Medicaid Health Plans Research Articles

Population Health Implications of Medicaid Prerelease and Transition Services for Incarcerated Populations.

As states expand prerelease and transition services for incarcerated individuals under the Medicaid Reentry Section 1115 Demonstration Opportunity, we sought to systematically inform Medicaid state and plan administrators regarding the population size and burden of disease data available on incarcerated populations in both jails and prisons in the United States. We analyzed data on eligibility criteria for new Medicaid prerelease and transition services based on incarceration length and health conditions across states. We estimated the potentially eligible populations in prisons and jails, considering various incarceration lengths and health status requirements. We also compared disease prevalence in the incarcerated population with that of the existing civilian Medicaid population. We found that rural and smaller states would experience a disproportionately large proportion of their Medicaid populations to be eligible for prerelease and transition services if new Medicaid eligibility rules were broadly applied. Self-reported psychological distress was notably higher among incarcerated individuals compared with those currently on Medicaid. The prevalence rates of previously diagnosed chronic hepatitis C and kidney disease were also much higher in the incarcerated population than the existing civilian Medicaid population. We estimated large volumes of potentially Medicaid-eligible entrants as coverage policy changes take effect over the coming years, particularly impacting smaller and more rural states. Our findings reveal very high disease prevalence rates among the incarcerated population subject to new Medicaid coverage, including specific chronic, infectious, and behavioral health conditions that state Medicaid programs, health plans, and providers may benefit from advanced planning to address.

Correlates of Self-Reported Executive Function Impairment Among Medicaid Beneficiaries With Type 2 Diabetes

Aims Executive function (EF) impairment is associated with poorer outcomes for individuals with type 2 diabetes. Previous research has identified risk factors for EF impairment, but many of these are also associated with type 2 diabetes. To address this issue, this study identified relevant variables from the literature and compared their association with EF in a sample of people with type 2 diabetes. Methods Adult members of a Medicaid health plan diagnosed with type 2 diabetes were enrolled in a social needs intervention trial. Using baseline data from the trial, bivariate and multivariable regression analyses examined associations between EF and demographic, health, and psychosocial factors. Results When controlling for other factors, we identified six significant correlates of EF impairment: age (β = 0.10), education (college vs. no college; β = −0.38), depression symptoms (β = 0.18), comorbidity burden (β = 0.21), diabetes-related distress (β = 0.14), and future time orientation (β = −0.13). Conclusion Our analysis identified several factors associated with greater EF impairment, which may interfere with diabetes self-management. Providers should consider these factors when prescribing treatments and determine whether additional resources or accommodations are warranted.

Adaptations to a patient navigation program for follow-up colonoscopy in rural primary care practices.

Patient navigation is a recommended practice to improve cancer screenings among underserved populations including those residing in rural areas with care access barriers. We report on patient navigation programme adaptations to increase follow-up colonoscopy rates after abnormal fecal testing in rural primary care practices. Participating clinics delivered a patient navigation programme to eligible patients from 28 affiliated clinics serving rural communities in Oregon clustered within 3 Medicaid health plans. Patient navigation adaptations were tracked using data sources including patient navigation training programme reflections, qualitative interviews, clinic meetings, and periodic reflections with practice facilitators. Initial, planned (proactive) adaptations were made to address the rural context; later, unplanned (reactive) adaptations were implemented to address the impact of the COVID-19 global pandemic. Initial planned adaptations to the patient navigation programme were made before the main trial to address the needs of the rural context, including provider shortages and geographic dispersion limiting both patient access to care and training opportunities for providers. Later unplanned adaptations were made primarily in response to COVID-19 care suspension and staff redeployments and shortages that occurred during implementation. While unplanned adaptations were implemented to address the contextual impact of the COVID-19 pandemic on care access patterns and staffing, the changes to training content and context were beneficial to the rural setting overall and should be sustained. Our findings can guide future efforts to optimise the success of such programmes in other rural settings and highlight the important role of adaptations in implementation projects.

