Establishing baseline rates of CPS utilization

We obtained de-identified 2014 data representing patients age 50+ from five CHCs, including: 1) demographics; 2) receipt of six “high-value” CPS (influenza and pneumococcal vaccinations, cholesterol screening, colorectal, breast and cervical cancer screenings) and 3) insurance type and status. We used the 2014 U.S. Preventive Services Task Force A and B guidelines^10,11 as benchmarks to determine the proportion of patients “up-to-date” on the selected CPS. We used SPSS version 23.0 for Windows for analysis (SPSS, Inc., Chicago, IL).

Key informant interviews with CHC personnel

To learn about barriers and facilitators to CPS delivery and use, we conducted 34 in-person key informant interviews with CHC personnel (healthcare providers, chief executive officers, chief medical officers, chief financial officers, quality improvement directors, referral coordinators, and community outreach specialists) from five CHCs. We inquired about organizational context; current practices related to serving older adults, including marketing and outreach efforts; how CPS were monitored and evaluated; and strategies used for engagement with community partners and collaborators.

Interviews were audiotaped and independently summarized by two research members. A matrix was developed to organize the data across CHCs and identify emerging themes (e.g., CHC culture, CPS delivery, CPS referrals, and geriatric training) by CPS at individual, organizational, and system levels.

In-service training of CHCs

We developed and delivered training for professionals at the CHCs to promote CPS delivery. The curriculum was informed by a multidisciplinary competency framework developed by the Partnership for Health and Aging¹² and by findings from the CHC capacity assessment.

The training was directed at system-level and practice-based changes to increase utilization of CPS and included seven competency domains (table I).

The training format included lectures and group discussions about modifications to CHC practices and systems needed to align with current standards of care for older adults, and possible roles for NGO-CHC partnerships in boosting CPS utilization. Each group discussion used a worksheet as a basis for developing an “action plan” that could be implemented given the CHC’s capacity and resources (table II).

HAPPI Community Council

Building community capacity to promote and increase CPS utilization required broad partnerships. Over 40 NGOs serving priority populations in the target area were invited to form a HAPPI Community Council. Thirty-four NGOs representing faith-based, community services, housing, worksite/labor, social justice, and volunteer organizations participated in quarterly meetings. The Community Council provided input on the HAPPI community training and small grants program and helped recruit organizations to participate in these activities.

HAPPI Ambassador training of NGOs

Community training goals included: 1) using a train-the-trainer model to develop knowledgeable and skilled communicators -HAPPI Ambassadors- to diffuse CPS knowledge and motivation to community members through local workshops; 2) fostering partnerships with CPS providers and NGOs to improve access to and use of CPS; and 3) sustaining CPS practices.

The HAPPI Ambassador curriculum applied a train-the-trainer model successfully used in previous community capacity building programs¹⁴ which draws on NGO’s knowledge of their communities to adapt CPS topics to workshops or other educational sessions they conduct. The curriculum also engaged CHCs that completed the HAPPI in-service training as experts and co-learners to foster sustainable relationships. The design included breakout groups where CHC representatives discussed strategies to advance knowledge and use of CPS with NGO representatives (table II). We conducted the training in English and provided educational materials for community residents in English and Spanish. Participants who completed the training and conducted a community workshop received a 250 dollars stipend and their organizations became eligible to apply for a HAPPI Community Small Grant.

Baseline CPS utilization rates

Baseline data gathered from five CHCs in the Southside Coalition on CPS use by individuals 50 years and over documents their 2014 use of the six high-value CPS. According to the California Health Interview Survey, about two-thirds of 50+ Californians reported being adherent with guidelines for any type of colorectal cancer screening6 as compared with only about one-third of people receiving care in one of California’s CHCs (figure 1). During the same period, guideline-compliant colorectal cancer screening rates reported to the federal government across the CHCs participating in HAPPI ranged from 22.9 to 50.9%.¹⁵ However, data gathered directly from CHC medical records indicate even lower rates, ranging from 4.3 to 16.8%. CHC key informants suggested possible underreporting due to a lack of reliable documentation and variation in the coding used to extract the CHC data.

