From Barriers to Bridges: A Dialogue for Action to Increase Colorectal Cancer Screening in New York

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1 From Barriers to Bridges: A Dialogue for Action to Increase TIMELINE July 2005 Start of Project October 2005 Pre-Orientation Dialogue core team completed a background survey for the NY Dialogue. October 2005 Orientation Planning committee members began planning the summit and completed a satisfaction survey regarding the orientation and their expectations for the process. February 2006 Stakeholder Interviews The core team conducted interviews with individuals from diverse occupations and specialties. June 2006 Leadership Summit 127 people attended the summit in Albany, NY. Feedback was collected from the participants and organizers. July Present Post-Summit Activities The Dialogue for Action, a signature program of the Prevent Cancer Foundation (formerly the Cancer Research and Prevention Foundation), offers a unique opportunity for a state to develop a working consensus to increase colorectal cancer (CRC) screening rates. The process brings together a diverse group of individuals and organizations united by their dedication to decrease morbidity and mortality from CRC. cancer control plan, Dialogue identifies collaborative solutions to increase screening, provides the tools participants need to take action and stimulates the building and maintaining of statewide partnerships. The Dialogue process culminates in an innovative and interactive leadership summit that provides a creative forum for identifying collaborative strategies. The summit concludes with tangible outcomes. The process serves as a catalyst for increased activity around CRC screening. State outcome activities have included: updating CRC objectives in the state plan, creating or revitalizing a statewide coalition, creating a media campaign, agreeing on a universal message regarding screening modalities, conducting provider or pharmacist outreach and initiating legislative activities. NY Dialogue Planning Committee (See pages 3-4 for a complete list of Core Team and Planning Committee members.) Pre-Dialogue Activities New York State (NYS) has made colorectal cancer screening a priority for more than a decade. Prior to being selected for a state-level Dialogue for Action, NYS had many collaborative initiatives underway to provide public and professional education, as well as screening services to residents in need. In 2003, the New York State Comprehensive Cancer Control Plan was published as a result of the collaboration of many stakeholders. Get to Know New York Population: 19,306,183 Population 50+: 5,946,304 CRC Incidence: 51.7 per 100,000 CRC Mortality: 18.1 per 100,000 See References #1 and #2 on page 6. July Year Post-Summit survey and phone calls State-Level LEGEND CDC/Prevent Cancer Project States States with Other Funding Glossary: Page 5 References and Notes: Page AI/AN WA KY 2007 AI/AN NJ MN SC 2006 CA MA NE NY VA 2005 MD NE OH 2004 CO MI 2003 AZ/NM 2002 UT To learn more about Dialogue for Action visit 1

2 New York State CRC Goal and Objectives Goal By 2010, increase the proportion of colon and rectum cancers detected at an early stage to 50%. (NYS Baseline: Males 42.6%, Females 39.2% [1999]) Objectives Increase the use of Fecal Occult Blood Test among New Yorkers over age 50. By 2006, increase colorectal cancer screenings for people over age 50 to 50% (NYS Baseline: 44.6% 2002 BRFSS). Identify those at high-risk due to personal or family history and refer for appropriate screening. Create culturally, linguistically and developmentally appropriate messages to increase awareness of the need for screening tests. Develop strategies to assess current capacity for provision of colorectal cancer screening tests and methods to increase capacity, where needed. New York State Comprehensive Cancer Control Plan: Strategic Directions for New York State Pre-Dialogue continued A number of other initiatives were also underway, including: The Cancer Services Program Colorectal Cancer Screening Initiative In 1997, the New York State Department of Health (NYSDOH) established the first state-funded CRC screening program by building upon local partnerships that were providing breast and cervical cancer screening to uninsured residents. From August 1997 through December 2005, more than 52,500 people were screened for CRC. More than 51,000 people at average risk completed fecal tests and of those 1,500 people completed a diagnostic colonoscopy following a positive result. More than 1,100 people at elevated risk for CRC due to personal or family history completed screening colonoscopies. (See graphs below for more detail on screening rates.) Number of CRC Screenings Number of CRC Screenings by Calendar Year Provider Awareness Campaign In 2005 the NYSDOH completed a provider mailing, which included a letter from the Commissioner of Health and tools to help providers discuss CRC screening with their patients. More than 18,000 primary care providers and gastroenterologists received the direct mail letter. Public Awareness Campaigns In February and March 2005, the NYS- DOH sponsored a public awareness campaign using paid television and radio public service announcements promoting Screen for Life campaign materials. In 2005 and 2006, the American Cancer Society (ACS) Eastern Division launched a campaign to promote awareness, including a paid Web site and Web ads Year Source: NYSDOH Cancer Services Program CRC Screening Initiative, 2007 Outcomes of 2,606 Colonoscopies Performed from August 1997 through December 2005 Other Diagnoses (9%) Diverticulitis (8%) Hemorrhoids (17%) Normal (27%) See Reference #3 on page 6. CRC (3%) A. Polyps (20%) Crohn's or Colitis (1%) Other Polyps (14%) Source: NYSDOH CSP,

