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How are EBI selection and implementation connected to sustainability?

This part of the CLD highlights the importance of selecting the right combination of EBIs that are sustainable to meet population needs. Clinics evaluating their readiness for EBI implementation is crucial because it allows them to be aware of which EBIs are feasible given their specific context.[[140, 198-200, 273, 334, 455]] Knowing the feasibility of EBIs enhances a clinic’s ability to select and adapt EBIs that meet their population needs,[[245, 264, 271, 443]] which allows clinics to effectively address gaps and barriers to screening using EBIs. Increasing the sustainability of EBIs increases the clinic’s ability to use EBIs to address gaps and barriers to CRC screening.[[139, 153, 245]]

Diagram 2.0 Overview

Sustaining EBIs for Long-Term CRC Screening

Diagram 2.1

CRC Screening & EBI Sustainability

Diagram 2.2

Funding’s Role in EBI Sustainability

Diagram 2.3

Sustainability in Early EBI Implementation

Diagram 2.4

Factors Supporting Early EBI Sustainability

Diagram 2.5

EBI Selection, Implementation & Sustainability

Diagram 2.6

Key Relational Factors in EBI Sustainability

Diagram 2.7 Conclusion

Recommendations for Sustaining EBIs and EBI Impact

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Variables move in opposite directions

Variables move in the same direction

Research evidence supports relationship

Research team hypothesizes relationship

How are EBI selection and implementation connected to sustainability?

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139

Implementation readiness — an organization’s combined capacity, commitment, and willingness to implement a new program, policy, or practice — facilitates implementation success.[[16–18]] Because public health resources are limited, identifying a clinic’s readiness to successfully implement and sustain interventions, as well as gaps in clinic resources or practices that need to be addressed before implementation, is critical. Such assessment practices can guide clinics to select interventions with the greatest potential for long-term sustainability, and in turn help maximize the impact of public health spending, optimize clinic success, reduce cancer disparities, and improve population health.

Hohl SD, Melillo S, Vu TT, Escoffery C, DeGroff A, Schlueter D, Ross LW, Maxwell AE, Sharma KP, Boehm J, Joseph D, Hannon PA. Development of a Field Guide for Assessing Readiness to Implement Evidence-Based Cancer Screening Interventions in Primary Care Clinics. Prev Chronic Dis. 2022 May 12;19:E25. doi: 10.5888/pcd19.210395. PMID: 35550244; PMCID: PMC9109642.

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140

Key informants who represented current and previous recipients generally said that mixed-methods assessments conducted before implementation prepared them to use results to inform development of tailored action plans for EBI implementation and technical assistance with partners.

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153

Only 58% of clinics reported having good leadership support to maintain implementation of CRC screening EBIs, including mailed fecal testing. Fewer clinics reported having funding stability, organizational capacity, or the ability to adapt practices to ensure sustainability of EBI implementation. Although the CRCCP and other programs are designed with sustainability as a long-term goal, sustainability is an on-going challenge in clinics with limited resources and changing priorities that are reflected in budget changes.

Hohl SD, Maxwell AE, Sharma KP, Sun J, Vu TT, DeGroff A, Escoffery C, Schlueter D, Hannon PA. Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement. Prev Sci. 2024 Apr;25(Suppl 1):124-135. doi: 10.1007/s11121-023-01496-3. Epub 2023 Mar 23. PMID: 36952143; PMCID: PMC10034905.

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198

This study demonstrates that EBIs to increase CRC screening may be effective in clinics with fewer resources that serve populations who have poor access to or under-utilize health care services. Tailoring the EBIs to the needs and capacity of participating clinics may have been key to their effectiveness.

Kim KE, Tangka FKL, Jayaprakash M, Randal FT, Lam H, Freedman D, Carrier LA, Sargant C, Maene C, Hoover S, Joseph D, French C, Subramanian S. Effectiveness and Cost of Implementing Evidence-Based Interventions to Increase Colorectal Cancer Screening Among an Underserved Population in Chicago. Health Promot Pract. 2020 Nov;21(6):884-890. doi: 10.1177/1524839920954162. Epub 2020 Sep 29. PMID: 32990041; PMCID: PMC7894065.

