Rural Health Clinic Colorectal Cancer Screening Toolkit

A Toolkit for Implementing Evidence-Based Colorectal Cancer Screening Interventions in South Carolina Rural Health Clinics

Purpose

The purpose of this toolkit is to provide guidance to Rural Health Clinics in South Carolina that want to implement evidence-based strategies to improve colorectal cancer screening among their patient population. As a key provider of primary care in rural communities in the Palmetto State, you have the opportunity to reduce the incidence and mortality of this cancer. This toolkit provides information on colorectal cancer screening recommendations, evidence-based strategies to increase screening, and practical tools to evaluate screening uptake in the clinic using your clinic’s EHR and to develop standard operating procedures to help your clinic improve screening rates. Some of this information is applicable to all clinical settings, while some is tailored to the unique needs of Rural Health Clinics. 


Colorectal Cancer Overview

Overall description

Colorectal cancer is the third most common cancer and the third leading cause of cancer deaths in the U.S. The  American Cancer Society  estimates that nearly 150,000 Americans will be diagnosed with colorectal cancer and nearly 53,000 Americans will die from colorectal cancer in 2021. In South Carolina, it estimated that 2,570 cases of colorectal cancer will be diagnosed and 880 people will die from the disease in 2021.

Colorectal Cancer in Rural Areas

National studies have shown that, compared to their urban counterparts, people in rural areas are  more likely to be diagnosed with colorectal cancer , more likely to be diagnosed at a  more advanced stage of disease  and are  more likely to die from colorectal cancer . This is also true in South Carolina, specifically, as well. While incidence and mortality rates are improving in both rural and urban populations, rates are consistently higher among rural South Carolinians.

Colorectal Cancer Incidence Rates in South Carolina, 1996-2016 SC Central Cancer Registry Data

Colorectal Cancer Mortality Rates in South Carolina, 1996-2016 SC Central Cancer Registry Data

For more information about colorectal cancer screening statistics and risk factors, watch the short video below:

- YouTube. Presentation on the burden of colorectal cancer and related risk factors by Dr. Whitney Zahnd, Faculty Affiliate at the Rural and Minority Health Research Center.

Screening Recommendations and Options

 The United States Preventive Services Task Force (USPSTF)  provides evidence-based guidelines for preventive services, including colorectal cancer, based upon research. This guidance also helps determine what preventive services are covered by Medicare and private insurers. With their updated recommendations released in May 2021, the USPSTF recommends screening for average-risk individuals aged 45 to 75 years of age using stool-based or direct visualization applications (see table below). The  American Cancer Society  has also endorsed screening for persons aged 45 to 75 years old. Both organizations suggest that persons aged 76-85 years old make an individual choice whether or not to be screened based on one's health and life expectancy.

Cancer Screening Modalities, Frequencies, and Characteristics (adapted from the  National Cancer Institute Colorectal Cancer Screening Fact Sheet  and  USPSTF )

Some tests are generally not recommended due to insufficient evidence/lack of evidence of their effectiveness or their likelihood for complications. These include blood-based DNA tests (liquid biopsy), double-contrast barium enema, and single specimen FOBT collected during an in-office rectal exam. Further, the National Colorectal Cancer Roundtable recommends against using older versions of guaiac FOBT, such as Hemoccult II, since they are less sensitive. 

For more information about screening recommendations and testing options, watch the short video below:

- YouTube. Presentation of USPSTF colorectal cancer screening guidelines and testing options by Dr. Jan Eberth, Rural and Minority Health Research Center Director.


Evidence-based Interventions (EBIs) to Increase Colorectal Cancer Screening

 The Community Guide  is a collection of evidence-based findings from the Community Preventive Services Task Force (CPSTF). Their guidance provides communities, clinics, and other organization with guidance on effective interventions. The CPSTF reviews and provides evidence-based recommendations for interventions for preventive services to improve population health.

Several e vidence-based interventions  (see below) for colorectal cancer screening identified by the CPSTF including both client- and provider-oriented interventions as well as multicomponent interventions. Several recommended client-oriented interventions target patients with reminders, education, or reduction of structural barriers that may inhibit screening. Provider-oriented interventions include provider assessment and feedback and provider recommendations.

Evidence-based Interventions for Colorectal Cancer Screening, as recommended by the  Community Guide .

There are many free resources available that may be enable your clinic to implement these recommended approaches. Below are a couple of resources that may aid with small media messaging or that could be used as part of one-on-one education:

Customizable postcard from the MIYO website

  •  The National Colorectal Cancer Roundtable recommends the "Make It Your Own" website  from the Health Communication Research Lab at Washington University in St. Louis , which enables you to create high-quality small media and patient reminders, such as postcards, posters, social media messages in either English or Spanish and using images that reflect the diversity of your community and evidence-based, tested messaging.

    • The  Colorectal Cancer Prevention Network  (CCPN) at the University of South Carolina has developed a series of educational videos on colorectal cancer screening that may provide patients with important information on the risk factors for colorectal cancer, the role of family history in the development of colorectal cancer, and the colorectal cancer screening process both for colonoscopy and for FIT kits. Nine educational videos are available  here , but an example video is embedded below:

-Vimeo. Educational video on colorectal cancer screening produced by the Colorectal Cancer Prevention Network at University of South Carolina.


Implementation of EBIs

There are steps your clinic can take to successfully implement EBIs to improve colorectal cancer screening rates in your clinic.

