2019 Community Grants

For 2019, the C4 Board of Directors released a Request for Proposals that was distributed throughout California. The Board agreed to distribute $139,000 for grants that met the competitive review criteria. The projects propose to build upon resources available for Californians to ambitiously raise screening rates for colorectal cancer and improve patient outcomes. The project abstracts and funded amounts for 2019 can be accessed through the individual links below:

  1. Altura Centers for Health
  2. Champions for Health
  3. CommuniCare Health Centers
  4. Family Health Care Centers of Greater Los Angeles
  5. Family Health Centers of San Diego
  6. North County Health Services (NCHS)
  7. North East Medical Services (NEMS)
  8. Northeast Valley Health Corporation
  9. St. Vincent de Paul Village (dba Father Joe’s Villages)
  10. Tiburcio Vasquez Health Center, Inc.
  11. Tri-City Health Center
  12. Vista Community Clinic

Altura Centers for Health

Project Title: C4 Colorectal Cancer Screening Project
Project Director: Anna Fellmann, MD
Total Grant Amount Funded: $10,000

Altura Centers for Health (ALTURA) is a 501(c)(3) non-profit Federally Qualified Health Center which serves the low income population in the San Joaquin Valley in Central California. ALTURA has eight clinical sites, and is the largest provider of primary health and dental care to the underserved in the city of Tulare and surrounding rural communities. ALTURA has seven clinical sites in the city of Tulare, and one in Woodville. In the calendar year 2017, ALTURA provided medical, dental and behavioral health care to 26,735 patients. Seventy-five percent (73%) of patients are Hispanic, and 21% are Migrant and Seasonal Farm Workers. ALTURA provides free door to door transportation for patients via minivan shuttle.

The goal of this C4 FIT project is to increase colorectal cancer screening rates from 54.54% (2018 baseline) to 60% by the end of the project period. Altura will implement multicomponent interventions to increase screening. The following interventions will be used: Increase Community Demand through client reminders; Increase Community Access by providing transportation and translation; and Increase Provider Delivery through provider reminders. Grant funding will allow Altura Centers for Health to increase capacity for colorectal cancer screening by contributing towards the salary of a Patient Care Coordinator who will send text reminders to patients due for colorectal cancer screening, identify patients needing the screening during daily appointments (as identified in the Morning Huddle provider reminder report generated by the NextGen electronic health record system), distribute a FIT kit during annual exams, provide bilingual patient education on the importance of the screening, and track the patient’s lab results for reporting and referrals. During flu season, ALTURA will implement the Fit Flu program. Progress towards meeting the clinic-wide colorectal cancer screening rate will be discussed at Quality Assurance-Quality Improvement Meetings to monitor trends and quality performance.

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Champions for Health

Project Title: FIT-San Diego
Project Director: Rebecca Valenzuela
Total Grant Amount Funded: $10,000

FIT-SD continues to coordinate vital efforts throughout San Diego County to increase colorectal cancer screenings among low-income uninsured adults at federally qualified health centers (FQHC), and improve access to life-saving diagnostics and subsequent treatment. Champions for Health focuses on high-risk populations, particularly monolingual and uninsured Latino adults, whose screening rates are historically and disproportionately low due to lack of access, and the high cost of diagnostics and treatment.

FIT-SD reduces cultural and structural barriers to access for patients, and supports FQHC and free clinic efforts to improve their overall screening rates by convening clinics annually to discuss best practices, providing in-service training to providers and healthcare workers, and expanding the network of gastroenterology physicians and endoscopy facilities willing to provide pro-bono diagnostic services to uninsured adults requiring such care.

During this program year, our objectives are to: (1) provide a minimum of 9 community clinic partners with in-service training, education and support to increase CRC screening rates (2) secure a minimum of 20 CRC champions to attend annual CRC roundtables and share best practices (3) provide intensive case management, navigation and pro bono treatment to a minimum of 50 low-income, uninsured San Diego County adults requiring colorectal cancer diagnostics (4) secure two new facilities for pro bono endoscopy and (5) implement a community-centered FIT screening pilot.

The FIT-SD collaborative expands on an eight year community partnership which has facilitated more than 417 pro bono diagnostic colonoscopies and flexible sigmoidoscopies since 2008. Through these collective efforts, positive community screenings for the uninsured have a system of care ready to act. Colorectal cancer are able to be detected and treated, and polyps identified and removed, thus preventing the development of cancer.

