Closing Preventive Care Gaps in Underserved Areas
- Need: Address the need to increase cancer screening rates as well as other preventive care measures in Appalachian Kentucky, a region with high cancer incidence and mortality rates, and noted health disparities.
- Intervention: Federally Qualified Health Centers (FQHCs) and an academic center partnered to adapt and implement an office-based intervention, building on existing primary care resources to decrease gaps in preventive care measures, including cancer screenings.
- Results: After intervention implementation, White House Clinics saw a marked increase in various preventive care measures, including screenings for cancer, human immunodeficiency virus and hepatitis C.
Evidence-levelPromising (About evidence-level criteria)
Cancer continues to be a leading cause of death in the United States. Early detection through evidence-based cancer screening remains an important mitigation step. In an effort to decrease the burden of cancer in Appalachian Kentucky, White House Clinics partnered with the University of Kentucky College of Public Health to create the Appalachian Center for Cancer Education, Screening, and Support (ACCESS) partnership. ACCESS served as a collaborating center of the Centers for Disease Control and Prevention's (CDC) Cancer Prevention and Control Research Network (CPCRN) 2014-2019.
This academic-community partnership adapted and implemented an office-based intervention, known as the proactive office encounter (POE), originally developed by the integrated healthcare system, Kaiser Permanente. Integrated into the POE intervention are motivational interviewing techniques, workflow modifications, electronic health record (EHR) adaptations, and daily team huddles.
The researchers noted, "This model expands the reach of an acute or maintenance visit to include preventive care for which a patient with limited access might never seek on their own."
The intervention uses an EHR review paired with changed workflows to identify care gaps in advance of the patient's visit. Clinic team members prepare for patient-centered discussions around preventive care gaps and also complete pre-visit preparations for those preventive measures, such as preparing the room for a Pap test to screen for cervical cancer, having a Fecal Immunochemical Test kit ready for patients to take home to screen for colorectal cancer, and completing standing orders for immunizations.
Both the purpose of the scheduled visit and the preventive care tasks were completed with no significant impact on visit cycle time.
Due to the successes with the original organization, in 2018, the academic team also partnered with two other Kentucky health care groups in order to implement POE in their respective clinical settings: Appalachian Regional Healthcare – Harlan, Kentucky and the Daniel Boone Clinic, and HealthFirst Bluegrass, a FQHC in central Kentucky.
This project was supported by Centers for Disease Control and Prevention. The CPCRN funding cycle concluded in September 2019.
Additional services included in the scheduled visit:
- For those patients agreeing to preventive services completed outside of the clinics, an in-house referral team initiates the appointment scheduling process and tracks completion of the service and secures test results; for example, mammography, colonoscopy with lung cancer screening recently added.
- Patient-centered education regarding risks/benefits of preventive services.
In 2015, nearly 10,400 patients (34%) were evaluated using the POE intervention at White House Clinics. In 2016 and 2017 respectively, roughly 15,420 patients (52%) and patients (57%) were evaluated using the POE intervention at White House Clinics. As of 2018, 58% of 17,787 patients were evaluated.
Compared to pre-implementation levels, breast cancer screening rates increased by 40% and stayed consistent from 2016 to 2018; colorectal cancer screening rates increased by 46% in 2016 and 2017. Adult pneumococcal and herpes zoster immunizations as well as influenza immunizations for all ages maintained their improved rates as compared to pre-implementation baseline.
In addition, screening rates for hepatitis C, a precursor to liver cancer, increased eight-fold while HIV screening rates increased five-fold. Cervical cancer screenings also increased by 32% in 2018 when compared to baseline.
Workflow was maximized by increasing the number of standing orders, which also allowed clinic staff to utilize their full scope of practice. An increased strategic role in patient care raised staff's job satisfaction.
A continual focus on quality improvement (QI) allowed for annual guideline updates and inclusion of additional preventive care guidelines, such as those for osteoporosis and lung cancer screening.
Implementation of POE was also studied against theoretical models for change management. For example, a QI tool known as a Failure Modes and Effects Analysis (FMEA) was conducted with White House Clinics leadership, providers, and staff. The purpose of the FMEA was to identify and correct potential challenges to the implementation of the POE model. The FMEA resulted in a corrections list from identified failure-modes and commitment to developing additional written policies and procedures to guide the POE intervention workflow.
The impact of Kotter's change management theory was also studied in relationship to the implementation and sustainability of POE within the White House Clinics.
Results from 2018 program implementation at the two additional sites:
In 2018, the ARH-Harlan Daniel Boone Clinic served 11,566 patients with 48,657 documented visits. Nearly 17,000 patient charts were reviewed using the POE framework. Pre- and post-POE implementation data on preventive measures showed decreases in care gaps. For instance, breast (51% to 67%), cervical (36% to 49%), and colorectal (34% to 63%) cancer screenings increased. There were also increases in flu and pneumococcal vaccinations as well as diabetic eye examinations.
In 2018, HealthFirst Bluegrass served over 22,200 patients and demonstrated several decreases in care gaps post POE-implementation. For example, baseline colorectal cancer screening rates were 38% in 2016; in 2018, post-POE implementation rates had increased to 46%.
For more detailed program results see:
- Vanderpool RC, Moore SC, Stradtman LR, Carman AL, Kurgat HL, Fain P. Adaptation of an Evidence-Based Intervention to Improve Preventive Care Practices in a Federally Qualified Health Center in Appalachian Kentucky. Journal of Health Care for the Poor Underserved. 2016;27(4A):46-52.
- Carman, A. (2016, August). A Change Management Approach to Closing Care Gaps. Presentation at the meeting of the Kentucky Rural Health Association, Bowling Green, KY.
- Stradtman LR, Vanderpool RC, Carman AL, Moore SC, Kurgat HL, Fain P. Addressing Cancer Disparities in Appalachian Kentucky through Proactive Office Encounters in Community Health Centers. American Public Health Association Annual Meeting, Denver, CO. October 31, 2016.
- Carman AL, Vanderpool RC, Stradtman LR, Moore SC. Standardizing a Federally Qualified Health Center's Preventive Care Processes: A Failure Modes and Effects Analysis. Health Care Management Review. Feb. 13, 2018.
- Carman AL, Vanderpool RC, Stradtman LR, Edmiston, EA. A Change Management Approach to Closing Care Gaps in a Federally Qualified Health Center: A Rural Kentucky Case Study. Prev Chronic Dis. 2019;16:E105.
- Assessing preventive care coverage and reimbursement by major payors
- Extracting needed data from EHR system
- Patient reluctance to pay for additional preventive screenings (based on perceived and real costs and/or perceived risk)
- High volume of care gaps at the launch of the project
According to the researchers, the model fits well for clinics in underserved, rural area because the of alignment with FQHCs' foundational goal of addressing poor health outcomes among those with limited access to care, lack of transportation, and geographic isolation.
Prior to implementation, various internal assessments should be made, including a review of the EHR system's ability to provide accurate data for evaluation efforts. Staffing needs assessments should also be conducted, as additional non-clinical staff, known as Care Coordinators, were needed at White House Clinics in order to conduct proactive patient chart reviews.
An advanced commitment to changing workflows and overall workplace culture.
Staff training on the POE intervention, including motivational interviewing and leading effective team huddles, should be conducted.
Due to the intervention's success, an implementation toolkit has been developed.
Project Community Cancer Resources Guide:
Contact InformationAngela Carman, DrPH, Associate Professor
University of Kentucky College of Public Health
Federally Qualified Health Centers
HIV and AIDS
March 29, 2017
Date updated or reviewed
June 5, 2020
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