Composition of buprenorphine prescribing networks in Medicaid and association with quality of care

IntroductionDespite Medicaid's outsized role in delivering and financing medications for opioid use disorder (MOUD), little is known about the extent to which buprenorphine prescriber networks vary across Medicaid health plans, and whether network characteristics affect quality of treatment received. In this observational cross-sectional study, we used 2018–2019 Medicaid claims in Oregon to assess network variation in the numbers and types of buprenorphine prescribers, as well as the association of prescriber and network characteristics with quality of care. MethodsWe describe prescribers (MD/DOs and advanced practice providers) of OUD-approved buprenorphine formulations to patients with an OUD diagnosis, across networks. For each patient who initiated buprenorphine treatment during 2018, we assigned a “usual prescriber” and assessed four measures of quality in the 180d following initiation: 1) continuous receipt of buprenorphine; 2) receipt of any behavioral health counseling services; 3) receipt of any urine drug screen; and 4) receipt of any prescription for a benzodiazepine. We used multivariable linear regressions to examine the association of prescriber and network characteristics with quality of buprenorphine care following initiation. ResultsWe identified 645 providers who prescribed buprenorphine to 20,739 eligible Medicaid enrollees with an OUD diagnosis. The composition of buprenorphine prescriber networks varied in terms of licensing type, specialty, and panel size, with the majority of prescribers providing buprenorphine to small panels of patients. In the 180 days following initiation, a third of patients were maintained on buprenorphine; 69.9 % received behavioral health counseling; 88.4 % had a urine drug screen; and 11.3 % received a benzodiazepine prescription. In regression analyses, while no single network characteristic was associated with higher quality across all examined measures, each one unit increase in prescriber-to-enrollee ratio was associated with a 1.18 p.p. increase in the probability of continuous buprenorphine maintenance during the 180 days following initiation (95 % confidence interval = [0.21, 2.15], p = 0.017). ConclusionsMedicaid plans may be able to leverage their networks to provide higher quality care. Our findings, which should be interpreted as descriptive only, suggest that higher prescriber-to-enrollee ratio is associated with increased buprenorphine maintenance. Future research should focus on isolating the causal relationships between MOUD prescribing network design and patient outcomes.

Assessing a pharmacist provided mental health screening service in a rural community to address anxiety and depression

BackgroundThe current state of the mental health crisis has been a topic of discussion around the nation, with those in rural communities being at a particularly higher risk. Community pharmacists are uniquely positioned to screen patients for mental health disorders and provide education and patient monitoring following medication changes by prescribers. ObjectiveThe objective of this study is to assess mental health screening outcomes provided by rural community pharmacists. MethodsThis retrospective evaluation of a pilot project describes a behavioral health service. Eligible patients were 18 years of age or older, taking one or more mental health medications and covered by the specific Medicaid health plan. Participating pharmacies were those that had a considerable patient population participating with that plan, as well as credentialed and trained pharmacists. Pharmacists performed telehealth visits with eligible patients where they confirmed their mental health diagnosis and medications. Based on patient confirmed diagnosis, a Generalized Anxiety Disorder Questionnaire-7 (GAD-7) or Patient Health Questionnaire-9 (PHQ-9) test was administered. The pharmacists then made recommendations to the patients or their prescribers and created a plan with the patient for implementation based on their score.Follow-up calls were conducted to readminister the appropriate test to identify changes in mental health scores. ResultsThere were 61 patients who participated in the services across 4 pharmacies. Mean GAD-7 scores were 8.1 at initial appointment and 6.4 at follow-up (n = 24). Mean PHQ-9 scores were 11.2 initially and 10 at follow-up (n = 37). ConclusionThis implementation project supports the creation of additional mental health services in the community pharmacy setting to reinforce and encourage follow-up provider visits in areas where there are mental health provider shortages and may possibly improve patient outcomes.

Value-Based Proposition of an Adapted Integrated Care Telehealth Service for Accountable Care Organization Members.