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CommuniCare Health Centers

Project Title: FIT test compliance Quality Improvement
Project Director: Aileen Barandas, MSN,NP
Total Grant Amount Funded: $10,000

CommuniCare Health Centers is proposing a Quality Improvement project to reduce disparity for colorectal cancer screening in its population of uninsured patients ages 50 to 75. The 12-month project proposes to increase the rate of FIT test compliance among the targeted population of uninsured patients from 37% to 50%, compared to the current rate of FIT test compliance for CommuniCare’s patients with health coverage of 53%. The project proposes an intensive program of automated electronic reminders (including texting, secure patient portal emails and automated phone messaging), postal delivery of FIT tests for patients unable to come to the clinics, and gift card incentives to help patients overcome barriers of transportation for clinic visits to receive and return FIT test kits. The project will also pay for Quest Diagnostics lab costs for FIT tests for the targeted participants, which is often a barrier for uninsured low-income patients that would otherwise have to pay out-of-pocket for the testing.

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Family Health Care Centers of Greater Los Angeles

Project Title: Increasing Screening Rates among Latino/Hispanic patients
Project Director: Sophia Chun, MD
Total Grant Amount Funded: $10,000

FHCCGLA proposes to reduce disparities in colorectal cancer screening by increasing its colorectal cancer screening to 40% of its Hispanic/ Latino patients ages 50-75. This increase represents an additional 300 patients being screened by the end of the project. In order to reach this goal, FHCCGLA looks to evidence-based interventions identified by the Community Preventive Services Task Force (CPSTF). The proposed strategies to increase the rate of colorectal cancer screening among the mentioned population will focus on those that increase community demand, increase community access, and increase provider delivery of screening services.

These interventions will include: (a) Culturally aware small media in Spanish paired with Spanish speaking Patient Engagement Specialists to educate the target group and increase patient demand for screenings; (b) A shift from a three-card Fecal Occult Blood Testing (FOBT) kit to a one-card FOBT, and starting a program that targets identified patients already visiting the center to complete screening while they come to receive other services in order to increase patient accessibility; and (c) offering providers of this service feedback based on statistical assessments gathered by EHR/PMS consultants in order to measure success of strategies and implement provider incentives, thereby increasing provider delivery of screening services.

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Family Health Centers of San Diego

Project Title: Increasing CRC Screening Rates among Underserved Populations
Project Director: Gracie Duran, B.S.
Total Grant Amount Funded: $10,000

Family Health Centers of San Diego (FHCSD) aims to decrease mortality associated with colorectal cancer and increase colorectal cancer screening rates for adults age 50-75 at our City Heights Family Health Center (CHFHC). FHCSD proposes to increase CRC screening rates at CHFHC from a baseline of 51.75% to 58% over a one-year period (by February 29, 2020) through the strategic efforts of a culturally- and linguistically- competent Patient Navigator (PN). In addition, through the work of the Patient Navigator, FHCSD aims to increase access to care for patients with abnormal FIT results by increasing the percentage of these patients who receive diagnostic evaluation, and decreasing the time from identification of the abnormality to diagnostic resolution of the abnormality.

CHFHC serves our region’s low-income and culturally-diverse populations. Ninety-six percent of clinic’s patients live at or below 200% of the Federal Poverty Level (FPL), while 79% are considered impoverished (with incomes at or below 100% of FPL). Approximately 90% of CHFHC’s patients are people of color, including 46% Hispanic, 16% African American, 7% Asian/Pacific Islander, and 21% multi-racial or other. Patients at CHFHC experience tremendous barriers to completing CRC screening, including limited English proficiency, low health literacy, lack of knowledge of the benefits of screening, in addition to pervasive fear often culturally-influenced around receiving a cancer diagnosis.

As a result of the complex and overlapping barriers experienced by many CHFHC patients, CHFHC has lower-than-average CRC screening rates. In fact, as FHCSD aims to attain 80% screening rates, FHCSD’s 11/2017 to 10/2018 agency-wide rate is 52.02% (up from 46.42% the previous year). As mentioned above, the current baseline for CHFHC is slightly below FHCSD’s at 51.75%.

FHCSD proposes to add a 0.30 FTE Patient Navigator to CHFHC’s clinical team to specifically address CRC screening rates and diagnostic evaluation among underserved patients. The PN will (a) ensure adult patients receive both a FIT kit and culturally- and linguistically-appropriate education about screening, (b) provide follow-up and navigation for patients with incomplete screens or who are high-risk and need a referral for colonoscopy, and (c) provide intensive assistance for patients with abnormal screening results, to ensure they successfully access diagnostic evaluation services.