3 Pre-Dialogue Activities continued Satellite Broadcast for Primary Care Clinicians A satellite broadcast on CRC screening targeting primary care providers was produced in (The satellite broadcast can be accessed albany.edu/sph/coned/colorectal.html.) Statewide Survey of Endoscopic Capacity (SECAP) With Battelle, the CDC conducted a statewide survey of endoscopic capacity in In order to obtain more-current capacity information, a written survey was sent to health care facilities known to have bought flexible sigmoidoscopes and colonoscopes. Health Plan Assessment Screening Initiative (CCSI) was begun as a partnership between the New York Health Plan Association (NYHPA) and the ACS Eastern Division. It brought together NYHPA member health plans, non- Administration, New York City (NYC) Health and Hospital Corporations, NYS- DOH and the Westchester County CRC Screening Coalition. New York Dialogue Core Team Co-Chairs Martin C. Mahoney, MD, PhD, FAAFP Roswell Park Cancer Institute Sidney Winawer, MD Memorial Sloan-Kettering Cancer Center Co-Coordinators Lynn Couey, MSW, MA Eva Sciandra Core Team Susan Booth Sarah Brazzell Health Plan Awareness Initiative In 2004, the NYSDOH collaborated with Independent Health Association, a large managed care organization in Western New York, to distribute interactive CD- ROMs developed by the National Colorectal Cancer Research Alliance. A series of focus groups was also conducted with beneficiaries and providers to assess the effectiveness of the CD-ROM. New York City Colon Cancer Control Coalition In March 2003, a coalition called C5 (Citywide Colon Cancer Control Coalition) comprised of academic medical centers, community-based organizations and social service agencies came together under the leadership of the NYC Department of Health and Mental Hygiene (DOHMH) to develop strategies for improving CRC prevention. Despite all of these successful efforts, the state leaders felt there was a need for consensus on strategies to educate physicians, legislators and the public about the options for CRC screening. They believed the summit would provide a forum to address the different needs and priorities that exist across the state and help to create statewide strategies. Mari Carlesimo Kirsten Firla, MSPH Julie Herson Kim Kelly New York Health Plan Association Leslie Larsen, MPH Heather LeBlanc Carol Lindhorst Michele Tropper, MPH American Cancer Society New York Dialogue Planning Committee Birgit Bogler NYC Department of Health and Mental Hygiene Katherine N. DuHamel, PhD Mount Sinai School of Medicine Van H. Dunn, MD, MPH NYC Health and Hospitals Corp Maud Easter Center for Women in Government & Civil Society Tom Foels, MD Independent Health Janaera Gaston NY Business Group on Health Donald Gemson, MD, MPH Merrill Lynch Vito Grasso, MPA, CAE NY State Academy of Family Physicians Nilsa Gutierrez MD, MPH Centers for Medicare and Medicaid Services Grace Hillyer, MPH Columbia University CPI Program Elaine Kee, RN, BSN, CWHNP Warren/Hamilton Healthy Living Partnership Linda Lambert, CAE American College of Physicians Dale L. Mintz, MPA, CHES Hadassah Kate Murphy, BA Colorectal Cancer Coalition Mary Murphy, RN, CGRN Society for Gastroenterological Nurses and Associates John Rugge, MD Hudson Headwaters Health Network 3

