The Implementation Guide is a resource for implementing this program. It provides important information about the staffing and functions necessary for administering this program in the user's setting. Additionally, the steps needed to carry out the research-tested program, relevant program materials, and information for evaluating the program are included. The Implementation Guide can be viewed and downloaded in the Products page.
Smart Options for Screening (SOS)
|Program Title||Smart Options for Screening (SOS)|
|Purpose||Designed to promote colorectal cancer (CRC) screening among adults. (2013)|
|Program Focus||Awareness building and Behavior Modification|
|Topic||Colorectal Cancer Screening|
|Age||Adults (40-65 years), Older Adults (65+ years)|
|Race/Ethnicity||Alaskan Native, American Indian, Asian, Black, not of Hispanic or Latino origin, Hispanic or Latino, Pacific Islander, White, not of Hispanic or Latino origin|
|Funded by||NCI (Grant number(s): R01CA121125)|
|User Reviews||(Be the first to write a review for this program)|
The intervention is guided by two models. The chronic care model aims to improve and integrate six domains of careevidence-based guidelines for CRC screening and follow-up decision support, information systems, delivery design and processes of care, self-management support and informed decision making, health care policy, and community resourcesto address systemic deficiencies in care and improve clinical care for chronic health conditions. The preventive health model aims to increase a patients intent and action to screen; based on the health belief and theory of reasoned action models, the preventive health model describes moderators (e.g., patient demographics) and mediators (e.g., patients perceived susceptibility and worry) related to the patients intent and action toward completion of CRC screening.
SOS begins by identifying patients due or overdue for screening. The four stepped-intensity levels of care are described below:
-- Usual Care. Usual care includes patient handouts and an annual birthday letter containing completion dates and due dates for chronic care tests and prevention activities (e.g., immunizations such as influenza shots, screening tests such as CRC screening). In addition, medical assistants or nurses check EHRs for overdue tests prior to each patients clinic visit. A patient overdue for CRC screening is given an FOBT test kit during his or her visit unless he or she prefers colonoscopy or sigmoidoscopy.
-- Automated Care. In automated care, EHRs are used to identify patients due or overdue for CRC screening and automatically generate patient mailings. These patients receive a letter about the need for CRC screening and an informational pamphlet about the different CRC screening tests. Patients are also informed that FOBT cards will be mailed or that they may call the SOS telephone line if they prefer an alternate screening test (i.e., colonoscopy, sigmoidoscopy). Patients are mailed FOBT kits and a postage-paid return envelope if they do not request a different type of test. If patients do not complete an FOBT after 3 weeks, they receive a reminder letter.
-- Assisted Care. Patients who request an alternate screening test or do not undergo screening within 3 weeks of the FOBT test kit mailing receive assisted care. Medical assistants make up to three attempts to contact each patient by phone to determine the patients screening intent (e.g., plans to do the FOBT soon, prefers colonoscopy or sigmoidoscopy, does not want to complete screening) and encourage the patient to complete screening. During the brief telephone session, the medical assistant reviews education materials sent to the patient previously to assist him or her in making a choice or completing FOBT testing. If the patient chooses a colonoscopy or sigmoidoscopy, the request is forwarded to his or her primary care physician, and the medical assistant follows up with the patient to discuss the decision and instructions.
-- Navigated Care. Patients who do not undergo screening after receiving assisted care receive navigated care. A registered nurse contacts patients who prefer a colonoscopy or sigmoidoscopy instead of an FOBT, need assistance in making a screening choice, intend to do the FOBT but do not have FOBT results within 3 weeks of talking with the medical assistant, or could not be contacted by the medical assistant during assisted care. The nurse assesses each patients CRC risk; reviews procedural risk; provides motivational counseling to bolster the patients intent to undergo screening; creates a screening action plan; assists with referrals, appointments, and preparation for endoscopy; and tracks testing completion. If the nurse is unable to reach the patient, a letter or secure e-mail is sent to the patient to reiterate the importance of CRC screening and provide the nurses contact information.
