Okay. So, we're going to have a conversation. I'm Paula May. I'm a gastroenterologist and health service researcher at Easton Way Health. We are going to have a conversation here about provider interventions, and then we're all going to be convened, and we're going to need someone to report out. And because I'm moderating, it would be nice if someone who's going to be around but is mine was sharing very quick bullets of what we talked about in this group. Can you volunteer? And what we'll do just to be kind is we'll make sure that we leave some time at the end to summarize for you so that you people are left to figure that other out. Okay. Yeah. So, I don't know if you'll want to do this at the end or if you'll want to do it, which would be too restrictive. Okay. So, you can use the form, and you can either do your own notes and then fill it in. Okay. Awesome. Thank you. So, our task is just to talk in the context of what we've learned today in these wonderful discussions we've had today, talk about what we think would be useful at the provider level. So, we've talked about how this is a multi-level, multi-component challenge, a follow-up after an almost holistic screening. What can we do to address the provider barriers and challenges that we've heard about today? And what we're going to do is just brainstorm a bunch of ideas, and then we'll write down our top candidates on the sheet, which we will cover. And Patrice is going to volunteer to read out ours to the group. So, what do people think? Oh, for my barrier, I think one of the biggest provider barriers is that, you know, I think it was said in the presentation is that there's a least-liked patient. You know, I think that's one of the biggest barriers is that I think people, whether you're, I mean, I can't speak for physicians, but I'm not a physician, but I think it's, they feel that that is one of the biggest obstacles as a provider. Is they creating more of an obstacle than creating more of an ease for the patient to get what they need when it comes to caring? I think they create, it's, yeah, I think they do that. You're saying insurers, or? The provider. I'm not, like, in the message. I heard, well, what are you saying, the provider? So, I think that's what I, like, factored into the barrier. But I think it's not your question, though. I think there's multi-sectoral stakeholders here, right? Like, the provider isn't just the one who ordered the school-based test. It's not the whole GI that's going to follow up, right? It's all of the people that touch the patient in a provider capacity. You have to know the provider capacity. That makes it a little confusing. Perhaps there needs to be a multi-component message, or intervention, or whatever you want to call it, so that you reach the stakeholders. I agree. So, just to kind of break this down, I think what will be easy is let's just think aloud what the provider barriers are, because that will inform some ideas of what to measure. So, for example, when we were talking today, I wrote down one of the provider barriers or challenges is the providers that don't order the colonoscopy or don't order the ortho, right? So, don't order it if it's not going to happen, so that's a branch barrier. The other one that I wrote down, and I'd love for people to share, so start thinking about it, was that some people—I wrote down that many providers attribute it to a false positive result. So, maybe we can just think of those major themes, and then that will help us think of it. But wasn't that a false positive? Yeah, so maybe sometimes the providers attribute the abnormal to a false positive. You know, I would jump in and say, I think it starts at the beginning of recommending a test. So, I think some type of education to primary care providers who are actually recommending a test in the first place, and those are typically either kindergarteners, family practice doctor, or OBGYNs, and just making sure they're well educated about the most recent recommendations that are available for recommending, which is now confusing because of what ECB is announcing. It's a little gnarly, but I think it starts with just making sure we are adequately educating our providers who are ordering the test so that they do get ordered. And then one step further, even providing some level of education to understanding the importance behind why we're doing these things. A lot of times, and with what you mentioned at one point, the mistrust of education or the healthcare system, this being to the point that, yes, these are things that we are recommending to people that fit the people in the long term, et cetera, as opposed to us just ordering the tests that we could benefit from, not benefit from. Yeah, or at least from, like, you know, you've seen some situations in primary care, God bless them, where the patients, you know, you address all these active medical problems, and they're walking out of the room and you hand them a picket. I guess me, before primary care, I'm a primary care provider, especially. So, you know, one of the things that has worked best for us at CDC is to actually not rely on the provider. That is the last person that you want to be the one to remember to order the test, you know, whatever. You want to build a system that makes it easy for the provider to just go, oh, you're new to this, and then they sign in and they go off their way. The education needs to be somebody else's. The education needs to come from somebody else. By the time the person gets all the way to the provider in their primary care appointment, they've already had their education, there's something in the system that flags the provider, says, oh, this person's new or overdue. You know, they had an XYZ test in the past. You know, they either need a colonoscopy or they can have a stool test, whatever, and then they can order it, and then the same goes for any follow-up that needs it. It needs to be an automatic flag, hey, this person also had their BIT test, it was positive, now they need a colonoscopy. If you're relying on people to remember when they're busy and they've got, you know, a bazillion patients and they've got a problem with this test, but as long as it's true, it's not going to happen. So