Breast cancer is the most common cancer affecting women in the United States. While mammography screenings are proven to reduce breast cancer mortality rates, many women forgo the annual exams.1
Recognizing this, one South Carolina health system took action. Working with radiologists, referring physicians, and scheduling staff, the population health team at Bon Secours St. Francis Health System, a market of Bon Secours Mercy Health, launched Save a Life, a campaign to increase access to mammography screening for women in the Greenville, S.C., area.
Since the team permanently adopted the program in March of 2018, following a successful pilot, the number of mammograms Bon Secours St. Francis Health System has performed has risen significantly. The campaign led to a 39 percent increase of monthly mammogram orders year over year, contributing to the health system’s 256 positive breast cancer diagnoses in 2018.
Identifying the Gap
Bon Secours St. Francis began the Save a Life campaign after it identified a care gap among its Medicare patient population. As part of an Accountable Care Organization (ACO), Bon Secours receives regular reports from payers and the Centers for Medicare and Medicaid Services about qualifying patients’ preventative health services, such as mammography screenings.
After reviewing this data for 2017, Tami Johnson, director of business development at Bon Secours St. Francis, and the health system’s population health team noted continuity of care gaps in mammography services for Medicare Shared Savings Program (MSSP)
and Medicare Advantage Managed Care
The report showed that approximately 30 percent of Bon Secours St. Francis’ MSSP and managed care patients were forgoing mammograms and around 50 percent of those who had mammograms received the screenings out-of-network. Recognizing the value of closing these gaps from both a business and continuity of care standpoint, the Save a Life campaign initially targeted those patient populations.
“We wanted to encourage patients to remain in-network for care not only because the health system receives incentives through its ACO but also because patients benefit when they receive care in one network,” says Keith Newnam, vice president of population health management for Bon Secours St. Francis. “For example, when a patient receives care in one network, the medical record delivers more efficient follow-up and care management alerts that can provide physicians with important health history information. Though out-of-network physicians may scan and send documents to our health system, those documents may not be as easily accessible in the record or may be absent entirely.”
Setting a Goal
Through Save a Life, Bon Secours’ population health team aimed to schedule 90 percent of its MSSP and Medicare Advantage Managed Care patients for in-network breast screenings. To solidify this goal, the team included imaging — mammography in particular — in the health system’s 2018 continuity of care goals.
“We focused on breast cancer screening because we know that early diagnosis improves outcomes,” Newnam says. “Plus, mammography screening doesn’t require an order from a primary care physician, so schedulers can schedule patients and help improve our coverage without putting extra strain on the ordering physicians.”
With its goal set, the population health team met to discuss ways to achieve its objective. During one meeting, Johnson recalled an initiative that she had participated in when she worked in the radiology scheduling department: Whenever a woman called to arrange an imaging exam, the scheduler would check her medical record to see whether she was due for a mammogram.
If so, the scheduler would offer to make a mammography appointment. “We did this for three weeks and scheduled 55 patients for mammograms,” Johnson recalls. “It was very successful. Tapping into the power of the frontline staff has been effective in the past, so we wanted to see if we could start there and replicate this effort.”
This idea was the seed that grew into the Save a Life campaign.
Launching the Campaign
In the fall of 2017, population health administrators named Johnson the Save a Life campaign project manager, and she embarked on a plan to establish a proactive scheduling initiative in which radiology department schedulers would call MSSP and Medicare Advantage Managed Care patients who were overdue for mammograms. After calculating how many patients the schedulers would need to reach to achieve its goal, the Save a Life team determined that four radiology schedulers could manage the outreach program.
To start, Johnson reached out to Dana Hagy, director of woman’s imaging and diagnostics at Bon Secours St. Fran-cis, who liked the idea but knew the mammographers would have to adjust their work hours to meet the objective. When Hagy presented the idea to the mammographers, they were initially apprehensive. “Nobody likes change,” Hagy explains. “But we had open discussions about this process and gave the mammographers five to six weeks before we implemented the new schedule. They made the adjustments because they recognized the positive impact this would have on patient care.”
Johnson and Newnam met with the revenue cycle director to secure additional funding for the schedulers’ extra work hours. The four schedulers each added six to eight additional hours to their weekly schedules, time they dedicated exclusively to identifying and calling MSSP and Medicare Advantage Managed Care patients who were due for mammograms.
The schedulers initially used a report generated by population health analysts to identify patients for the program. To make identifying patients easier, Bon Secours St. Francis’s population health, quality, and information technology departments partnered to develop an electronic medical record (EMR) alert that automatically flags patients who are overdue for mammograms and prompts the schedulers to ask the patients about scheduling a mammogram.
Communicating with Patients
Once they identified a candidate for screening, the schedulers would call the patient and follow a script that Johnson provided to facilitate the discussions. The script had patient convenience in mind: “Okay Mrs. Jones, your CT is scheduled for Monday, April 2, 2018, at the downtown campus at 8:30 a.m. I see here you are also overdue for your screening mammogram. I would like to schedule that for you, as well.”
In the beginning of 2018, all of the radiology schedulers began participating in an effort that broadened the initiative to include inbound calls: When a call came in from an MSSP or Medicare Advantage Managed Care patient whose medical record indicated she was overdue for a mammogram, the scheduler would ask whether she wanted to schedule a mammogram, too.
In March, quality performance and informatics teams began reaching out to patients using the patient portal through its EMR messaging system to encourage MSSP and Medicare Advantage Managed Care patients who were overdue for mammograms to schedule their exams.
