Brief descriptions of clinic partner approaches to integrated implementation of CRCCP activities are provided in Additional file 5. In the following sections, we present our results based on the four guiding integrated implementation constructs. These results are summarized in Figure 3.
Funding Environment
The clinic partners received funding from the CRCCP programs, typically to support start-up and ongoing costs associated with implementing the CRCCP within their sites. Two aspects of the funding environment were identified as facilitating integrated implementation: (1) coordination of funding by awardees across multiple chronic disease programs to support consolidated application processes for clinic partners, and (2) contracting with expert implementation partners to provide training and technical assistance to clinic partners that emphasized integrated implementation.
Participants discussed programs providing braided funding—a process that involves coordinating separate funding streams from multiple programs, such as CRCCP and the National Breast and Cervical Cancer Early Detection Program (NBCCEDP)—to pay for common activities such as patient navigation across programs, provider reminders and patient reminders (e.g., reminders for breast, cervical, and colorectal cancer screening). However, each funding stream is kept separate so programs can track requirements and outcomes. For example, program staff discussed developing funding opportunity announcements for clinic partners that braided funding streams from multiple programs. This approach enabled clinic partners to consolidate their funding applications and reporting processes while tracking distinct activities and outcomes for each funding stream. Participants also reported that by braiding funding from multiple chronic disease programs, clinic partners could submit a single funding application and receive a larger amount of funding that could be used to integrate implementation efforts across multiple chronic diseases. For instance, participants reported the use of braided funding to support patient navigation staff who coordinate screening and follow-up for CRC, breast cancer, and cervical cancer.
“The [health department’s] women’s cancer screening and colorectal had patient navigation contracts with all the [Federally Qualified Health Centers] throughout the state and in order to get the FQHCs to agree to do the colorectal, right from the beginning she integrated the contracts so we essentially were doubling the money that we were offering to them and it was an all or nothing kind of thing.”
– Program staff
“[We aim to] present different contract options which combine all the different funding sources…in an integrated way, approaching them with this single menu of different options collectively…versus one of us [from the health department] approaching them one month and then another one approaching them 3 months later.”
‒ Program staff
“[Braided funding supports] staff time and the training that we need for our staff to do the outreach for all of the cancer screenings.”
– Clinic staff
Participants also described how technical assistance and training, provided by expert implementation partners, facilitated integrated implementation. For example, implementation partners assisted clinics in adapting EHR or other referral systems to integrate CRC screening with existing referral systems for breast cancer screening such as mammography.
“[Implementation partner agency] is our partner in understanding how to look at [clinic] practice flows and how to coordinate, integrate, align the work we do…. They say, ‘Okay, you really need to work on your electronic referrals [for screening]. Let’s look at how you’re doing that with mammograms. Let’s look at how you’re doing that with colonoscopy.’"
– Program staff
“We strongly encourage [clinic partners] to consider how their efforts could be better integrated with their other programs and activities in their clinic systems. For example, when they describe [clinic] workflows to us on these technical assistance calls, we try to prompt them to consider how these efforts may impact other efforts ongoing in their clinics, other screening activities…if they're going to look at, for example, whether or not a patient is due for colorectal cancer [screening as part of workflow processes], seeing if there are opportunities in their other cancer screening activities and workflows.”
– Implementation partner staff
Governance Structure
Effective team-based care, a factor related to governance structure, ensured that CRC screening was integrated into clinic practice as part of comprehensive, coordinated patient care. For example, some clinics used “health hubs” comprised of clinic staff from CRCCP, WISEWOMAN, and NBCCEDP to implement coordinated EBIs across programs. Participants reported that effective teaming supports a shared sense of responsibility for providing comprehensive (such as multiple health topics), coordinated patient care. For example, participants described training all clinic staff—such as patient registration staff, lab technicians, and nurses—to address CRC and other health conditions with each patient encounter. Workforce development (e.g., learning collaboratives) also included clinic staff representing multiple chronic disease prevention areas. Additionally, participants described the integration of CRC screening with other services (e.g., coordinated patient enrollment with WISEWOMAN and NBCCEDP; coordinated patient and provider reminders) as being consistent with their commitment to applying a Patient Centered Medical Home (PCMH) model.
