampling techniques for human papillomavirus (HPV) screening:

1. Establish a protocol for self-sampling for HPV that adheres to evidence-based guidance and risk and benefit assessment and adheres to effective sample handling and processing.
2. Educate clinicians and support personnel about self-sampling options so that they are able to discuss the options with patients and process materials effectively. See the CDC self-sampling education program under resources for this activity.
3. Identify patients who are eligible for self-sampling, inform them of the option, and discuss the risks and benefits of self-sampling for HPV.
4. Inform patients about the risks and benefits of self-sampling, discuss the sampling technique, respond to questions, and provide materials and guidance for returning the sample.
5. Identify workflows that enable patient education, timely return of the specimen, specimen processing, communication of test results, and appropriate patient follow-up based on test results.
6. Send patients reminders about the timing of sampling and sampling technique.
7. Process self-samples that are returned to the practice.

This technique is still under scientific study and global use is limited.

Should this method be approved by HRSA, PHMI will provide more detailed guidance for practices.

Evidence base for this activity

• Di Gennaro G, Licata F, Trovato A, Bianco A. Does self-sampling for human papillomavirus testing have the potential to increase cervical cancer screening? An updated meta-analysis of observational studies and randomized clinical trials. Front Public Health. 2022 Dec 8;10:1003461. doi: 10.3389/fpubh.2022.1003461. PMID: 36568753; PMCID: PMC9773849.
• Centers for Disease Control and Prevention. (2023a, June 1). Self testing. Centers for Disease Control and Prevention. https://www.cdc.gov/stophivtogether/hiv-testing/self-testing.html
• Van Der Pol B, Taylor SN, Mena L, Lebed J, McNeil CJ, Crane L, Ermel A, Sukhija-Cohen A, Gaydos CA. Evaluation of the Performance of a Point-of-Care Test for Chlamydia and Gonorrhea. JAMA Netw Open. 2020 May 1;3(5):e204819. doi: 10.1001/jamanetworkopen.2020.4819. PMID: 32407506; PMCID: PMC7225902.
• NCI Cervical Cancer “last mile” initiative. Division of Cancer Prevention. (n.d.) https://prevention.cancer.gov/major-programs/nci-cervical-cancer-last-mile-initiative
• Madzima TR, Vahabi M, Lofters A. Emerging role of HPV self-sampling in cervical cancer screening for hard-to-reach women: Focused literature review. Can Fam Physician. 2017 Aug;63(8):597-601. PMID: 28807952; PMCID: PMC5555324.
• Wong EL, Cheung AW, Wong AY, Chan PK. Acceptability and Feasibility of HPV Self-Sampling as an Alternative Primary Cervical Cancer Screening in Under-Screened Population Groups: A Cross-Sectional Study. Int J Environ Res Public Health. 2020 Aug 27;17(17):6245. doi: 10.3390/ijerph17176245. PMID: 32867315; PMCID: PMC7503998.
• Winer RL, Lin J, Anderson ML, et al. Strategies to Increase Cervical Cancer Screening With Mailed Human Papillomavirus Self-Sampling Kits: A Randomized Clinical Trial. JAMA. 2023;330(20):1971–1981. doi:10.1001/jama.2023.21471.
• Serrano B, Ibáñez R, Robles C, Peremiquel-Trillas P, de Sanjosé S, Bruni L. Worldwide use of HPV self-sampling for cervical cancer screening. Prev Med. 2022 Jan;154:106900. doi: 10.1016/j.ypmed.2021.106900. Epub 2021 Nov 30. PMID: 34861338.

KEY ACTIVITY #20:

Develop Customized Culturally Appropriate Educational Materials

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

Overview

This activity provides guidance on how practices can curate and use existing educational materials and/or develop and use culturally appropriate educational materials to increase the rate of patients who complete recommended colorectal cancer, breast cancer and cervical cancer screening.

Action steps and roles

1. Use data to determine the populations of focus for new educational materials.

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

All patients can benefit from educational materials, and we cover the tailoring and use of existing educational materials in Key Activity 10. Use Culturally Appropriate Educational Materials for Cancer Screening.

This step, however, is focused on determining which populations will require new customized culturally relevant materials to increase their rates of recommended cancer screenings. To determine who might require more new materials, determine which populations or sub-populations within your practice have the lowest rates of screening.

These populations vary by practice but often include:

• Patients of color.
• Patients for whom English in not their primary language.
• Immigrants and refugees.
• Patients with no insurance or high-deductible insurance plans.
• Patients with behavioral health needs.
• Patients experiencing homelessness or housing instability.
• Patients with physical or developmental disabilities.
• Other people who are underserved or medically disadvantaged.