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199

Using a participatory implementation approach, a pre-implementation assessment was conducted to assess readiness for implementation of EBIs in order to increase CRC screening uptake.

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200

First, the pre-implementation process allowed the awardee to determine the infrastructure needs and their capacity to implement EBIs.

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245

Given the limited nature of public health funding cycles, it is critical that health systems change efforts not only work to achieve population health outcomes but also dedicate time and resources to integrating effective strategies for increased likelihood of long-term sustainability. Integrating EBIs and SAs into existing FQHC processes proved essential to CRCCP sustainability.

Schlueter D, DeGroff A, Soloe C, Arena L, Melillo S, Tangka F, Hoover S, Subramanian S. Factors That Support Sustainability of Health Systems Change to Increase Colorectal Cancer Screening in Primary Care Clinics: A Longitudinal Qualitative Study. Health Promot Pract. 2023 Jul;24(4):755-763. doi: 10.1177/15248399221091999. Epub 2022 May 18. PMID: 35582930; PMCID: PMC9672135.

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264

Integrating evidence-based processes into multiple aspects of clinic operations—including funding allocation, staff training, care delivery models, and EHR systems—can be complex but improve the prospect of sustainability.

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271

A key theme across all awardees was the essential nature of coordinating EBIs and SAs with existing FQHC practices to expand reach of clinics’ prevention efforts and increase efficiency.

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273

Respondents from three awardees described working with FQHCs to formally assess their implementation readiness during the application process or initial site visits. Although the scope of assessments and definitions of “readiness” varied, awardees generally examined: (a) CRC burden and risk, (b) CRC screening practices, (c) experience implementing similar EBIs and SAs, (d) effectively engaging partners, (e) current EHR systems, including problems with EHRs related to EBI implementation or measuring CRC screening rates, and (f) CRC screening rates. FQHC staff, in collaboration with awardees, used assessment results to inform selection of EBIs and SAs for implementation and address EHR issues.

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334

To determine appropriate EBIs and ensure clinic capacity to implement them, programs can conduct readiness assessments of clinics prior to implementation. However, clinics may lack resources to implement all available interventions, and may strategically choose EBIs that are less resource intensive.

Sharma KP, DeGroff A, Hohl SD, Maxwell AE, Escoffery NC, Sabatino SA, Joseph DA. Multi-component interventions and change in screening rates in primary care clinics in the Colorectal Cancer Control Program. Prev Med Rep. 2022 Jul 9;29:101904. doi: 10.1016/j.pmedr.2022.101904. PMID: 35864930; PMCID: PMC9294188.

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443

Integrating CRC interventions into the standard operating procedures and work flow processes of health systems, when possible, will contribute to sustainability (e.g., incorporating client reminders into the electronic health record system so that reminders are automated).

Tangka FKL, Subramanian S, Hoover S, Lara C, Eastman C, Glaze B, Conn ME, DeGroff A, Wong FL, Richardson LC. Identifying optimal approaches to scale up colorectal cancer screening: an overview of the centers for disease control and prevention (CDC)'s learning laboratory. Cancer Causes Control. 2019 Feb;30(2):169-175. doi: 10.1007/s10552-018-1109-x. Epub 2018 Dec 14. PMID: 30552592; PMCID: PMC6382575.

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455

According to ID-DHW stakeholders, there were several program elements that facilitated the initiation of cancer screening prevention integration after their planning phase. The first of these elements was a pre-implementation checklist for health clinics to determine their capacity for implementing each type of cancer screening and undertake specific enhancements for coordinated and integrated screenings to be initiated.

Tangka FKL, Subramanian S, Hoover S, Cariou C, Creighton B, Hobbs L, Marzano A, Marcotte A, Norton DD, Kelly-Flis P, Leypoldt M, Larkins T, Poole M, Boehm J. Improving the efficiency of integrated cancer screening delivery across multiple cancers: case studies from Idaho, Rhode Island, and Nebraska. Implement Sci Commun. 2022 Dec 16;3(1):133. doi: 10.1186/s43058-022-00381-4. PMID: 36527147; PMCID: PMC9756516.

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