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Service Delivery Innovation Profile

Quality Improvement Collaborative Helps Clinic Serving the Uninsured to Significantly Increase Colorectal Cancer Screening and Smoking Cessation Education


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Snapshot

Summary

Wayne Action Teams for Community Health, or WATCH, a nonprofit organization that offers primary care to uninsured residents of Wayne County, NC, participated in a 12-month collaborative quality improvement initiative sponsored by the North Carolina Prevention Collaborative. As part of this collaborative, WATCH decided to focus on improving the provision of colorectal cancer screening and smoking cessation education to eligible patients. To that end, it created new processes to identify those in need of these services, formed partnerships with community-based organizations and providers to offer additional support to such patients, and participated in ongoing performance monitoring, reporting, and improvement. The program significantly increased the percentage of eligible patients receiving the targeted services, and convinced several patients to make important health-related decisions, such as quitting smoking and getting a colonoscopy after an abnormal screening result. Because of these successes, WATCH now routinely uses these new processes and partnerships as a routine part of patient care.

Evidence Rating (What is this?)

Moderate: The evidence consists of a pre- and post-implementation comparison of the percentage of eligible patients who received colorectal cancer screening and smoking cessation education, along with the cumulative number of patients who made critical health decisions after receiving these services.
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Developing Organizations

North Carolina Prevention Collaborative; Wayne Action Teams for Community Health
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Date First Implemented

2007
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Patient Population

Vulnerable Populations > Medically uninsured; Insurance Status > Uninsuredend pp

Problem Addressed

Colorectal cancer and smoking-related diseases are common and often prove to be fatal. Many of these deaths could be prevented with proper screening and smoking cessation education and support. However, staff at busy clinics serving uninsured patients often have limited time to provide such support.
  • Major causes of mortality: In 2008, more than 108,000 new cases of colon cancer and more than 40,000 new cases of rectal cancer occurred, making colorectal cancer the third most common form of cancer in the United States. It is also the third leading cause of cancer deaths among U.S. adults, with almost 50,000 individuals dying from the disease in 2008.1 For its part, smoking increases the risk of heart and lung diseases and several types of cancer, and accounts for 440,000 deaths each year in the United States.2
  • With such deaths often being preventable: The majority of colorectal cancer deaths can be prevented with appropriate screening, which enables the detection and removal of polyps before they progress to cancer.1 However, despite a growing awareness of its necessity, screening remains underutilized, with only 57 percent of eligible U.S. adults being current with recommended screenings.3 Smoking remains a leading cause of preventable deaths, but most smokers have difficulty quitting without outside assistance.2
  • Failure to provide screening and education at busy clinics: Due to time constraints, primary care clinics that serve large numbers of uninsured patients tend to focus on immediate health needs (e.g., wounds, foot problems, respiratory infections) and/or easily diagnosable chronic problems (e.g., high blood pressure, depression, asthma). At WATCH's clinics, for example, most patient visits last only 15 minutes, making it difficult for staff to provide comprehensive preventive care and screenings. Before WATCH's participation in the program, only 16 percent of age-appropriate patients received colorectal cancer screening (well below the North Carolina Prevention Collaborative's target of 70 percent) while only 66 percent of smokers received smoking cessation education (again below the target of 80 percent).

What They Did

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Description of the Innovative Activity

