The comprehensive analysis of the causal loop diagram reveals several key insights and recommendations for clinics aiming to enhance CRC screening through EBI implementation. By understanding the interconnected factors that influence EBI sustainability, clinics can take strategic actions to improve their screening programs.

Here are some high-level recommendations:

• Embed EBIs within Clinic Practices: Ensure that EBI implementation is integrated into key clinic documentation such as job descriptions, standard operating procedures, and workflows. Integrate EBIs with existing clinic practices, where possible, and consider opportunities for EBIs to support multiple health outcomes (e.g., multiple cancer screening types, other preventive health measures).
• Secure Buy-in and Support for Implemented EBIs: Engage clinic champions and partners routinely in EBI implementation and continue to foster new partnerships (e.g., partnerships with endoscopy providers to strengthen care linkages, partnerships focused on addressing individual-level barriers to care). Share successes of EBI implementation with clinic staff and partners to foster support and commitment and collectively problem-solve challenges.
• Select and Implement EBIs with Sustainability in Mind: Use data-driven decision-making and local needs assessments to select EBIs that will successfully address barriers to screening. Evaluate the potential for long-term sustainability of different EBIs when exploring possible EBIs to implement.
• Use Funding to Support Sustainability Early in Implementation: Consider ways to use program funds to better support and integrate EBIs into clinic practices and plan for sustainability. This may include using funds to automate the use of electronic health records to support screening initiatives or building other necessary infrastructure critical to EBI implementation.
• Explore Multiple Funding Sources: Plan for potential challenges in securing additional funding to support EBI implementation after observing initial gains in screening rates. Be innovative in identifying different funding sources.
• Be Prepared for Staffing and Leadership Changes: Be aware that changes in staffing or leadership may affect momentum of screening programs. Create opportunities for ongoing training to ensure all clinic leaders and staff are aware of and engaged in EBI implementation. Integrate EBI implementation into standard workflows so that EBI implementation can continue with changes in staffing.

By integrating these recommendations, clinics can enhance their capacity to sustain EBIs effectively, ultimately increasing CRC screening rates and improving population health outcomes.