IMPROVING COLORECTAL CANCER SCREENING IN A SAFETY NET CLINIC THROUGH A RETURN- BY-MAIL FECAL IMMUNOCHEMICAL TEST PROGRAM

STATEMENT OF PROBLEM/QUESTION: Can establishing a return-bymail fecal immunochemical test (FIT) program increase the colorectal cancer screening rate in a safety net primary care clinic? DESCRIPTION OF PROGRAM/INTERVENTION: Colorectal cancer (CRC) screening rates are typically lower in safety net health systems. This trend has been exacerbated by the COVID-19 pandemic, which has limited access to colonoscopy for screening. There is evidence that FITs are costeffective and mailed FIT programs can increase screening rates for vulnerable patients. We implemented a return-by-mail FIT program in the adult primary care clinic of New York City Health + Hospitals/Bellevue, a public safety net hospital. We evaluated adults aged 50-75 who were not up to date with CRC screening. All patients due for CRC screening were only offered FIT as a screening modality. We implemented a partial mailed FIT program, in which FIT tests picked up in clinic could be returned by mail directly to the lab. Prior to our intervention, patients were required to return FITs to the clinic in person. MEASURES OF SUCCESS: We evaluated FIT completion rates within our clinic 30 days before and after the introduction of return-by-mail FIT kits in July 2021. We also evaluated our clinic's pre- and post-intervention performance relative to other clinics within the New York City Health + Hospitals system using claims data. Additionally, we randomly surveyed patients who received a FIT and did not complete it in the period prior to our intervention to assess reasons for incompletion. FINDINGS TO DATE: A total of 5,153 and 5,180 patients aged 50-75 were seen in clinic 30 days before and 30 days after the implementation of a mailed FIT program. 571 patients were provided a return-in-person FIT kit 30 days prior to our intervention. Of these patients, 289 (50.6%) completed a FIT. By contrast, 781 patients were provided a return- by-mail FIT kit 30 days following our intervention. Of these patients, 464 (59.4%) completed a FIT (p < 0.01). Additionally, the proportion of patients who completed annual CRC screening prior to our intervention was lower in our clinic (48.2%) compared to the average across the New York City public hospital system (51.4%) according to managed care Medicaid claims data (MetroPlus, June 2021). Four months following our intervention, our clinic's year-to-date CRC screening rate exceeded the average system-wide rate (59.3% vs. 57.6%, November 2021). We also called 45 patients who were provided a FIT test prior to our intervention and did not complete it. 12 patients were reached, and 2 of these patients cited difficulty dropping off the test as the primary barrier to FIT completion (16.7%). KEY LESSONS FOR DISSEMINATION: By implementing a return-bymail FIT program, we were able to increase our clinic's CRC screening rate by 8.8%. Our data are similar to previous programs implementing mailed FIT programs in safety net patient populations. Future aims are to implement a mail-to-patient FIT program in addition to our initial return-by-mail program.

CAN YOU HEAR AND SEE ME NOW? A TELEMEDICINE QUALITY IMPROVEMENT PROJECT IN A ARGE, URBAN SAFETY NET HEALTH SYSTEM

BACKGROUND: Since the onset of the COVID-19 pandemic, healthcare systems have faced significant barriers to providing quality primary care, particularly as practices shifted to telemedicine modalities without established technical and educational frameworks for patients, teams, and clinicians. We created an iterative quality improvement project with Unannounced Standardized Patients (USPs) to explore variation in telehealth practices across three public ambulatory care clinics. METHODS: Clinical leadership designed two USP cases reflective of local patient populations and their common clinical needs. USPs portrayed either;(1) a 40-45-year-old Black male with hypertension, or (2) a 40-45-year-old Latina with an asthma exacerbation and hypertension. Both were vaccine hesitant. USPs evaluated visit workflow and clinician's communication skills across core domains (Table 1). After each visit, the USPs completed a behaviorally anchored checklist. Domain summary scores were calculated as mean percent marked “well done.” A t-test was used to compare scores across phases and cases. RESULTS: 60 visits (48 video, 12 audio-only) were conducted in two phases (May-August 2021;September-December 2021). Of the 24 USPs (18 calls, 9 texts) contacted prior to their visit, only 4 spoke directly to a care team member. 74% of USPs recommended the clinic. There were no significant differences in domain scores between phases or cases (Table 1). Most clinicians (82% in both phases) introduced the topic of the COVID-19 vaccine appropriately. Regarding screening, most providers asked about smoking (79%) and alcohol use (72%), but few screened for vaping (22%) or depression (4%). 70% of clinicians or care teams replied to a MyChart portal message that was sent by the USP to the care team after the visit. CONCLUSIONS: Findings highlight opportunities for system-based change to optimize telehealth care (particularly the integration of team members in previsit planning, standardized screenings, and patient follow-up). Data across phases indicate sustained need for quality improvement efforts;reviewing comparative data with clinic leadership will inform further evaluation of health systems and educational methods.