4 Financial Contributors Dialogue Silver EXACT Sciences Bronze Custom Ultrasonics Hemosure, Inc. New York Health Plan Association Olympus Quest Diagnostics Contributors to this Report NY Dialogue Core Team and Planning Committee Jessica Abeita, MPH Sara Barrett, MPH Erica Childs, MPH Jasmine Greenamyer, MPH Alex Khalaf, BS Karen Peterson, PhD Prevent Cancer Foundation Judith Blanchard, MS JS Blanchard and Associates Emily Turk Prevent Cancer Consultant Ena Wanliss, MS Centers for Disease Control and Prevention Dialogue for Action together individuals and organizations to implement CRC objectives in the state comprehensive cancer control plan. This project is supported by Cooperative Agreement #U58/CCU from the Centers for Disease Control and Prevention. The Dialogue Summit On June 29, 2006, New York held its leadership summit, From Barriers to Bridges: A Dialogue for Action to Increase Colorectal Cancer Screening in New York, in Albany, with more than 100 participants representing a spectrum of professions and organizations. The participants developed a set of recommendations for increasing colorectal cancer screening in New York and were then charged with transforming them into action steps and measurable outcomes. The summit recommendations included: Provide universal access to comprehensive health care including coverage for all evidence-based clinical services. Create legislation to provide full funding for CRC screening for all according to established guidelines with treatment coverage for all insured. Create a prevention services model to improve collaboration between statefunded programs and other community coalitions and to move away from the individual/chronic disease model to a more coordinated approach. Collaborate with professional communities, such as obstetrician/ gynecologists (OB/GYNs) and other primary care physicians, to establish CRC screening as the standard of care. Develop screening and treatment outreach with non-traditional partners like employers and faith-based organizations and create consumer-direct outreach. Work with NYSDOH and NYC programs to develop and implement strategies to better market their successful initiatives. Post-Dialogue Momentum A number of efforts have been implemented since the 2006 Dialogue. Medicaid Treatment Coverage As a result of the work of summit participants, legislation was approved authorizing Medicaid coverage of CRC treatment for any person screened or diagnosed through the NYSDOH Cancer Services Program as of April Universal Health Care Initiatives As a result of the interest generated at the summit, the NYS Cancer Consortium selected universal access to health care as their major theme for the 2007 Annual Summit. During fall 2007, seven public hearings were convened to discuss health care reform initiatives. (Visit (http://partnership4coverage.ny.gov/.) Statewide Expansion of NYSDOH CRC Screening Initiative: Twenty new contractors were selected in early 2007 to provide colorectal cancer screening in 21 more counties. This expansion represents the final phase towards implementation of a statewide CRC screening initiative. FIT Pilot CDC has funded the NYSDOH Cancer Services Program to work with CRC screening partnerships to evaluate the acceptability and feasibility of using fecal immunochemical test (FIT) for clients screened through NYSDOH. Professional Development Initiative The state provided funds for FY to support development of a new CRC cancer statewide training initiative in collaboration with the ACS, NYS Academy of Family Practice (NYSAFP), NYS medical societies and managed care organizations. As a result, grand rounds, train-the-trainer 2008 annual conference are under development. 4