that's one thing I've learned from doing this is do not let the provider be the one to do it. There are other sort of stakeholders, so to speak, that can actually play that role? Yeah, so I think this is where sort of the public health provider partnership comes in because a lot of what our, you know, grantees, our public health staff, they're the ones who do education, or they're like supporting our patient navigator, and that person is the one who does the education, so they even educate the providers about, you know, about the test choices and, you know, what the implications are and why you do this test or that test and what the outcome is and all that sort of thing. But, yeah, it's just, it's time consuming, right? Because, you know, I was almost recently at the VA, you know, with a 30-minute appointment, and let me tell you, I got two minutes, 29, 30 seconds left, and I was like, okay, now let's talk about doing the test. Absolutely. Yeah, so all that stuff needs to be tinkling outside of the actual visit, so the provider is just, you do need to have a provider voice because a lot of times patients won't do anything until their provider says, you missed. So you need them to say, and yes, you should have this, but that should come at the end, right, not at the beginning. So another example about, so a lot of the work that I do is in health system interventions and population health, and one intervention we did in the FQHC that I thought was really effective was that we had the MAs who were checking locations in for the appointment go through a checklist, and one of the items was if they were not able to get out of their colorectal cancer screening, explain what the fit kit was, they would open it up and go through with the patient and tell them why it was being done. Right. Then they would hand the patient over to the MD, the MD would do the consultation, and all the MD had to say was, and that fit kit that the MD was using, and in that alone, improved the return. Yeah, yeah. So they were introduced to the idea, and then the doctor reinforced it. Yeah. And you're offloading the provider. Yeah. It's a team of five people. Yeah. Yeah. And that's the key. So I'm understanding what you guys are saying is having people within the office front of the patient more or less. Right. Before you, the provider comes in and has a conversation, so you're easy to have, okay, oh, by the way, you've talked about that, you know. So it's kind of like you said, having that checklist with the staff when the patient comes in so they, as the provider, you guys know that the staff has covered, or whomever has covered a conversation with the patient to ensure that you guys, that the patient is able to have a conversation with you. Right. And having that system in place to do that, because it can't be, I haven't. Yeah. So, like, a lot of times with our grantees, they'll sit down with the clinic and they'll just, like, literally start with the meeting, okay, what is your screen grade? And so, you know, once they figure out how to get that, then they'll start pulling lists, like, these are all the patients in your clinic who are eligible, who are not up to date. Okay, well, can we reach out to those people before they even get to the clinic and say, hey, Mr. Jones, you know, so either the nurse or the MA or the patient navigator or some other person does that. So that does a couple things. It also, as a provider, it's also repetition. People rarely remember what they had to say to their mom the first time around. So it's really obvious to us that, you know, they should have a good dancer, they should get their follow-up on that, because sometimes the message has to be repeated. Maybe the MA needs to say it, and then the nurse, and then the provider, and then somebody calls them later and says, well, I didn't know this, and then it kind of starts to sink in a little bit. Yeah. Do you want to go with it? I do want to make sure. So the interventions we're proposing, though, are about the follow-up activity. Right. So how do we apply this concept of offloading the PCP and repeating the message to that step, the second step, which is we know the patient has a normal result. They're at home, right? They're out of the clinic anymore. So how do we offload, how do we apply this idea to that? Because that's the intervention we have to do it. Right. For sure. I think from what I was hearing in there about the two-step process, and I think that would be incorporating something into the checklist in advance of having the fit test or something, because the patients don't know that they have to have that, or could possibly have to have that colonoscopy. And I know, like, you talk about time, and trying to be mindful of time for some of the patients. I think that's where you just don't have, you just can't have that long conversation with somebody. Because we sit up here and we have a conversation for 15 minutes about it, and you can't have a 15-minute conversation with a patient. So how do you prepare the patient for having a possible abnormal result? And having them say, okay, the doctor told me this could come back as a positive result. What do I do next? Or do they know? Sometimes if you have the staffing that's back to utilize the current days on our support side, especially dedicate one person for all the positive tests that we receive, we have like a standard phone call that we give to individuals and say, hey, this is what your positive test means. We recommend that this is what you follow up with subsequently. And that might be a catch-all way for those positive people. Yeah. And that saves the conversation. Right. I mean, I'm not in the medical field, so this may not be an option. Is there an option or potential to say, as part of that call, they're also making the appointment right there. So do you think people, is it immediate? Okay, I'm going to make that appointment. I think it's easier for people to say yes versus I now have to think about it, I have to call back. Right. Life gets busy. Yeah. And this is why a lot of what I stress is that solving this problem is very different depending on what health system you're studying. Right? So I looked at this research question in three