JUST-IN-TIME EDUCATION: IMPLEMENTING A SIMULATIONBASED TELEMEDICINE TRAINING AND ASSESSMENT PROGRAM ACROSS OUR EDUCATIONAL CONTINUUM AND HEALTH SYSTEM

SETTING AND PARTICIPANTS: Clinician trainees across our health system, including: 1) 107 internal medicine faculty and residents who participated in workplace-based learning at public, private, and federal (Veterans Affairs) ambulatory practices, 2) 16 clinicians at our student health center, and 3) upwards of 250 medical students, residents, and newly-hired general internal medicine (GIM) faculty members from medicine, neurology, and pediatrics departments in our simulation center. DESCRIPTION: While core communication skills have always been at the forefront of medical trainee assessment, information on transference of those skills and integration of the in-person clinical workflow to the virtual care environment was limited prior to COVID-19. NYU Grossman School of Medicine (NYUSOM) implemented a telehealth improvement program across medical students, residents and faculty. In order to assess and improve our systems' ongoing telehealth practices, we employed three distinct educational methodologies across our health systems since March 2020: objective structured clinical exams (OSCEs) and announced (ASPs) and unannounced standardized patient (USPs). Cases were designed to target common, site-specific issues (i.e., hearing loss, COVID-19 vaccine hesitancy, social determinants of health, and sexual and mental health concerns). In line with previous work, all SPs were trained to use a standard behaviorally-anchored checklist to assess communication and telemedicine-specific skills over video visit ( Zoom or WebEx). USPs, professional actors who conduct visits unbeknownst to the clinician, were also trained to collect data on clinic functioning. EVALUATION: Summary reports on performance were provided to both clinical and education leadership and learners to identify future training needs. Data on telemedicine skills across all projects demonstrates room for improvement (mean % marked 'well done' across learners: 46% in the OSCE, 68% at the SHC, and 48% in the public clinics, respectively). Common telemedicine challenges included prompting the SP to adjust their video frame or remove distracting background noise. Most health systems conducted fewer screenings virtually than they did inperson (e.g., at the SHC only 41% and 6% of SPs were screened for alcohol and vaping, respectively;at the public clinics, 25% and 20% were screened for depression and vaping, respectively). Participant feedback reports highlight performance across core domains and provide resources for improvement. DISCUSSION / REFLECTION / LESSONS LEARNED: Our ongoing telemedicine training program demonstrates a highly scalable educational assessment methodology that can be leveraged to optimize common care practices. Data confirm that SPs, ASPs, and USPs can be used across the health care system in simulated and real-world scenarios to identify areas for intervention.

INCREASE IN COLORECTAL CANCER SCREENING IN A SAFETY-NET HOSPITAL AFTER IMPLEMENTING MAIL-ABLE FECAL IMMUNOCHEMICAL TESTS

Background Colorectal cancer (CRC) screening rates are typically lower in public safety-net hospital systems, and optimal screening modalities have yet to be determined in this population. There is evidence that fecal immunochemical test (FIT) is a cost-effective approach in this setting, especially as the COVID-19 pandemic decreased the accessibility of colonoscopy. Mailed FIT outreach programs have been shown to markedly increased CRC screening for vulnerable patients. However, there is limited evidence regarding individual facets of these programs, such as returning FIT by mail. In the process of establishing a complete mailed FIT program during the pandemic, we evaluate the effect of allowing patients to mail back a completed FIT they received in person. Methods Patients at a safety-net hospital in New York City aged 50-75 who were not up to date with CRC screening were evaluated. We included patients 30 days before and after the implementation of mail-able FIT kits in July 2021. All patients due for CRC screening were only offered FIT as a screening modality, and prior to the intervention were required to visit the clinic to both obtain and return the FIT. We implemented a partial mailed FIT program, in which FITs picked up in clinic can be mailed directly to the lab after completion. We also randomly surveyed patients who received a FIT and did not complete it in the period prior to our intervention to assess reasons for incompletion. Results A total of 5,153 and 5,180 patients aged 50-75 were seen in clinic 30 days prior and 30 days after the implementation of the mail-able FIT kit respectively. A total of 571 patients were provided a FIT kit that required a return trip to the clinic for completion. Of these patients, 289 (50.6%) completed a FIT. In comparison, there were a total of 781 patients who were provided a FIT kit allowed to be mailed back for completion. Of these patients, 464 (59.4%) completed a FIT (p < 0.01). A total of 45 patients with an incomplete FIT prior to the intervention were called, and 12 patients were reached. Of these patients, 10 endorsed forgetting about the test, and 2 endorsed difficulty scheduling time to drop off the test. Conclusion Organized mailed FIT outreach was previously shown to improve CRC screening in a safety-net setting. We have further shown that implementing a program with FIT kits that can be mailed back significantly improves screening. While our mail-able kits would improve screening in patients with difficulty returning to clinic, many in our population would potentially benefit from reminders to complete. Future work could assess long-term completion rates of our program, and compare it with a full mailed FIT outreach program to quantify the potential increased benefit of also mailing kits to patients.