5 Post-Dialogue continued Survey of NYS Health Plans An online survey was developed by a Dialogue work group and distributed to 21 member health plans of the NYHPA. The survey was designed to assess current health plan activity around CRC screening. Nineteen health plans (90%) responded. The survey found that four plans reported Pay for Performance (P4P) to be somewhat or very effective and that the majority of plans without P4P would consider adopting this initiative. It also discovered that the U.S. Preventive Services Task Force or the ACS screening guidelines were being used by health plans, and it identified these CRC screening priorities among respondents: developing standard patient information in multiple languages and delivering continuing education for primary care providers. Impact of Dialogue on Advancing State CRC Objectives 10% 6% 84% n=50 Regional Implementation In December 2006, a post-dialogue videoconference was held at five locations across the state. Seventy stakeholders discussed the eight priorities identified at the state Dialogue, and it was decided to divide the state into five regions to enable implementation of the priorities. The Capital Region team has identified professional education and health plan assessment as its priorities. (The NYS- DOH has secured $500,000 in state funding to conduct the professional development initiative for primary care physicians.) The NYC Metro Region team is currently of resources available for insured and uninsured residents. A collaborative approach to more consistent messaging is the NYSDOH. Strong/Somewhat Strong Neutral Don't Know In the year following the Dialogue summit, all participants (including core team and planning committee members) were asked if the Dialogue had an impact on advancing state CRC objectives. Eighty-four percent saw a strong or somewhat strong impact. Glossary Core Team: small group of individuals responsible for the implementation of the New York Dialogue process (n=14). Participants: individuals from diverse fields who attended the New York Dialogue summit (n=127) Planning Committee: a group of individuals who make recommendations on the design and implementation of the Dialogue summit. Comprised of leaders in diverse areas and includes the core team (n=16). Stakeholders: individuals who participate in a one-time interview at the development stage of the conference by giving feedback on the proposed meeting purpose and design (n=11). State Coordinators: individuals responsible for the management of the New York Dialogue process. Most participants saw a strong or somewhat strong impact on identifying new partners to work with, one year after the Dialogue. When asked about the impact on strengthening existing relationships, most (also 86%) saw a strong or somewhat strong impact. Impact of Dialogue on Identifying New Partners 4% 2% 8% Strong/Somewhat Strong Not much 86% Neutral Not at all n=50 5

6 Dialogue Summit June 2006 Conversations build consensus and produce action steps for change. Dialogue presenters, from left: Dr. Richard Wender, Dr. Thomas Weber, Carolyn Aldige, Dr. Sidney Winawer Regional Implementation continued In June 2007, the Western Region team held a local meeting modeled after the state Dialogue. The region chose to focus on working with professional organizations and medical societies and building relationships with non-traditional partners, such as employers and faithbased organizations to promote screening. Goals include engaging employers in eight counties of the In August 2007, the Southern Tier Region team hosted a smaller local meeting modeled after the NYS Dialogue. Fifty stakeholders came together and decided to focus on increasing CRC screening rates through professional education and on utilizing non-traditional partners to promote screening to the public. References and Notes The Central Region team is reaching out to non-traditional partners to help promote screening initiatives and to create a culturally sensitive health care system that removes barriers to screening and treatment. The team is currently working on developing a welcome and information packet to be distributed to local agencies and residents. Dialogue for Action has benefited New York State by bringing many stakeholders from different organizations and regions together. As a result, several sustainable efforts are underway toward increasing colorectal cancer screening across the state, and developing a consensus on statewide strategies continues. 1. Population statistics from the US Census 2006 estimates. 2. CRC incidence and mortality from the NYS Cancer Registry, , New York State. 3. The New York State Comprehensive Control Plan at cancer/cancer_control/pdf/nys_cancer_plan.pdf. Prevent Cancer Foundation, formerly the Cancer Research and Prevention Foundation, is a national non profit health organization whose mission is the prevention and early detection of cancer through scientific research, education and community outreach. Since 1985, the Foundation has provided more than $97 million in support of research, education and community outreach. Methodological Notes 1. Level of involvement of key groups and numbers of respondents: The core team was most involved with the Dialogue, followed by the planning committee and then the summit participants (see Glossary for definition of these terms). While core team and planning involvement was limited to the summit itself. The evaluation design reflected this difference in the intervention itself. Where all three groups responded to the same questions and the data are displayed as a combined result, the overwhelming number of respondents would be summit participants. 2. Attrition: The percentage of one-year post-summit surveys completed by summit participants was lower than the percentage completed at the summit: 68% of participants completed paper surveys at the summit, but only 24% completed electronic surveys one year later. For the planning committee members, completion rates were 94% and 19% respectively. However, completion rates for the core team remained steady, with about three-quarters of the core team members completing all evaluation surveys. 6

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