It might also be useful to develop more customized 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).

2. Gather insights on each population of focus identified by the gap reports.

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

Using one or more human-centered design methods, such as focus groups, 7- Stories, Journeymapping, etc. (see resources on human-centered design below), and work with patients of the population of focus to better understand:

• Their assets, needs and preferences.
• Cultural beliefs, including traditional healing practices.
• Beliefs and level of trust in healthcare generally and in cancer screenings specifically.
• Barriers to getting screened for this population.
• Trusted sources of information or communication mechanisms for this population.
• How they like to receive information (e.g., written, video, as a part of a conversation, etc.).
• Their ideas for increasing cancer screening rates.

3. For each population of focus, use the insights to develop new ideas.

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

Based upon the insights your practice has developed for a population of focus, use one or more human-centered design methods (see resources on human-centered design below), to develop ideas for new educational materials for them. Creating these ideas is best done with representatives of the population of focus, as they have expertise and experience that may be missing from the practice’s care team.

Before developing the ideas, it is useful to remind the team involved of the common elements and approaches involved in tailoring educational content and messaging for any population of focus. This includes:

Language and tone:

• Developing materials in language(s) spoken by the population of focus.
• Using simple language free from medical jargon. Ensure readability and comprehension of material for all education levels.
• Ensuring that the tone is empathic, respectful and culturally sensitive.
• Using familiar concepts for the population of focus, including incorporating familiar symbols, metaphors and analogies that resonate with their culture(s).

Use of visuals: Use images, familiar symbols, graphics, illustrations, video and/or other visual media that are culturally relevant to population of focus.

Incorporate storytelling:

• Use personal stories from patients of the population of focus who have undergone screenings to emphasize the benefits.
• Share success stories of community members who have undergone screenings to encourage others.

Identify the most appropriate messengers and mechanisms: This includes asking and answering the following questions:

• Who are the best people or groups to get the message across? Should we partner with others for this?
• What communication mechanisms are most appropriate for the population of focus?
• Are there culturally significant events or holidays to convey the message of prevention and care?
• Where should we distribute these materials (e.g., practice waiting areas, community events, local organizations trusted by the population of focus, etc.)?

Accuracy and alignment with clinical guidelines: This involves having new materials reviewed by experts to ensure they adhere to clinical guidelines.

4. Organize the ideas for testing that your practice has come up with.

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

Now that you have a lot of ideas, it may be helpful to organize them by theme or other criteria. This might include organizing the ideas for new materials in the following categories:

• Materials related to education on the importance of cancer screening.
• Materials related to education on the testing modalities available.
• Materials related to education on the benefits and potential risks of screening.
• Materials related to education on common misperceptions related to cancer screening.
• Materials related to addressing specific barriers to screening, including coverage and potential out-of-pocket expenses.
• Miscellaneous materials or ideas that don’t fit into the above categories.

5. Prioritize ideas for testing.

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

The steps above have likely generated dozens of ideas for new materials. Your practice likely doesn’t have the bandwidth to test all of them, at least not at the same time,so now is the time to prioritize a few to begin testing. There are many ways to prioritize ideas. The Institute for Healthcare Improvement often recommends a .

If you have organized your ideas for new materials into themes or categories (see step above), you may choose to work on one category or select one or two ideas per category to work on.

The number of ideas that you prioritize for testing first should be based on the team’s bandwidth to engage in testing. So, it is critical to determine the bandwidth for the team(s) who will be doing the testing so that you can determine how many ideas to test first.

6. Begin testing your prioritized ideas for the population of focus.

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

Whenever testing new educational material or communication mechanisms, we recommend that the practice:

• Start with smaller scale tests (e.g., test with one patient, for one afternoon, in a mailing to 10 patients, etc.).
• Study the successes and challenges of the test. When feasible, this should include getting feedback from patients directly after testing new materials or a new approach with them and incorporating their feedback into your next test.
• Refining the process or material, as needed, based on the test
• Testing again, increasing the scale of the test as these tests result in fewer challenges and better results.

7. Once you have tested, refined and scaled up the initially prioritized ideas, begin testing other ideas.

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

This might include going back to the ideas developed previously but not prioritized and/or going back through steps three to six above to develop and prioritize new ideas and potentially for additional populations of focus.

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

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

To help ensure that new educational materials are meeting 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 draft materials with the population of focus to gather feedback and ensure accuracy before testing.
• Getting feedback from patients directly after testing new materials or a new approach 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) provide feedback.

For the care team, feedback loops might include:

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

APPENDIX A:

Sample Idealized System Diagram

WEAVING YOUR MEASUREMENT STRATEGY AND LEARNING SYSTEM INTO PRACTICE OPERATIONS

The below graphic provides an example to visualize the flow of information between a practice’s measurement strategy and actions at the practice and care team levels, including how to use the information for continual learning and improvement.