CHC: community health centers

FOBT: fecal occult blood testing

FIT: fecal immunochemical test

Figure I Healthy Aging Partnershipin Preven tion Initiative. Colorectal cancer screening, percent up-to-date in 2014, California and CHCs, age 50+. SouthLos Angeles, CA, USA 

CHC key informant interviews

The objective of the CHC assessment was to understand CHCs role in increasing CPS use among the 50+ population. Through key informant (KI) interviews we identified three inter-related barriers to CHCs delivery of CPS to aging adults: 1) CHCs have a history of serving younger populations and are often not prepared for an influx of new, older patients, 2) despite their experience in providing well-child care, their adult services focus on acute care with a reactive versus prevention-oriented paradigm; and, 3) they work in “silos”, independent of surrounding NGOs.

While CHCs serve people of all ages, they have not historically focused on older adults. However, several KIs recognize that older adults are a growing proportion of their service population and acknowledge that serving this “new” group requires organizational culture change. Some attributed the patient shift to the 2010 Affordable Care Act’s (ACA) expansion of health insurance coverage (table III). Interestingly, this created a new environment of competition among CHCs, as previously uninsured patients started using the clinics significantly more once they became insured. The CHCs scaled up to meet the pent-up demand of newly insured patients, including many 50-64 year old’s, who now had more choices. To retain as well as grow their patient population, KI administrators suggested that aging adults represent an “emerging market.”

CHCs serve low-income, high-need communities, and historically funding was for treating episodic health problems rather than disease prevention among adults. Many KIs acknowledged an untapped opportunity to expand the delivery of CPS services to aging adults to prevent disease, disability, and premature death by educating patients and providers.

Finally, funding mechanisms have incentivized CHCs to operate independent of NGOs and other community resources that provide services and supports to an aging population. When they do partner with NGOs, these partnerships typically rely on special project funding. Efforts to increase the use of specific CPS are typically tied to specific quality improvement goals and are both resource and time-limited.

CHC key informant perspectives on colorectal cancer screening

Colorectal cancer screening is one of the most complicated CPS for CHCs, especially when referring out for additional diagnostic and treatment visits. KIs identified obstacles for patients including mobility, transportation, paperwork, low health literacy, and language barriers for monolingual Spanish speakers. Patients given FOBT/FIT cards often did not return them, and when the FOBT/FIT was positive there were long wait times at the county’s public hospitals for screening and treatment colonoscopies. Once completed, there were challenges to getting results back to the CHCs due to legal regulations intended to protect patient privacy. Facilitators for increasing colorectal cancer screening and other CPS included the capacity of CHCs to conduct the low-cost first screening test (FIT) on-site and the commitment of practitioners who were highly motivated to improve patient health.

In-service training of CHCs

A total of 164 CHC staff took the training. Those obtaining Los Angeles County CME credit completed the post-training evaluation survey, giving the course a 2.8 average on a three point scale (three-point scale: 3=fully met, 2=somewhat, 1=did not meet) for meeting course objectives. In open-ended questions asked only of physicians, most reported they intended to make practice modifications, such as working with clinic staff to implement system-level changes (e.g., readily available FIT kits; patient coordination for return of specimen; developing EMR documentation process noting supplies were given; develop patients reminder system to return completed test kits). CHCs later reported they planned to collect and analyze data for quality improvement and clinic-wide dissemination. Anticipated barriers included: money, time, habits, and routines. They identified additional staffing needs and the potential to involve multiple staff like medical assistants to educate patients about colorectal screening.

Through follow-up meetings with CHC leadership we learned that the trainings had increased CHCs intent to modify clinical practices and improve CPS service delivery. Two of the five CHCs that focused on colorectal cancer screening reported implementing changes shortly after the training concluded. One CHC revised their FIT colorectal screening kit protocol immediately following the training. Another adapted the Flu-FIT Program, a research tested intervention¹⁶ that increases patient access to colorectal cancer screening by offering them home tests at the time of their annual flu shots.¹⁷ This CHC added a Flu-FIT education intervention during patient visits for flu shots. Project staff continues to monitor the results of modifications made by participating CHCs.

HAPPI Ambassador training of NGOs

A separate set of trainings were conducted with NGO staff; their satisfaction scores with the HAPPI Ambassador’s train-the-trainer course averaged 4.5/5. Of the 28 out of 32 (88%) who submitted follow-up workshop training plans, 26 workshops were ultimately completed. HAPPI Ambassador’s reached a total of 385 Latino and African American adults with healthy aging and CPS information through community workshops, fulfilling a key objective of the Ambassador role in the project (table IV).

HAPPI small grantees

HAPPI received 20 applications; eight grants were made including five for colorectal screening bundled with another CPS, e.g., combining with cholesterol. Six grantees partnered with participating CHCs, and two well-designed projects without CHC partners received smaller awards.