-- Nurse navigators receive 3 half-days of training, a 30-minute conference call every other week, and direct observations of patient communications quarterly
-- Time for a programmer to build an EHR-linked ACCESS database
-- Administrative staff time to prepare and mail letters and materials (approximately 25 minutes for 100 participants)
-- Administrative staff time to monitor the SOS telephone line
-- Approximately 6 hours weekly for medical assistants to deliver the assisted intervention and 4 hours weekly for the registered nurse to deliver the navigated intervention
-- SOS Auto Continued (Group 2) Work Flow
-- SOS MA Electronic Medical Records Training
-- SOS MA LPN and RN Work Flow Diagram
-- SOS Assisted (Group 3) Work Flow Diagram
-- SOS Updated MA_LPN Protocol
-- SOS MA LPN and RN Work Flow Diagram
-- SOS Nurse Navigation (Group 4) Work Flow
-- SOS RN Motivational Interviewing Training
-- SOS RN General Overview of Counseling
-- SOS Updated RN Protocol
-- SOS Quality Assurance for Positive FOBT-FIT Completion of Diagnostic Testing and Follow-up
Automated, Assisted, and Navigated Care
-- SOS ICD Codes
-- SOS Preferred Language
-- SOS Updated FIT Instruction Sheet
-- SOS Intervention Letter mailed with FOBT kit
-- SOS Follow-up Letter
-- SOS Updated Screening Options Brochure
For costs associated with this program, please contact the developer, Beverly Green. (See products page on the RTIPs website for developer contact information.)
A total of 4,664 patients were included in the analysis as follows: 1,166 in the usual care group, 1,169 in the automated group, 1,159 in the assisted group, and 1,170 in the navigated group. Participants were 54.5% women and 45.5% men. Further, 85.2% were aged 50‒64 and 14.8% were aged 65‒73; 80.1% were White, non-Latino; 5.1% were Asian; 4.9% were African American, non-Latino, 3.3% were Latino; and 6.0% self-identified as other.
The primary outcomes were (1) completion of any CRC screening (i.e., colonoscopy, flexible sigmoidoscopy, FOBT) in year 1 or 2 of the study and (2) being current for CRC screening in years 1 and 2 of the study. Current for CRC screening was defined as receipt of a colonoscopy or flexible sigmoidoscopy in year 1, FOBT in years 1 and 2, or FOBT in year 1 and flexible sigmoidoscopy or colonoscopy in year 2. Primary outcomes were based on evidence from the EHR or claims data of CRC test completion.
- All intervention groups had a significantly higher percentage of participants receiving at least one screening compared with the usual care group, with significant incremental increases in percentage with each level of the intervention (p<.001 for all comparisons).
- All intervention groups had a significantly higher percentage of participants being current for screening in years 1 and 2 compared with the usual care group, with significant incremental increases in percentage with each level of the intervention (p<.001 for all comparisons except the assisted vs. automated group, p=.001).
Green BB, Wang CY, Anderson ML, Chubak J, Meenan RT, Vernon SW, Fuller S. (2013). An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening: a randomized trial. Annals of Internal Medicine, 158 , 301-311.
Green BB, Wang CY, Horner K, Catz S, Meenan RT, Vernon SW, Carrell D, Chubak J, Ko C, Laing S, Bogart A. (2010). Systems of support to increase colorectal cancer screening and follow-up rates (SOS): design, challenges, and baseline characteristics of trial participants. Contemporary Clinical Trials, 31 (6), 589-603.
Green BB, Anderson ML, Chubak J, Fuller S, Meenan RT, Vernon SW. (2016). Impact of continued mailed fecal tests in the patient-centered medical home: Year 3 of the Systems of Support to Increase Colon Cancer Screening and Follow-Up randomized trial. Cancer, 122 (2), 312-321.
Green BB, Anderson ML, Chubak J, Baldwin LM, Tuzzio L, Catz S, Cole A, Vernon SW. (2016). Colorectal Cancer Screening Rates Increased after Exposure to the Patient-Centered Medical Home (PCMH). Journal of the American Board of Family Medicine: JABFM, 29 (2), 191-200.
Meenan RT, Anderson ML, Chubak J, Vernon SW, Fuller S, Wang CY, Green BB. (2015). An economic evaluation of colorectal cancer screening in primary care practice. American Journal of Preventive Medicine, 48 (6), 714-721.
Murphy CC, Vernon SW, Haddock NM, Anderson ML, Chubak J, Green BB. (2014). Longitudinal predictors of colorectal cancer screening among participants in a randomized controlled trial. Preventive Medicine, 66 , 123-130.
Green BB, Anderson ML, Wang CY, Vernon SW, Chubak J, Meenan RT, Fuller S. (2014). Results of nurse navigator follow-up after positive colorectal cancer screening test: a randomized trial. Journal of the American Board of Family Medicine: JABFM, 27 (6), 789-795.
Green BB, Bogart A, Chubak J, Vernon SW, Morales LS, Meenan RT, Laing SS, Fuller S, Ko C, Wang CY. (2012). Nonparticipation in a population-based trial to increase colorectal cancer screening. American Journal of Preventive Medicine, 42 (4), 390-397.
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