The proposed project will leverage significant in-kind resources, including lessons learned by FHCSD in our implementation of C4-funded patient navigator programs at our Chase Avenue (CAFHC), Chula Vista (CVFHC), and North Park Family Health Centers (NPFHC ‚Äì in 2015, 2016, and 2017 respectively). This includes the addition of two experienced staff ‚Äì the Project Director for this CHFHC proposed project is Clinic Director Gracie Duran, who was previously the Project Director/Clinic Director for our 2016 C4-funded PN program at CVFHC, and the Patient Navigator (Gabriela Armijo) who was also at Chula Vista during that project’s funding. While at Chula Vista, Ms. Duran and Ms. Armijo were able to increase the CRC screening rate from a baseline of 51% to its current rate of 57.82%. In the last six months, Ms. Duran has been able to increase CHFHC’ss CRC screening rate by 4 percentage points, and the additional capacity and resources available through C4 will allow her to assign 1/3rd of Ms. Armijo’s time to this project, furthering improvements in the screening rate and reducing disparities in CRC screening, diagnoses, and treatment among CHFHC’s adult patients. The project also will benefit from the University of California San Diego (UCSD)/ San Diego State University (SDSU) Cancer Center Comprehensive Partnership, a National Cancer Institute (NCI)-funded research team that, in partnership with FHCSD, is building on recommended intervention strategies described in the Guide to Community Preventive Services to ensure complete diagnostic follow-up for patients with abnormal cancer screening tests.

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North County Health Services (NCHS)

Project Title: Increasing Colorectal Cancer Screening via Care Coordination
Project Director: Teresa Kau
Total Grant Amount Funded: $10,000

North County Health Services (NCHS) proposes to use a California Colorectal Cancer Coalition (C4) Community grant to increase colorectal cancer screening rates (CRC) amongst primarily low-income, minority, and underserved patients at the NCHS Loma Alta Health Center in Oceanside. NCHS is a federally qualified health center that was established in 1971 to provide comprehensive medical, dental, and behavioral health services to primarily underserved and low-income residents of northern San Diego and southwestern Riverside counties. NCHS patients are predominately low income (95.9% below 200% federal poverty level (FPL) and 68.9% at or below 100% FPL), uninsured (20.8%), and underserved. In 2017, 74.6% of patients were a racial or ethnic minority, 10% were migrant or seasonal farm workers, and 6.2% were veterans.

Research suggests that minority populations like NCHS’ have a disproportionate health burden and are at an increased risk for a host of chronic diseases. This risk is compounded in the NCHS Loma Alta target population as 3,658 of our patients also do not have any insurance coverage. NCHS does not turn any patient away due to their inability to pay and offers care on a sliding fee scale (typically $25 to $45 for a bundle visit which includes the appointment, x-rays, and any ordered tests including CRC screening) based off of federal poverty guidelines. Additionally, socioeconomic status (SES) has been tied to disparities in treatment options for several principal diagnoses, among which colorectal cancer is included. Taken together, this factors indicated that a significant need exists for the proposed project in Oceanside.

Currently, NCHS Loma Alta has a colorectal cancer screening (CRC) rate of 52%. Through the proposed project, NCHS will utilize a bilingual English/Spanish care coordinator who will be primarily dedicated to following-up with patients who were issued FIT kits. This care coordinator will be integrated as part of the patient’s healthcare team, working with the medical provider and medical assistant to complete the CRC screening process. The care coordinator will follow-up with patients once the CRC screening process has been initiated by a provider to ensure that barriers to the completion of screening are addressed, notifications of results are communicated, and referral appointments are made as necessary. NCHS‚Äô goal is to increase completed CRC screenings at NCHS Loma Alta to 60% by February 2020 through these efforts.

NCHS has a long history of success increasing access to cancer screenings amongst our low-income, minority, and underserved patients. In 2014, NCHS was honored with the American Cancer Society’s Care Partner of the Year award for our endeavors to promote cancer screenings, increase cancer screening rates, and provide the northern San Diego community with access to these crucial and oftentimes lifesaving services. NCHS has continued these efforts by incorporating cancer screenings at our thirteen health centers throughout northern San Diego and southwestern Riverside counties.