different health settings, the VA, UCLA, which is like a primary care health system, and federally qualified health centers. What you're saying works in an integrated health system where someone can call and say this is not normal, Dr. Jones here at UCLA is your primary care doctor and wants you to get a colonoscopy. Dr. May is also at UCLA and I can schedule your colonoscopy with her. That works. But if you're in an FQHC, you can't schedule, you have no interaction with that colonoscopist. And that's what becomes, I think, their biggest barrier is that disconnected. Right. But I think absolutely that's an intervention because what we're talking about now is kind of navigation, right? You have this spokesperson for the clinic that has a list of all the positive events and you're calling all of them and then potentially even scheduling the colonoscopy in the settings where that's possible. Well, that's where I think it becomes important to have a good relationship with the gastroenterology group in the area that's on board. And like I mentioned, we have this fast track process where patients are immediately screened. Are they appropriate for office visit or should they go right to screening? We have to have a relationship with at least, you know, a couple of community gastroenterologists who are on board, can expect the phone call, know that we need to get them screened in for a procedure within what, sweet spot is what, three, four months? So I think you have to have some kind of cooperation with the person who's going to be doing the procedure. And so I think, you know, what that recommendation would be to make sure you sort of identify who those people are and not leave it to the patient to find a gastroenterologist or if it's already kind of established. Right. Yeah. So I mean, in network, right? Okay. Well, but if you're talking about one of these, the federally, so then you're talking about people who are uninsured or none. And so that's more, I think, that relationship with a group that's willing to kind of help out. Right. So when that's those persons who is navigating the patient and reaching out to those patients who have to add them to a test, are they kind of, like, kind of, you know, segregating the patients? Like, okay, so maybe this patient is uninsured, maybe this patient is insured. And so that could tell you where you have your, you would send that person, but then that could be a GI. This GI accepts more, does more patients for a better pay versus this one doesn't. I don't know. But I'm just saying from that perspective, would you need to have, like, relationships with multiple GIs? Obviously. I don't know. Because you have different circumstances for different patients. Sure. What about patients in different areas? You know, we talked about transportation and all that. Yeah. Yeah. This is just this. Yeah, I think it's hard logistically for a primary care. I think logistically for a primary care, that would be difficult just because of the sheer number. Like, I mean, I'm trying to, like, figure out. I don't give people advice about their insurance coverage because there's so many different types and so many different variations. I mean, one thing that did work for our programs, particularly working with fairly qualified health centers, is that we had a patient out here that was a bridge between the clinic and their GI partner. So they have an established GI partner or partner. So a lot of times because people in this population are sometimes hard to reach, they would get them on the phone and be like, oh, you need to go to the hospital. Oh, you're ready to step up, right? Let me transfer you to, or they would do a three-way call with the GI clinic and schedule them on-spot so you didn't lose them. But I will say that, you know, going back to making sure you follow up on positives, like, if you don't track it, you can't follow up. Like, if you don't keep track of how many you handed out, how many were positive, how you want to know. And so when it shows back up, you're like, just again, how are you going to know what they got? And so tracking, tracking, tracking data really, really matters. And having a list on paper, Excel, I don't remember how you do it, of people who came back with a positive test and what we used to call them tickle charts where you put the little flag names on. And just make sure you just, yeah, keep calling, calling, calling, calling. Or document, you know, you can call three times, you send a certified letter. If you cannot get it to Mr. Jones, then, you know, you have to stop at some point. But, yeah, if you don't have a list, it really needs somebody who's going to take responsibility to follow up. Yeah. A lot of times I'll make that initial call, like, hey, Mr. Jones, it's all your joke. If the test is positive, you need to go and ask the dean, you know, and then either a nurse or somebody, MA or somebody else will sort of step in and help them make that connection to GI. But, again, yeah, just rely on the provider to do it. But you can't just make a referral and rely on the GI to then start following up? No, no. No. It's attempted, but the GI offices are not incentivized to chase these patients. No. And in many cases, especially in the F3Cs, these are the most challenging patients. Yeah. They want to come unprepared, uncrafted, don't show up at all. So you really aren't going to chase those patients. Yeah. And you have so many, there's so many more. There are, there are. There's other ways. You don't have to chase them. Right. So is there a dedicated person in your offices that now does at least some of this stuff or no? Is that the challenging part? I would say that this is a newer idea, the idea of a point person or a navigator for this problem. I think for screening, we do, a lot of practices have that champion, but for the idea of follow up after a normal screening, it's a newer area. So who's at the end of the game though? Like who's? Right. So the GI doesn't really have to be at the end of the game. It really falls under primary because there's a mantra where it says, you order it, you're responsible for it. So until, you know, until the GI does their colonoscopy and then they're responsible for that. But