Pollsters and political canvassers aren’t the only people making a lot of phone calls in California lately. San Francisco Bay Area Schweitzer Fellows Martha Benitez and Tyler Fleming have been working the phones, too, in an effort to get patients to administer and return at-home colorectal cancer screening tests.
Benitez’s and Fleming’s outreach and education program has produced dramatic results at the two Vallejo clinics where they are working. Prior to starting the project, the return rates for the tests, known as FITkits, was about 16 percent. Now, it’s approaching 85 percent.
After receiving an American Cancer Society Grant to do the screenings in 2014, two La Clínica de la Raza health centers in Vallejo were struggling to get the program off the ground because of a rapidly increasing patient load (a benefit and a challenge of increased access to healthcare through the Affordable Care Act) and limited resources. A mass mailing of FITkits to all patients between 50-75 years of age who hadn’t had a colorectal cancer screening in the past year resulted in many people receiving them unnecessarily, without any follow-up contact to answer questions or encourage patients to return the kits. On top of that, like many urban clinics, La Clínica serves a large population of homeless and transient patients, so many of the addresses the clinic had on file were invalid.
Benitez and Fleming provided critical assistance by delving more deeply into patient medical records to weed out those who were excluded from the screenings. If a patient was due for a screening, Benitez and Fleming called them to discuss the steps to completing the test and explain that it was simple and non-invasive so that they’d know what to expect when the FITkit came in the mail. In some cases, they followed up with calls to patients to encourage them to complete the test. “Clearly, this individualized contact makes a difference, particularly when the word ‘rectum’ is involved,” says Benitez, a student at Touro University California College of Osteopathic Medicine & a Public Health student.
Indeed, Fleming recalls speaking with a patient who declined a FITkit—and any screening alternatives—after hearing his educational pitch. Fleming asked her why. As it turns out, she was fearful of the result because of her family’s history of cancer and not wanting to know. Switching gears, Fleming talked with her about the benefits of knowing, especially with colorectal cancer which is highly treatable if caught early enough. Ultimately, the woman agreed to accept a kit. “Sometimes you just have to listen and care about the person on the other end of the line,” says Fleming. “It’s a lesson I’ll remember as I move through the rest of medical training and beyond.”
When they couldn’t speak directly with a patient, Benitez and Fleming left a detailed educational voice message followed up by a letter to reinforce the important of the screening. The voicemails and letters asked patients to call the clinic to request a kit, thereby ensuring they would only be sent to patients who were interested and motivated to do the screening. Last, patients visiting the clinic for regular check-ups who were due for screenings received education and FITkits from their providers.
While obviously happy with the growth in returns, Fleming, a student at Touro University California College of Osteopathic Medicine and Public Health student, was surprised by the endurance the project required. He spent about 170 hours in the project’s first seven months at a computer reading records and making phone calls. More often than not he was leaving messages or finding the numbers had been disconnected. It was only when he finally looked at the percentage of the kits that had come back that he realized the return rate had jumped, which meant that patients were getting screened, and strengthening their relationship with the clinic and its providers in the process. “Once I saw the numbers I realized that all that work was worth it,” says Fleming.
Seeking to sustain the project, the team is training staffers at the clinics to do the record vetting and outreach phone calls. He and Benitez are also in the early stages of organizing a volunteer program that would have Touro med school students do the same work outreaching to the area’s underserved population by supporting La Clinica’s panel management.
Benitez and Fleming both say their Fellowship experience will shape their approach to practicing healthcare going forward.
“Being a Fellow has given me a pragmatic lens of experience that will inform how I approach public health throughout my career,” says Fleming.
“It has been important for me to spend this time at a dynamic clinic serving an incredibly diverse population,” says Benitez. “It has helped me to understand the challenges that we face in healthcare and reinforced my belief that community organizing approaches to healthcare can have multiple benefits to direct service provision and strengthening people’s self-care practices.”