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North East Medical Services (NEMS)

Project Title: NEMS CRC Screening Rate for Low Income Asian Populations
Project Director: Eddie W. Chan, Pharm.D.
Total Grant Amount Funded: $29,000

Established in 1968, North East Medical Services (NEMS) is one of the largest Federally Qualified Health Centers targeting the medically underserved, low-income, and uninsured/underinsured population of the San Francisco Bay Area. The mission of NEMS is to provide affordable, comprehensive, compassionate and quality health care services in a linguistically competent and culturally sensitive manner to improve the health and well-being of our community. NEMS serves nearly 70,000 patients annually. Of these patients, 90% are Asian, many of whom are new immigrants from China, Hong Kong, Taiwan, and Vietnam. Most patients are monolingual in Chinese or other Asian languages, with over 81% reporting being best served in a language other than English.

Since 2014, NEMS has made it an organizational priority to improve or maintain high rates for colorectal cancer (CRC) screening. In three short years, we have seen a remarkable increase in CRC screening rates among our patients, ages 50 to 75, from 55% at the beginning of 2014 to 80% as of November 2017. With support from the California Colorectal Cancer Coalition, that rate is up to 82% as of November 2018.

CRC is the second most commonly diagnosed cancer and the third highest cause of cancer-related mortality among Asians. Culturally influenced assumptions about colorectal health and socioeconomic barriers to accessing health care are just a couple of reasons that Asians in our service area are reluctant to get screened for CRC.

We have found that easy-to-use testing options, such as the Fecal Immunochemical Test (FIT), in addition to linguistically appropriate and culturally sensitive education are the most effective and impactful approaches with the Asian population. We expect the FIT to continue to become more popular with our patients due to its non-invasive nature and improved sensitivity to detect colon cancer. Our long-term objective is to remove the stigma around colorectal health and continue to emphasize the importance of CRC screening so that the practice becomes second-nature in this community.

Our project aims to increase CRC screening rate to 83% by December 2019. We use multiple evidence-based interventions recommended by the United States Preventive Services Task Force including: the distribution of multilingual educational materials on CRC and screening; outreach to patients through in-person counseling, reminder letters, and phone calls; and mailing FIT kits with postage-paid return envelopes free of charge to patients to reduce barriers to cost and access.

Additionally, we aim to focus on our clinics in San Francisco’s Sunset District to determine the cause(s) of CRC screening rate being lower (78.9%) than the organizational goal. NEMS Population Management Committee‚Äîa group made up of providers, nursing team leaders, Clinic Operations Managers, project managers, Health Education staff, and Health Information Services staff‚Äîwill review the current process at NEMS for tracking abnormal FIT results and making referrals for follow-up screening or treatment services. This committee will identify any service gaps, propose improvements to the workflow, and draft a plan to improve care coordination of patients with abnormal FIT results.

  • NEMS received supplemental funding as part of a restricted donation from an external partner agency. They received $10,000 through the normal C4 2019 grant mechanism plus an additional $19,000 as this supplemental support.

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Northeast Valley Health Corporation

Project Title: Increasing Colorectal Cancer Screening (ICCSR)
Project Director: Robert Veliz, MPH
Total Grant Amount Funded: $10,000

Northeast Valley Health Corporation (NEVHC), a non-profit, Joint Commission Accredited, Federally Qualified Health Center (FQHC) serving medically underserved residents of the San Fernando and Santa Clarita valleys in Los Angeles County, respectfully requests $10,000 from the California Colorectal Cancer Coalition to help improve the health outcomes of our predominantly Latino patients by improving the percentage of patients who return a completed fecal immunochemical test (FIT) kit.

Specifically, your funds will support staff training and supplies needed to increase the percentage of NEVHC’s 10,938 patients 50-75 years of age that complete colorectal cancer screening from a baseline of 53.5% in October 2018 to 60.5% by February 2020. To do so, NEVHC will focus efforts on interventions that increase the number of FIT kits distributed at the Point of Care and increase the percentage of patients who return FIT Kits through patient recall interventions that include texting, mailing letters and live phone calls.

Our first objective is to increase the percentage of FIT kits distributed at Point of Care at NEVHC health centers. In order to do so, the NEVHC Quality Improvement (QI) team will conduct training sessions with lab staff and medical assistants at nine NEVHC health centers that will emphasize the importance of timely colorectal cancer screening, proper test kit documentation as well as review “Missed Opportunities” data on health center FIT kit distributions.