“So, every clinical person from our lab person to our [patient] registration staff to every nurse [and] medical assistant understands that they're required to address all of these [health topics] with every patient. It’s just the way we train them when they come in…it’s the way we do business.”
– Clinic staff
“Going back to the PCMH [model] of having all staff [perform at] the highest ability that they’re able to. So, our frontline, our medical assistants, our front-desk staff are very involved and very engaged in these management activities, cancer screening activities.”
– Clinic staff
“We have a team medical assistant [who] is able to follow up on closing the loop to patients about, ‘Hey, I see you haven’t done this,’ or ‘Your [test]was high. We need you to come back in or follow up on those things.’ And then the RN is able to really take the time and educate the patients on different dietary concerns, different ways to manage whatever specific chronic condition that they have.”
– Clinic staff
Information Sharing
Access to and sharing of accurate patient information, including EHR data, were identified as other factors supporting integrated implementation of CRC screening. Identifying patients who are due for multiple preventive screenings, including CRC, was an example shared by participants. Once patients could be identified, referrals could be made and follow-up actions—such as appointment scheduling and confirming screening completion—could be carried out.
Participants indicated that clinic staff, particularly patient navigators and care coordinators, rely on the availability of accurate EHR reports to identify patients for screening and/or diagnostics for multiple chronic disease conditions. Clinic staff emphasized that the utility of the EHR data in supporting integrated implementation is contingent on data accuracy.
“The challenges we face with CRC, breast cancer, and cervical reporting [are] the same challenges we face with everything else. Making sure [EHR data] are entered correctly and data validation.”
– Clinic staff
Aside from EHRs, participants identified data dashboards and meetings of the quality improvement team as strategies for sharing information that facilitated integrated implementation. Electronic dashboards presented summary metrics on multiple cancer screenings in real-time for each provider and their respective patients. Through data sharing and making comparisons between physicians that invite friendly competition, the dashboards promote action on multiple conditions that contribute to integrated implementation. Similarly, data sharing among quality improvement (QI) teams promotes a collective understanding of where clinics stand on delivery of health promotion activities that can foster understanding of opportunities to potentially improve these metrics through integrated implementation.
“All of our staff have access to the provider dashboard, which is updated once a month and that shows where their particular provider is and what the [clinic] average is and then… they can go and look at any other provider…it’s just starting with the cancer screening metric, but eventually we’ll put all of our metrics on that…it will give them more of a real-time feel of where they’re at.”
– Clinic staff
“We also…had monthly quality improvement meetings, where all of the clinic’s leadership and the QI department got together, and we talked about things that we are working on, and things that could potentially be shared…beyond just cancer, or beyond just diabetes care, or whatever thing we were talking about.”
– Clinic staff
Leadership Support
Clinic leadership plays a primary role in promoting integrated implementation by setting and reinforcing expectations. Participants indicated that strong and ongoing support from health system and clinic leadership establishes an expectation for integrating CRC EBIs and SAs within the clinic practice and incorporating CRC screening efforts with other chronic disease activities. Additionally, leaders are crucial in encouraging staff from across the clinic team to support these activities.
“Leadership support is critical.… It’s evident, if you see the [screening] numbers of the teams that have the leadership support and the ones from the team that didn’t [have leadership support], it’s night and day.”
‒ Implementation partner staff
“I’m the clinic manager and so I set the tone for the sense that the evidence-based interventions are important. We need to integrate them and so you talk about it, you bring it up frequently. As a group, we collectively talk about what we think works for us and what doesn’t work for us.”
‒ Clinic staff