WATCH, a nonprofit organization that offers primary care to uninsured residents through a permanent and mobile clinic, participated in a 12-month quality improvement collaborative focused on improving the provision of colorectal cancer screening and smoking cessation education to eligible patients. As part of this collaborative, WATCH created new initiatives to identify those in need of these services, formed partnerships with community-based organizations and providers to offer additional support to patients, and participated in ongoing performance monitoring, reporting, and improvement. Key elements of the program included the following:
  • New initiatives to identify those in need of services: WATCH identified and implemented several new initiatives designed to promote the identification of those in need of colorectal cancer screening and/or smoking cessation education, as outlined below:
    • Amendment to patient problem list: WATCH amended a list of common patient problems in each patient's chart to create a health promotion section that lists when the patient has received colorectal cancer screening and smoking cessation education. (This new section also captures information on the provision of other services, such as Pap smears, mammograms, and flu shots.) Any provider who opens the chart can easily see when the patient last had these services, and hence can determine if the patient currently needs either service.
    • Colorectal cancer screening and smoking cessation guide: WATCH staff use a guide to help determine who needs colorectal cancer screening, based on age and personal/family history. The guide is a compilation of research and guidelines from the American Cancer Society and the U.S. Preventive Services Task Force as well as other sources.
    • Signs and pamphlets: To encourage patients to ask about these two issues, WATCH posted signs with information on colorectal cancer screening and smoking cessation in patient waiting rooms, and also put out pamphlets that patients can take with them.
    • Reminder note: The nurse practitioner on the mobile unit keeps a reminder note about these two services in the examination room and on her prescription pad.
  • Provision of targeted services: WATCH provides colorectal cancer screening and smoking cessation education as part of the services offered in its permanent and mobile clinics, as outlined below:
    • Colorectal cancer screening process: For those identified as needing colorectal cancer screening, WATCH offers initial testing through fecal occult blood tests, using the most sensitive/specific cards available. Patients with positive test results may be referred to a gastroenterologist for a followup colonoscopy. (See bullet on partnerships below for more details.) At-risk patients also receive printed material with information on colorectal cancer and recommended prevention strategies. All staff use a process flow map with a checklist with each patient to make sure no steps are missed. Before this project, there was no specific policy or process for screening; screening was inconsistent, based on provider preference, and was focused on acute management instead of health promotion.
    • Smoking cessation education process: WATCH's smoking cessation education program uses the stages-of-change theory, which suggests that individuals considering making a behavioral change go through four stages: precontemplation, contemplation, preparation, and action. The health educator uses this theory to gauge smokers' readiness to quit and then personalizes the interventions based on their readiness. The educator also offers one-on-one education and followup with all smokers. Before this program, tobacco use screening was inconsistent, based on provider preference. Additionally, providers' time was minimally dedicated to cessation education due to many competing demands.
  • Outside partners to provide additional support: WATCH has forged partnerships with several community-based organizations and resources that support patients after the screening and/or smoking cessation counseling services have been received. Key partnerships are described below:
    • Local gastroenterologists: WATCH identified and partnered with two local gastroenterologists willing to provide colonoscopies and other followup care to patients with positive test results.
    • Federal government's quitline: WATCH encourages smokers to seek additional information and help from sources such as the federal government's 1-800-QUIT-NOW program, which includes a toll-free number for finding counseling, a Web site (www.smokefree.gov), and other tools for helping people quit smoking.
    • Local YMCA: The local YMCA (which also serves as host to WATCH's permanent clinic), agreed to let WATCH's health educator run a weekly smoking cessation support group for interested patients and their families.
    • Pharmaceutical companies: WATCH built partnerships with multiple pharmaceutical companies to provide medication for smoking cessation, including Chantix and Zyban.
  • Ongoing performance measurement and improvement: To track progress, WATCH staff audited 20 patient records per month to estimate the degree to which eligible patients received the targeted services. Results were shared with the Collaborative's quality improvement coordinator, who then provided feedback to WATCH based on its performance. This process enabled WATCH leaders to see what had and had not worked, and to adjust the program accordingly.

Context of the Innovation

Operating from 2007 to 2009, the North Carolina Prevention Collaborative included the University of North Carolina at Chapel Hill, the North Carolina State Health Department's Chronic Disease and Injury Prevention Section, and the Wake Area Health Education Center. The Collaborative worked with local nonprofit practices and clinics to assess and improve the quality of their preventive services, with a focus on helping them develop links with state and local community partners and resources. After developing a list of roughly 35 nonprofit practices in central and eastern North Carolina that care for underserved populations, the Collaborative chose 6 to participate in a 1-year initiative, including WATCH. WATCH, a nonprofit organization in Wayne County, NC, provides primary care to uninsured county residents, many of whom are homeless, via a stationary clinic located at a YMCA and a mobile medical unit that travels to 20 sites each month.

Did It Work?

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Results

The program significantly increased the percentage of eligible patients receiving colon cancer screening and smoking cessation education. Several patients made important health decisions as a result of getting these services, such as undergoing a colonoscopy after an abnormal fecal occult blood test result and quitting smoking.
  • Significantly greater provision of targeted services: Based on a random audit of 20 patient charts each month for 1 year (from January to December 2009), the percentage of age-appropriate patients receiving colorectal cancer screening rose from 16 percent before the program to 98 percent afterward, while the percentage of smokers receiving cessation education increased from 66 to 98 percent.
  • Leading to important health decisions: The audits identified 8 patients with positive test results who decided to get a colonoscopy that removed precancerous polyps, along with 16 patients who quit smoking after receiving counseling. The program identified 52 patients with positive stool cards; all received screening and referral for evaluation. During the year, 32 people quit smoking; many others were in the process of reducing their daily consumption at the end of the year.

Evidence Rating (What is this?)