Our second objective is to increase the percentage of patients who return their FIT kits. In order to improve our FIT kit return rate, we will send reminder text messages to patients who have yet to return them. Moreover, our QI Volunteer Student Interns will send reminder letters as well as make phone calls to patients who have yet to return their FIT kits. The reminder text messages, letters and phone calls will enable our QI Department to provide patients with additional colorectal cancer screening education as well as allow patients to request another FIT kit if needed.

i2iTracks, an automated patient population management system that is interfaced with NextGen, our electronic health record system, will be used to help conduct and track program activities.

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St. Vincent de Paul Village (dba Father Joe’s Villages)

Project Title: Reducing CRC Disparities in Homeless Population, San Diego
Project Director: Ruth Bruland
Total Grant Amount Funded: $10,000

The Village Family Health Center (VFHC) is a Federally Qualified Health Center caring for approximately 2,500 patients annually, almost all of whom are homeless or at-risk of homelessness. VFHC is in the Central San Diego region that has the highest population of the County of San Diego’s homeless residents (an estimated 57%). As a safety-net provider, we provide primary care, licensed mental/behavioral healthcare, psychiatry, addiction treatment and recovery services, case management, referral coordination, an on-site dispensary, laboratory services, a full-service dental clinic, and coordination with extensive social services in the rest of Father Joe’s Villages (a large social services agency to which the VFHC belongs).

To increase colorectal cancer (CRC) screenings rates, VFHC is implementing the Reducing CRC Disparities in Homeless Population, San Diego Project. One of the greatest barriers faced by our patients experiencing homelessness is access to a safe and sanitary environment needed for the requisite preparation for a colonoscopy. Living on the streets, or in a shelter without a private bathroom, prevents many patients from completing both screening and diagnostic (after positive FIT) colonoscopies. Access to a private hotel room for one or two nights to prepare for a colonoscopy will help many patients who lack the safe, clean, and dignified living environment needed immediately preceding colonoscopies.

Our long-term goal is to increase CRC screening rates (according to the Uniform Data Systems definition) from 21% to 28% among eligible VFHC patients, by February 2020. To do this, we will identify patients who are due for CRC and either homeless or in an environment without a private bathroom. These patients will be offered CRC, which is part of our usual processes. While such patients normally are encouraged to do FIT primarily (and colonoscopy is discussed but not generally encouraged), they will now also be offered access to a hotel room for two nights in order to complete a colonoscopy. These patients will also be provided transportation to and from the hotel as well as to the colonoscopy facility. We already work with colonoscopy facilities on transportation after the colonoscopy, whether that be transportation with a friend/family, taxi, or other options given patients are often sleepy post-sedation.

We believe that these efforts will effectively address a social barrier to completing CRC screening. While FITs do work in our patient population, they are only valid for one year, meaning there is significant work to be done each year by the patient and our staff to maintain higher CRC screening rates. Colonoscopies are often valid (depending on results) for years. Thus, by increasing the number of patients getting screening colonoscopies, we can increase the overall and long-term CRC screening rate in our patients.”

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Tiburcio Vasquez Health Center, Inc.

Project Title: Colorectal Cancer Screening Project
Project Director: Jessica Jamison, MPH
Total Grant Amount Funded: $10,000

“The long term objective of the continuing Colorectal Cancer Screening Project is to improve Tiburcio Vasquez Health Center’s rates of early colorectal screening by 1) Providing FIT kits to 85% of eligible patients by February 29, 2020; 2) Increase FIT Kit Return Rate from 36% to 50% by February 29, 2020; and 3) Referring 100% of patients with a + or abnormal FIT for Dx Colonoscopy by February 29, 2020.

The specific aim of the project is to increase to percentage and number of TVHC patients screened for colorectal cancer. TVHC aims to increase baseline screenings (12/1/17-11/30/18) from 38.6% to 53%.

The project will serve TVHC’s patients who are at average risk of developing cancer; increasing the number of patients 50-75 years old who are given and who complete FIT kits, and to improve TVHC’s colorectal screening rates.

