Quality of Client Care
We know how we're doing by measuring:
- the quality of care we deliver to clients
- client access to that care
Quality
We have identified some 30 clinical quality measures across all of our disciplines to ensure that our clients receive high-quality care. We track these measures monthly, and each month we highlight one of them to take a deeper look into how we're doing on that measure, and how we can use that data to continuously do better.
July 2016: Colorectal cancer screening
The above chart shows the percentage of clients who are eligible for colorectal cancer screens and are up-to-date with those screens in a given month. At Health Care for the Homeless, we screen all women and men ages 50 to 75 for colorectal cancer. For those who pose a high risk for colorectal cancer, such as those with a family history of colorectal cancer, we screen up to age 85. Cancer of the colon is the third most common cancer and the second deadliest, after lung cancer.
During 2016, screening among Health Care for the Homeless clients has decreased steadily. We don’t have hard data to explain the trend, but we have some pretty good hunches.
On the client side: “Our client population is so complex and has so many co-morbidities and urgent needs. So a screen can fall lower on the totem pole when a client has major complaints that take up most of a visit, ” says Tracy Russell. Plus, she adds, “Some people just don’t like the thought of playing with their poo!”
On the provider side: Until now, only providers have been able to request standing orders for colorectal cancer screens through the Electronic Health Record, or EHR.
The colorectal game plan
A registered nurse, Tracy Russell splits her time between client nursing visits and helping lead our efforts to improve population health. In the latter capacity, she is currently tasked with increasing our colorectal screening rate.
As a first step, Tracy is revising the standing orders that trigger colorectal screens. Right now, only providers request the screens through the EHR. Tracy is working to reset those orders to allow medical assistants and nurses to also request colorectal screens, and is currently piloting new standing orders with nurse practitioner Laura Garcia and medical assistant Veronica Dennis.
“Setting the standing orders for MAs and nurses to begin screening for colorectal cancer will open up the number of people who can initiate the orders for providers to sign off on,” Tracy says. “We are still working out kinks, but I am hopeful that by October 1, the whole medical team will be up and running.”
So, just how will new standing orders lead to increased colorectal screening if time and client priority is really the issue?
“It streamlines the process to make it more a part of the workflow, because we’re asking all MAs to do it during the client rooming before the provider arrives,” Tracy says.
Providers will still need to approve the orders, but anyone on the medical team will be able to make the request and get the screening process rolling.
The actual colorectal screening
There are two tests that screen for colon cancer, and we give our clients a choice.
The FIT
The least invasive and most popular screen for colorectal cancer is the fecal immunochemical test, or FIT. A test that is administered annually, the FIT checks for hidden blood in the stool, a key symptom of colon cancer. The client receives an easy-to-use kit that includes a collection paper and probe for gathering the stool sample and a tube for storing it. The client then brings the sample in and we send it out to the lab.
The Colonoscopy
The oft-dreaded colonoscopy is a much more labor intensive and invasive procedure than the FIT for which we refer clients out to a gastrointestinal specialist. It is a particularly difficult procedure for people who do not have a safe, comfortable place to stay at night with access to a toilet. It requires emptying the bowels during the night before, and the procedure itself involves inserting a camera inside the large intestine to identify and remove polyps as it goes. The advantage of a colonoscopy over the FIT test—and yes, there are a couple: The colonoscopy shows much more than the FIT, and it only has to be conducted every 10 years.
What is "rooming a client?"
The many things our medical assistants and nurses do each time a client comes for a medical visit—before the provider steps foot in the exam room:
Ask the client where she/he stayed last night | Check the client’s vital signs | Conduct a depression screening with the client | Conduct the substance screening, SBIRT, with the client | Conduct a “peak flow” breathing test with asthmatic clients | Check blood sugars with diabetic clients | Record main concerns or complaints the client would like to discuss with the provider
Clinical Quality Measures
The table below shows the clinical quality measures we track each month, minus a handful we have not started tracking yet, including supportive housing, case management, behavioral health, dental sealants, new HIV cases with timely follow-up, 1st-trimester prenatal care and healthy birth weight.