APPENDIX B:

Theory of Change

The key activities in this guide align with the PHMI theory of change for how practices can increase colorectal cancer, breast cancer, and cervical cancer screening rates through three primary drivers: 

• Effective implementation of well-visit protocols.
• Patients eligible and due for visits and immunizations have the information, education and access needed for screening.
• Practices have needed resources and support.

FIGURE 24: PHMI ADULT PREVENTION DRIVER DIAGRAM

APPENDIX C:

Developing a Robust Measurement Strategy

FIGURE 25: DEVELOPING YOUR MEASUREMENT STRATEGY MILESTONES

Figure 25 illustrates the key milestones in the development of a robust measurement strategy.

FIGURE 26: DEFINITION AND EXAMPLES FOR MEASUREMENT STRATEGY MILESTONES

Figure 26 provides guidance on each of these milestones as you work to put in place a robust yet practical measurement strategy to improve outcomes for adolescents and adults with behavioral health needs.

POPULATION HEALTH GUIDE FOR UNDERTAKING 3 PART DATA REVIEW

The three part data review is a tool that can be used to advance work related to population health. It draws on asset-based inquiry, to surface to identify needs and opportunities to understand the ways in which systems have discarded or undervalued the assets of individuals and communities. Groups can then work together to ensure that all can contribute to advancing population health and well-being and dismantling inequities. Access the full resource.

APPENDIX D:

Peer Examples and Stories from the Field

Practices across California and the U.S. offer a treasure trove of examples of how to improve colorectal cancer, breast cancer and cervical cancer screening rates. In many cases, these examples show how practices implemented multiple activities in this guide to increase cancer screening rates.

The table below provides links to some of these examples, along with the activities in this guide that the example is related to or touches on.
 

FIGURE 27: CORE POPULATION HEALTH MANAGEMENT FUNCTIONALITY REQUIREMENTS

APPENDIX E:

Guidance on Technological Interventions

EHRs were primarily designed to manage individual patients rather than groups of patients. However, over time EHRs have increasingly added functionality for population-level quality reporting and management and some degree of care planning and care coordination, especially to support value-based care tracking and reporting. Practices should evaluate your EHR capabilities against specifically designed population management applications. While these applications require interface with the EHR, they generally offer additional functionality. While EHR solutions are integrated with EHR data, they still usually require import of data from outside sources to be optimally useful. Managed care organizations may provide care coordination and population management applications, but usually only for their own enrolled patients. EHR-based solutions may also pose challenges where groups of practices using different EHR solutions are collaborating in value-based care contracts.

In value-based care arrangements, practices are responsible for attributed patients who may have never been seen. Since these patients do not have records in the EHR, practices need to consider how they can manage these patients to engage them into care at the practice in the absence – at least initially – of the patients having records within the EHR. If your practice is using freestanding applications for this, they need the capacity to handle these attributed patients who have not been registered as patients.
 

FIGURE 28: CORE POPULATION HEALTH MANAGEMENT FUNCTIONALITY REQUIREMENTS

Figure 28 below includes the technical functionalities required to support population management for adults with preventive care needs. These requirements can guide the evaluation of existing solutions or guide the development of requirements in evaluating potential new applications. The table also indicates the data sources required to enable the functionality.

FIGURE 29: USE OF TECHNOLOGY FOR RECOMMENDED SCREENING FOR KEY ACTIVITIES

This table identifies strategies for using digital tools to complete appropriate screeners as recommended by clinical guidelines. Using technology to facilitate screening may streamline the workflow and preserve patient confidentiality where necessary.

*A workflow should be codified for identifying emergent behavioral health risks. A workflow should be codified for preserving patient confidentiality.

FIGURE 30: USE OF TECHNOLOGY FOR PATIENT OUTREACH AND PRE-VISIT PLANNING FOR FOUNDATIONAL KEY ACTIVITIES

This table outlines the use of technology to facilitate specific activities and potential technology solutions that can optimize the uptake and efficiency of in-office visits.

FIGURE 31: USE OF TECHNOLOGY FOR ENHANCED PATIENT ENGAGEMENT AND VIRTUAL CARE FOR GOING DEEPER ACTIVITIES

The table identifies technology solutions to engage patients asynchronously from office visits for a variety of use cases to enhance care and patient experience.

FIGURE 32: USE OF TECHNOLOGY FOR INNOVATIONS IN CARE DELIVERY FOR ON THE HORIZON ACTIVITIES

The table describes technology strategies that can enhance care delivery by using artificial intelligence and advanced technology tools.