  • Assessing your organization's capacity to implement EBIs
  • Identifying which EBI or EBIs your clinic would like to implement
  • Developing standard operating procedures (SOPs) for implementation
  • Constructing process maps to visualize how EBIs will be implemented and/or how eligible patients will be identified, referred, and tested for colorectal cancer

Assessing Organizational Capacity

Before deciding what EBI your clinic will implement, it is important to assess your organization's resources and capacity; this may include type and number of personnel, physical space constraints, presence of an on-site laboratory, type and functionality of the electronic health record, and proximity to qualified endoscopists.

The National Colorectal Cancer Roundtable also has a guide for Community Health Centers wishing to implement colorectal cancer screening that may also be useful for Rural Health Clinics. This includes guidance on how to determine your clinic's baseline screening rate, how to choose which high-quality screening modality or modalities may work best for your clinic, and how to identify a "colorectal cancer screening champion" within your clinic. This guide is available at  this link here . Additionally, for clinics that have eClinicalWorks as their EHR system, there is a guide that can provide specific best practices for supporting CRC screening in your clinic by using the features within your EHR. This includes providing workflow guidance and providing best practices for making data queries, documentation results, placing orders, and notifying patients of screening results. This guide on best practices is available at  this link here .

Identifying EBIs

Deciding upon which EBI or set of strategies to implement should be based upon the results of your organizational assessment, which strategies your team are excited about and feel confident implementing, and what level of funding and resources your clinic has in place to support implementation (e.g., mailing out client reminders may be more cost-prohibitive than sending automated text messages). Remember, many small media resources are free upon request (mailed directly to you) from the American Cancer Society, Centers for Disease Control and Prevention, and other organizations, so this supportive strategy is easy to implement on top of other EBIs. Research shows that  multi-component interventions  are effective at increasing CRC screening rates and are  cost-effective  as well.

Developing Standard Operating Procedures

Standard operating procedures can provide a way for your clinic to operationalize colorectal cancer screening in your clinic by helping to identify who among your patient population needs colorectal cancer screening through chart audits, specific steps to integrate EBIs in your everyday clinic practice and EHR workflow. An example standard operating procedure used in practice by an RHC is  available at this link  for review and potential modification.

Constructing Process Maps

Process maps are flow diagrams that can enable your clinic to demonstrate processes such as implementing an evidence-based CRC screening intervention in your clinic. The development of process maps can allow your team to collaborative identify and improve processes and understand where challenges and complexities may occur. Process maps use specific symbols to demonstrate the components of the process:

  • An oval demonstrates where an input enters (e.g., running a report to see who needs to be reminded to be screened) or an output exits (e.g., a nurse contacts a patient to schedule an appointment)
  • A rectangle shows an action step (e.g., assembling patient reminder cards)
  • A diamond indicates where a decision is made (e.g., determining if the front desk is able to make an appointment for a patient)
  • Arrows demonstrate the direction of the process (e.g., the connection between determining a list of patients needing reminders and assembling postcards)

The video below provides guidance on how to develop process maps for clinical settings.

Creating Process Maps for Clinical Care

Below is an example of a process map that an RHC made to implement colorectal cancer screening reminders for their healthcare providers. This process map was made with Microsoft Visio, though the other programs like Microsoft Word, Powerpoint, and Publisher could be used as they all have the ability to construct shapes overlaid with text. Additional sample process maps for other EBIs can be found  here at this link .

Provider reminder process map designed and implemented in a partner Rural Health Clinic in SC

After drafting your process map, ask the following reflection questions:

  1. Are you skipping any critical steps?
  2. Are there any redundant or unnecessary steps?
  3. Is there a more logical way to organize the steps?
  4. Where might my process break down, and what fail-safe mechanisms could I put in place to mitigate possible failures?

Spotlight Rural Health Clinic

At the 2021 SC Office of Rural Health Annual Meeting, our team and project partner Fairfield Medical Associates presented on the lessons learned from implementation of EBIs in their clinic. The full presentation is shown below.

-YouTube. 2021 SCORH Annual Meeting Presentation on CRC Screening in Rural Health Clinics.


Other Resources

-YouTube. 80% in Every Community Pledge, established by the National Colorectal Cancer Roundtable.

A provider's guide for colorectal cancer screening, developed by the National Colorectal Cancer Roundtable and the American Cancer Society.


Acknowledgements

This project was made possible in part by funding from the Federal Office of Rural Health Policy, National Cancer Institute, and SC Center for Rural and Primary Healthcare. Team members who contributed to the design and implementation of the project include Drs. Jan Eberth, Whitney Zahnd, Heather Brandt, Lauren Workman, and Dave Murday, as well as Project Coordinator Ms. Cindy Calef.

The External Advisory Board included Annie Thibault from the South Carolina Colorectal Cancer Prevention Network, Kim Hale and Molly Black from the American Cancer Society, Henry Well from the South Carolina Cancer Alliance, Shannon Chambers and Michele Stanek from the South Carolina Office of Rural Health, and Mark Jordan from the South Carolina Department of Health and Environmental Control.

Rural Health Clinic Colorectal Cancer Screening Toolkit

Rural and Minority Health Research Center, University of South Carolina

Cancer Screening Modalities, Frequencies, and Characteristics (adapted from the  National Cancer Institute Colorectal Cancer Screening Fact Sheet  and  USPSTF )

Evidence-based Interventions for Colorectal Cancer Screening, as recommended by the  Community Guide .

Customizable postcard from the MIYO website

Provider reminder process map designed and implemented in a partner Rural Health Clinic in SC

A provider's guide for colorectal cancer screening, developed by the National Colorectal Cancer Roundtable and the American Cancer Society.