Mobilizing for More Mammograms
Before the Save a Life campaign began, Bon Secours St. Francis was already looking for ways to make mammography screening more accessible. As a result, the St. Francis Foundation, a charitable organization that supports Bon Secours St. Francis, funded the purchase of a mobile mammo unit equipped with 2-D mammography screening capabilities in 2012.
As the Save a Life team monitored the MSSP and Medicare Advantage Managed Care populations eligible for mammography screenings, they leveraged the mobile mammo to schedule more patients for mammograms. They selected the zip codes with the highest volume of these patients, and deployed the mobile unit to local businesses and Bon Secours Medical Group Practices in those areas. “Our mobile unit makes screenings more convenient for patients, particularly those who do not live near a screening center,” Johnson says. “We have patients tell us that they wouldn’t have been able to get screened if it hadn’t been for the mobile unit.” The mobile mammo unit is deployed five days a week, adding up to 25 additional screening slots per day, all of which are generally full.
The Save a Life team now plans to extend its mobile mammography reach. Based on the first unit’s success, the St. Francis Foundation is poised to fund a second unit, which will be equipped with 3-D mammography screening capabilities that provide a layered and clearer image of dense breast tissue. The unit will double the availability and scope of the service. “A lot of women don’t make the time to have their screening procedures done,” Hagy says. “Trying to reach out to them and make screenings convenient can make all the difference. This truly is a lifesaving program.”
Ramping Up to Meet Demand
As schedulers recruited more patients and the mobile unit made mammography screening more accessible, it quickly became apparent that the radiology department needed to expand its hours to accommodate the increased volume. The population health team monitored data from the campaign’s first few months and estimated that approximately 300 more appointments per month were needed to accomplish the screening goals.
“I thought the campaign was so brilliant that I wished I had thought of it myself, but when we were first presented with the data, 300 appointments sounded like an impossible number,” says Matthew T. Chaney, MD, diagnostic radiologist for Upstate Carolina Radiology and medical director of Bon Secours St. Francis’ Pearlie Harris Center for Breast Health. “We worked with the mammographers to extend our hours to cover the additional appointments and provide this critical service.”
The Pearlie Harris Center for Breast Health extended its hours to 8 p.m. Monday through Friday and added hours from 7 a.m. to 7:30 p.m. on Saturdays. Bon Secours St. Francis also opened an additional screening room at another location, and all of the system’s screening and diagnostic centers began accommodating walk-in patients who arrive without mammography appointments. “We had to get creative with schedules,” Hagy says. “Once staff saw how popular these evening and weekend appointments were and how thankful patients are for these additional hours, they were happy to be a part of this effort.”
While the campaign was meeting an important patient need, the new hours and additional exams significantly in-creased the radiologists’ workload. The Pearlie Harris Center alone saw up to 80 patients on Saturdays and several after-hours patients Monday through Friday. “With only one radiologist at the center, we struggled to keep up with both the screening exams and the diagnostic and follow-up exams that often require immediate attention,” Chaney says.
Luckily, Upstate Carolina Radiology regularly monitors productivity and adjusts staffing and workload several times a year based on which sections are growing the most rapidly. Due to the increase in mammography screens, the radiology center’s productivity increased and was therefore generating more revenue than originally projected. This allowed the center to staff an additional radiologist in April of 2018, an investment that Chaney says has more than paid for itself. “Adding a second radiologist helped immensely. Now one of us focuses on screenings while the other does the diagnostics,” he says.
Expanding on Results
Since the start of the Save a Life campaign, Bon Secours St. Francis has seen a 39 percent increase in its monthly screening mammogram orders year over year, and its radiology department has completed 11.7 percent more mammograms for MSSP patients than at the same time in 2016. This is equivalent to 859 more patients through Novem-ber of 2018 than at the same time in 2016. By working together, leadership, radiology schedulers, and care managers scheduled 195 documented mammograms through outbound calls alone, two of which were abnormal findings that resulted in surgery. Overall, this collaboration contributed to the 5,255 MSSP patient screenings and 2,282 Medicare Advantage Managed Care patient screenings conducted in 2018 at Bon Secours St. Francis.
The population health team credits the Save a Life campaign’s success to the radiology team’s hard work. “Often with screenings, a lot is left up to the patient. With the Save a Life campaign, we have flipped the tables,” says Marcus E. Blackstone, MD, internist at Stoneview Internal Medicine and physician lead for quality for the Bon Secours Medical Group at Bon Secours St. Francis. “You can’t do this without the radiology department buying in, so we are incredibly grateful for their effort and flexibility.”
During Breast Cancer Awareness Month in October of 2018, the Save a Life team expanded the campaign beyond MSSP and Managed Care patients to all patient demographics. Identifying and registering all qualifying patients for mammograms is now part of the standard workflow. “It’s the right thing to do,” says Newnam, whose wife is a breast cancer survivor. “If we could get 100 percent of the women who needed mammograms in and screened, that would be the greatest success we could ever have.”
The campaign now involves more than 10 departments, including quality, informatics, registration, and care management. The Save a Life team has also coordinated with primary care physicians and referrers from obstetrics, gynecology, cardiology, and other departments through meetings and phone conversations to get even more women in for breast cancer screening. It has also added alerts to the EMR’s notes section, encouraging clinicians to discuss mammography care gaps with their patients and encourage them to schedule screenings.
In addition to expanding the Safe a Life program’s impact on mammography screening, the group plans to investigate ways to use this same approach to address care gaps in areas such as colonoscopy and diabetic screenings, and it hopes other health institutions will find their own ways to leverage it. “This approach is like a spider web,” Johnson says. “It starts in the center with one focus and then stretches outward to cover other areas. If you know your part and your area of influence, consider how you can use it to make a positive impact on patient care. It’s an effective way to begin treating the whole patient.”