Moderate: The evidence consists of a pre- and post-implementation comparison of the percentage of eligible patients who received colorectal cancer screening and smoking cessation education, along with the cumulative number of patients who made critical health decisions after receiving these services.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Forming quality improvement team: After WATCH agreed to participate, WATCH and Collaborative leaders formed a quality improvement team that included WATCH's lead family nurse practitioner, a medical office assistant, two certified nursing assistants, a health educator, and the Collaborative's quality improvement coordinator. The coordinator coached and guided WATCH staff, teaching them to collect, analyze, and use data to improve the delivery of health promotion services. She also helped staff understand where service gaps existed and identify resources within the community to help fill those gaps. The team met monthly throughout the 12-month initiative, with phone conversations taking place as needed between meetings.
  • Identifying target areas: The team conducted a baseline chart audit to identify potential areas in need of improvement. This audit found that WATCH's performance exceeded target goals in hypertension control and provision of mammograms and Pap smears, but performance lagged considerably on the provision of colorectal cancer screening and smoking cessation education. As a result, WATCH leaders chose to focus on improving these two areas.
  • Using plan-do-study-act (PDSA) cycle of improvement: The quality improvement coordinator provided WATCH with training and guidance on the PDSA rapid change cycle to improve processes. Use of this approach helped identify small changes that could lead to significant improvements in service provision.
  • Consulting with health department: The team contacted a state health department employee for help in identifying other public health agencies and publicly available information that might benefit the initiative.
  • Local partnerships: The team made arrangements with its local partners to provide critical support services. To recruit gastroenterologists, project leaders met with doctors to explain their goals and issues. Once the providers agreed to work with their patients, project leaders worked with them to determine payment plans and reduced fees. The project built relationships with all community partners through active communication and ongoing sharing of information.
  • Training staff: A nurse practitioner and health educator attended outside training classes on colorectal cancer screening and smoking cessation. These individuals then held training sessions for all relevant WATCH staff, teaching them about the importance of these two issues to patient health and showing them how to use fecal occult blood test cards and how to tailor smoking cessation advice to patients' needs.
  • Sharing experiences via quarterly dinners: Throughout the project, teams from the six participating clinics and the quality improvement coordinator met over dinner on a quarterly basis. These gatherings served as a venue to share information on the resources available in the community and to discuss the experiences and needs of participating clinics.
  • Institutionalizing changes: Following the 1-year pilot program, WATCH made the new initiatives and processes related to colorectal cancer screening and smoking cessation education a routine part of patient care.

Resources Used and Skills Needed

  • Staffing: WATCH staff participate in this program as part of their regular job responsibilities; staff involved in the initiative included the lead family nurse practitioner, a medical office assistant, two certified nursing assistants, and a health educator. The Collaborative provided a quality improvement coordinator.
  • Costs: The annual cost of fecal occult blood cards was $1,500 and was paid for through WATCH's general supply budget, funded by grants and donations. Other project materials were obtained at no cost from the American Cancer Society, including patient education materials. The Collaborative provided WATCH a small stipend to help offset some of the costs related to participation in the quality improvement initiative.
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Funding Sources

Duke Endowment; Kate B. Reynolds Charitable Trust; Blue Cross Blue Shield of North Carolina; Korschun Foundation
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Tools and Other Resources

Smokefree.gov, a site created by the National Cancer Institute (a part of the National Institutes of Health) in collaboration with other agencies, includes information for helping people quit smoking. Relevant links include http://www.smokefree.gov/tools.aspx and http://www.smokefree.gov/expert.aspx.

Adoption Considerations

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Getting Started with This Innovation

  • Require monthly updates: As a condition of participating, the six clinics, including WATCH, provided the results of monthly chart audits to the Collaborative's quality improvement coordinator. This requirement served as an effective motivator for the clinics to implement and maintain changes in the provision of services.
  • Focus on patient education and compliance: Educate patients on the importance of completing the fecal occult blood tests, provide clear instructions on how to use them and be prepared to reeducate patients on how to use the tests. The program found that many patients were initially deterred from completing the tests due to the test's unpleasantness and that additional conversation with these patients was necessary to convince them to complete the test. Additionally, although 98 percent of the people who needed fecal occult blood tests received the cards, only 78 percent initially returned the cards in satisfactory condition for testing.

Sustaining This Innovation

  • Always seek new partners: Because WATCH provides care to those without insurance, it can be difficult to find specialists willing to provide free or discounted care (such as colonoscopies for those who test positive on the fecal occult blood test). As a result, staff need to search on an ongoing basis for new community-based partners willing to provide such services.
  • Look for ongoing sources of funding: Investigate potential sources of funding for followup care to uninsured patients; government-sponsored programs, foundations, charities, and other organizations may be willing to support the provision of colonoscopies, smoking cessation medications, and other services to the uninsured.

More Information

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Contact the Innovator

Sissy Lee-Elmore, MBA, MPA
Executive Director
WATCH
2700 Wayne Memorial Drive
Goldsboro, NC 27534
Phone: (919) 731-6653
E-mail: sissy.lee-elmore@waynehealth.org

Carol Ann King, DNP, FNP-BC
Nurse Practitioner
WATCH
2700 Wayne Memorial Drive
Goldsboro, NC 27534
Phone: (919) 731-6933
E-mail: phnmsn@yahoo.com

Innovator Disclosures

Ms. Lee-Elmore and Dr. King have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Additional details about WATCH can be found on the organization's Web site, available at: http://www.getwatch.org.

Footnotes

1 Colorectal Cancer Facts & Figures 2008-2010. Available at: http://www.cancer.org/acs/groups/content/@nho/documents/document/f861708finalforwebpdf.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
2 U.S. Department of Health and Human Services. The Health Consequences of Smoking: a Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; May 27, 2004. Available at: http://www.cdc.gov/tobacco/data_statistics/sgr/2004/index.htm.
3 Centers for Disease Control and Prevention. Increased use of colorectal cancer tests—United States, 2002 and 2004. MMWR Morb Mortal Wkly Rep. 2006;55(11):308-11. [PubMed]
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Original publication: September 15, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 30, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 30, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.