To accomplish these goals and objectives, TVHC will hold quarterly in-service trainings developed with our partners at the American Cancer Society. In addition, the project replicates Kaiser Permanente Northern CA’s model showing success with mailed FIT kits supported by patient outreach. Accordingly, TVHC will conduct patient outreach through the following steps in order:

  1. Using TVHC’s electronic health system, identify patients who need screening
  2. Send identified patients a personalized letter from their Primary Care Provider (a best practice)
  3. Two weeks later, TVHC mails each identified patient the FIT kit
  4. Text reminder sent (bilingual) and/or
  5. Reminder postcard sent (bilingual)
  6. TVHC staff telephones patients to remind and educate on the importance of FIT screening and encourages return
  7. TVHC staff mails patient incentive gift card once completed FIT test is received (funded by Boston Scientific)
  8. TVHC staff navigates patients who have received a positive FIT to the colonoscopy provider, including transportation assistance when needed

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Tri-City Health Center

Project Title: The “In 2 Your 50s” Project
Project Director: Harsha Ramchandani, MD, Chief Medical Officer
Total Grant Amount Funded: $10,000

With C4 funding, Tri-City Health Center (TCHC) will implement the “In 2 Your 50s” Project, which will integrate multi-component interventions that build awareness, educate and encourage patients between the ages of 50 to 75 to learn about and complete the Fecal Immunochemical Test (FIT). The project’s long-term goal is to exceed the U.S. National Benchmark for Colorectal Cancer (CRC) screening of 50%, reduce the incidence of CRC in TCHC’s region, and ultimately save lives. TCHC will seek as a short-term goal to increase the number of patients and community members who have access to CRC information and screening services and to increase TCHC’s CRC screening rates from 43% to 50% by February 2020.

To achieve these goals, TCHC will integrate multiple interventions, which include: in-reach, use of electronic health records (EHR), targeted outreach, small media marketing, mobile health vans, intensive follow up, patient navigation, and one-on-one education, all of which will motivate patients to learn about and complete the FIT. In-reach methods will identify current patients who utilize TCHC primary care services to improve the CRC screening rate through the use of TCHC’s electronic health record, NextGen, and i2i Patient Tracks. With these tools, TCHC will generate daily reports for patients in the 50 to 75-year-old age group who are due for their FIT test, to identify at-risk patients and engage them in intensive follow up. The project will implement direct marketing mailings in multiple languages and conduct targeted outreach and education that builds awareness about CRC health fairs and athletic events in the community, and through TCHC’s Senior Mobile Health Services Van, which makes regular stops at the Fremont Senior Center in Fremont, the Tropics Mobile Home Park in Union City, and other community locations. Upon subsequent visits, staff will provide patient navigation that reduces administrative barriers to completing the FIT and will educate patients about the importance of CRC screening and the process of properly using the FIT kits. If lab results return positive, project staff will continue to educate patients on detailed follow-up plans, and refer them for a colonoscopy.

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Vista Community Clinic

Project Title: Improving Colonoscopy Referral Completion Rates at an FQHC
Project Director: Kelly C. Motadel, MD, MPH
Total Grant Amount Funded: $10,000

Like many community health centers, Vista Community Clinic has struggled to achieve colorectal cancer (CRC) screening recommendations. Although still below the national average and Healthy People 2020 goals, between 2013 and 2017, VCC improved its CRC screening rate from 29.6% to 40.7%, a 36% increase. Some of this success can be attributed to past activities funded by the C4 program. Most notably, VCC has focused on institutionalizing more effective workflows that allow for broader distribution of FIT test kits. As a result, VCC has experienced a rise in the number of abnormal test findings, generating about 175 patient referrals a month for colonoscopies. Unfortunately, almost 70% of referred patients fail to complete their colonoscopies.

About 40% (n=840) of the colonoscopy referrals are for patients seen at our flagship clinic, VCC: Vale Terrace in Vista. New C4 funding is requested to partially support a Medical Assistant (MA) in Vale Terrace Family Medicine who will reach out to new and recalcitrant patients to help facilitate completion of colonoscopy referrals. We estimate we will contact up to 600 patients during the grant term. Referral Coordination staff will provide the project MA with a copy of initial colonoscopy referrals and a list of gastroenterologists in the area that accept Medi-Cal and uninsured patients. The MA will use i2i EHR software to identify patients due for screenings. Then she will utilize a variety of methods to reach patients with new and outstanding referrals, such as phone, text, email, postcard, and patient portal messages. The MA will help patients to identify and overcome barriers to referral completion such as limited appointment options, transportation, child care, and language. Our goal is to increase our current colonoscopy referral completion rate in Vale Terrace Family Medicine from 32% to 45%.

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