Implementation strategies in the Exploration and Preparation phases of a colorectal cancer screening intervention in community health centers

Renée M Ferrari; Jennifer Leeman; Alison T Brenner; Sara Y Correa; Teri L Malo; Alexis A Moore; Meghan C O'Leary; Connor M Randolph; Shana Ratner; Leah Frerichs; Deeonna Farr; Seth D Crockett; Stephanie B Wheeler; Kristen Hassmiller Lich; Evan Beasley; Michelle Hogsed; Ashley Bland; Claudia Richardson; Mike Newcomer; Daniel S Reuland

doi:10.1186/s43058-023-00485-5

Implementation strategies in the Exploration and Preparation phases of a colorectal cancer screening intervention in community health centers

Implement Sci Commun. 2023 Sep 20;4(1):118. doi: 10.1186/s43058-023-00485-5.

Authors

Renée M Ferrari^{1

2}, Jennifer Leeman^{3

4}, Alison T Brenner^{3

5}, Sara Y Correa³, Teri L Malo³, Alexis A Moore³, Meghan C O'Leary^{3

6}, Connor M Randolph³, Shana Ratner^{5

7}, Leah Frerichs^{3

6}, Deeonna Farr⁸, Seth D Crockett^{5

9}, Stephanie B Wheeler^{3

6}, Kristen Hassmiller Lich⁶, Evan Beasley¹⁰, Michelle Hogsed¹¹, Ashley Bland¹¹, Claudia Richardson¹², Mike Newcomer^{13

14}, Daniel S Reuland^{3

6

5}

Affiliations

¹ Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC, 27599, USA. rferrari@unc.edu.
² Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA. rferrari@unc.edu.
³ Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC, 27599, USA.
⁴ School of Nursing, University of North Carolina at Chapel Hill, 120 North Medical Drive, Chapel Hill, NC, 27599, USA.
⁵ School of Medicine, University of North Carolina at Chapel Hill, 5034 Old Clinic Building, Chapel Hill, NC, 27599, USA.
⁶ Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA.
⁷ UNC Institute for Healthcare Quality Improvement, CB #8005, Chapel Hill, NC, 27599, USA.
⁸ College of Health and Human Performance, East Carolina University, 2307 Carol G. Belk Building, Greenville, NC, 27858, USA.
⁹ Division of Gastroenterology & Hepatology, Oregon Health & Science University, 3161 SW Pavilion Loop, Portland, OR, 97239, USA.
¹⁰ Blue Ridge Health, UNC Health, 2579 Chimney Rock Road, Hendersonville, NC, 28792, USA.
¹¹ Blue Ridge Health, 2759 Chimney Rock Road, Hendersonville, NC, 28792, USA.
¹² Ahoskie Comprehensive Care, Roanoke Chowan Community Health Center, 120 Health Center Drive, Ahoskie, NC, 27910, USA.
¹³ Digestive Health Partners, 191 Biltmore Avenue, Asheville, NC, 28801, USA.
¹⁴ Western Carolina Medical Society, 304 Summit Street, Asheville, NC, 28803, USA.

Abstract

Background: Adoption of colorectal cancer (CRC) screening has lagged in community health center (CHC) populations in the USA. To address this implementation gap, we developed a multilevel intervention to improve screening in CHCs in our region. We used the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to guide this effort. Here, we describe the use of implementation strategies outlined in the Expert Recommendations for Implementing Change (ERIC) compilation in both the Exploration and Preparation phases of this project. During these two EPIS phases, we aimed to answer three primary questions: (1) What factors in the inner and outer contexts may support or hinder colorectal cancer screening in North Carolina CHCs?; (2) What evidence-based practices (EBPs) best fit the needs of North Carolina CHCs?; and (3) How can we best integrate the selected EBPs into North Carolina CHC systems?

Methods: During the Exploration phase, we conducted local needs assessments, built a coalition, and conducted local consensus discussions. In the Preparation phase, we formed workgroups corresponding to the intervention's core functional components. Workgroups used cyclical small tests of change and process mapping to identify implementation barriers and facilitators and to adapt intervention components to fit inner and outer contexts.

Results: Exploration activities yielded a coalition of stakeholders, including two rural CHCs, who identified barriers and facilitators and reached consensus on two EBPs: mailed FIT and navigation to colonoscopy. Stakeholders further agreed that the delivery of those two EBPs should be centralized to an outreach center. During Preparation, workgroups developed and refined protocols for the following centrally-delivered intervention components: a registry to identify and track eligible patients, a centralized system for mailing at-home stool tests, and a process to navigate patients to colonoscopy after an abnormal stool test.

Conclusions: This description may be useful both to implementation scientists, who can draw lessons from applied implementation studies such as this to refine their implementation strategy typologies and frameworks, as well as to implementation practitioners seeking exemplars for operationalizing strategies in early phases of implementation in healthcare.

Keywords: Cancer screening; Colorectal cancer; Community health centers; Exploration; Fecal immunochemical test; Framework; Implementation; Patient navigation; Preparation; Vulnerable populations.

Abstract

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