Nurse-Led Ambulatory Care Safety Net (ASN) to Help Close the Loop for Patients at Higher Risk for Colorectal Cancer (CRC) (Spotlight Poster)

Patients at high risk for colorectal cancer (CRC) commonly fall behind in their CRC screening due to a lack of processes/systems that help close the loop on follow-up. Colorectal cancer is the third leading cause of cancer-related deaths in the United States. During the COVID-19 pandemic, colonoscopy procedures were canceled, and high-risk patients were bridged with stool-based tests or no screening at all. As a result, high-risk patients became overdue for their recommended CRC screening.
Our organization, a university-affiliated ambulatory care practice, does not have a gastroenterology department; our patients have the option to schedule their colonoscopy at several external facilities. As a result, no streamline process existed to ensure patients scheduled/completed their colonoscopy. If the colonoscopy was completed, reports that relay colonoscopy findings and follow-up recommendations were not consistently received nor acted upon. PCPs are often inundated with other medical care tasks, and this can result in limited time to address healthcare maintenance items. In order to address these issues, we designed a nurse-led ambulatory safety net (ASN) program to help close the loop on overdue high-risk CRC screening and follow-up.
This ASN is managed by the population health manager (PHM). The PHM is a registered nurse that is able to perform extensive chart reviews of patients who are high risk for colon cancer. Once the chart reviews are complete and patients are confirmed to be overdue for colonoscopy, these patients are managed by a patient navigator (PN) team to help perform outreach and assess/eliminate barriers that contribute to their overdue status. The PNs utilize a registry to track all outreach attempts and colonoscopy status as patients move through the program. The PHM is an integral part to this program, as the nurse can provide a higher level of education tailored to a patient’s learning/cultural needs. In addition, the PHM can queue up colonoscopy orders for PCPs, review colonoscopy report findings, and independently set the colonoscopy interval date in the EMR for future tracking. As a result, this work is removed from the PCP so they can focus on other aspects of the patients’ health care. In addition, the PHM is responsible for monitoring program metrics and analyzing data to make program improvements.
Since the implementation of the CRC ASN, high-risk patients who were overdue for surveillance colonoscopy and converted to a “scheduled” or “completed” status increased from 33% to 89%. In addition, documentation of the next colonoscopy due date field has increased from 30% to >95%.
Learning objective: Learn strategies to help overdue high-risk patients complete their CRC screening.