I mean, that's always the mantra, you order it, it's yours. So yeah. So that's why, like once you order a fit and it's positive, it's really primary to make sure they can take that next step and you can make that handoff and the handoff, have a way to figure out if the handoff was completed. Because a lot of guys, they'll fling out referrals and then a year later when they come back from their physical, what happened to your colonoscopy? They forgot that. Would you say the patient you have had a colonoscopy on? Yeah. I know. I didn't know that. Yeah. Yeah. We have some folks that need 330 on the show. Yeah. So we're going to, do y'all need more time? Because we're going to close it at it. We need a few minutes just to synthesize. Okay. So we're going to get 330 and then y'all can take a picture and then go. So 330 picture and then back to the back. Okay. And let's make sure that in our list for Patrice that we focus on providers and a positive fit. Okay. How about the provider interventions? Yeah. So, I mean, ours are all going to be provider interventions. I thought you were going to be saying that. The PCP is the provider. The PCP is the provider. Oh, actually, you could have interventions on the VGI side or on the PCP side. So that's true. They could have some of those. But primarily, it's primary care. Yeah. Because they're taking, they've ordered a test or whatever. And I think, and let me know if you disagree, that the first one we came up with was on the front end of colorectal cancer screening, better communication that if it's abnormal, it needs to be followed with a blood oxygen. Because that's on the provider. That's correct. So that's intervention. To me, it sounded like you were saying we were going in sequential order. Now, the first thing is at the initiation of screening, it's very clear from the provider to the patient that when this is abnormal, you have to have a blood oxygen. I think one of the speakers even said that. Yeah. It's like you're signing a contract. So I think that can be our first intervention. And I think the thing that we said after that was more around offering the provider the navigation of the abnormal FIT patients. So this is the idea of using a champion who's a non-MD usually to keep a list of all the abnormal FIT patients. And like we said, call, call, call. Right? And so we get them on the phone, and when possible, even scheduling them for an oxygen treatment. So then you have to call, follow up. Yeah, the second one was the navigation. Right? Would we leverage the health care team on them too? Yes, we can. Absolutely. So that first point about the better education, that doesn't necessarily have to be from the physician. It can be from staff members, an MA. From the physician then validating. Yes. So generally, yes, that first one was better education up front, and then the second one was offloading the provider through navigation. What else did we feel we wanted to say that we would be targeting the provider barriers? Maybe we can come up with one or two. We're cheating. We're cheating. So first off, interpreters, cultural connection. We already mentioned care coordinators, but that intermediate step with the bowel prep and transport. Okay. So yeah, I don't know if that really helps. It's hard to say that all under system or provider. Right. The navigator helps with the whole step of that. The navigator, absolutely. But I'm sorry, I was referring specifically to the transportation, like using the transportation model. So if you're offloading, if one of the things is just to offload, offloading from the provider to, you know, via navigation, wouldn't that be relevant? What she's talking about, these subsequent things. Right. I mean, I would definitely say that one minute doesn't even need to be directed to the provider to educate them about, you know, it's positive, it's positive. Black traffic, all sorts of things. Excuse me. I'm sorry. I just wanted to say that. No, no. That's a great third one. It's just better provider education about how to manage an accident. So number one, you know, don't repeat it. Right, right. We have providers who repeat it, and it's negative, and it's like, oh, I'll just ignore that. It's probably a false positive. Yeah. We're supposed to say that. Yeah. Treat it to a false positive. Yes. So maybe we're coming up with some sort of manual or public document that's provider education. Don't do these things. Right, right. Don't use a note, because one and three go together, because one used to be, we said better communication by your patient. Oh, that's for the patient. Yeah. Direct education. This one is more about direct education. Right. Better provider education. Yeah. To deal with the patient. Mm-hmm. Or how to manage the accident. How to manage the accident. Okay. So that one is probably number one. Yeah. I would say that that one first, and then say, when the patient's in front of you, we need better education. Okay, so I'm going to change this one to number one. And two. And I think that's good. We have three really good ones. Yeah. I was going to say, one of the biggest fears I've had in my education is how much it's going to cost. Yeah. So I don't know if there's a way that, as a provider, you could empower them to say, hey, in order to avoid surprises, call your insurance company and see what, in your worst case scenario, what you can expect. Yeah. You can't really give solid predictions. I also think that goes back to, that's a good, wonderful word, because it's better provider education that I understand won't fit. But also, what is the checklist? You mentioned the checklist early on. What are the things that we have to cover? Should we mention insurance? Should we mention a ballpark? Should we mention what she just listed? Yeah. Or transportation insurance. Yeah. The navigators have to come from all of those. But I think this is three great buckets. We're educating providers so they do better. We're educating patients through the providers who they trust. And then we're using navigators to push patients through the process. Yeah. So that's helpful. Great.

colorectal cancer screening

provider engagement

patient follow-up

education for providers

navigators

follow-up care