The authors describe a real-world application of virtually integrated primary and behavioral health care implemented within an accountable care organization (ACO) system. Cost-of-care data from before and after a 6-month intervention were analyzed for 121 Medicaid and Child Health Plan Plus ACO members. The intervention was associated with a significant shift in the distribution of health care costs, from inpatient and emergency care to outpatient and preventive care. The program demonstrates a flexible and replicable approach to integration that can help expand effective primary care.

Is Primary Care Adapting to Medicaid Managed Care in North Carolina? Implications for Expansion and Future Managed Care Transitions.

Realizing North Carolina's comprehensive vision for Medicaid transformation requires strengthening the state's primary care infrastructure. This can be done by build-ing upon the value-based care incentives in the Advanced Medical Home model, strengthening payor data, aligning quality measures, easing administrative burdens, investing in primary care and its workforce pipeline, and ensuring pay-ment models adequately support serving Medicaid expan-sion and the growing number of Medicaid health plans.

Methods for scaling up an outreach intervention to increase colorectal cancer screening rates in rural areas

BackgroundMailed fecal immunochemical test (FIT) outreach and patient navigation are evidence-based practices shown to improve rates of colorectal cancer (CRC) and follow-up in various settings, yet these programs have not been broadly adopted by health systems and organizations that serve diverse populations. Reasons for low adoption rates are multifactorial, and little research explores approaches for scaling up a complex, multi-level CRC screening outreach intervention to advance equity in rural settings.MethodsSMARTER CRC, a National Cancer Institute Cancer Moonshot project, is a cluster-randomized controlled trial of a mailed FIT and patient navigation program involving 3 Medicaid health plans and 28 rural primary care practices in Oregon and Idaho followed by a national scale-up trial. The SMARTER CRC intervention combines mailed FIT outreach supported by clinics, health plans, and vendors and patient navigation for colonoscopy following an abnormal FIT result. We applied the framework from Perez and colleagues to identify the intervention’s components (including functions and forms) and scale-up dissemination strategies and worked with a national advisory board to support scale-up to additional organizations. The team is recruiting health plans, primary care clinics, and regional and national organizations in the USA that serve a rural population. To teach organizations about the intervention, activities include Extension for Community Healthcare Outcomes (ECHO) tele-mentoring learning collaboratives, a facilitation guide and other materials, a patient navigation workshop, webinars, and individualized technical assistance. Our primary outcome is program adoption (by component), measured 6 months after participation in an ECHO learning collaborative. We also assess engagement and adaptations (implemented and desired) to learn how the multicomponent intervention might be modified to best support broad scale-up.DiscussionFindings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings.Trial registrationRegistered at ClinicalTrials.gov (NCT04890054) and at the NCI’s Clinical Trials Reporting Program (CTRP no.: NCI-2021–01032) on May 11, 2021.

Effort Required and Lessons Learned From Recruiting Health Plans and Rural Primary Care Practices for a Cancer Screening Outreach Study.

Recruiting organizations (i.e., health plans, health systems, or clinical practices) is important for implementation science, yet limited research explores effective strategies for engaging organizations in pragmatic studies. We explore the effort required to meet recruitment targets for a pragmatic implementation trial, characteristics of engaged and non-engaged clinical practices, and reasons health plans and rural clinical practices chose to participate. We explored recruitment activities and factors associated with organizational enrollment in SMARTER CRC, a randomized pragmatic trial to increase rates of CRC screening in rural populations. We sought to recruit 30 rural primary care practices within participating Medicaid health plans. We tracked recruitment outreach contacts, meeting content, and outcomes using tracking logs. Informed by the Consolidated Framework for Implementation Research, we analyzed interviews, surveys, and publicly available clinical practice data to identify facilitators of participation. Overall recruitment activities spanned January 2020 to April 2021. Five of the 9 health plans approached agreed to participate (55%). Three of the health plans chose to operate centrally as 1 site based on network structure, resulting in 3 recruited health plan sites. Of the 101 identified practices, 76 met study eligibility criteria; 51% (n = 39) enrolled. Between recruitment and randomization, 1 practice was excluded, 5 withdrew, and 7 practices were collapsed into 3 sites for randomization purposes based on clinical practice structure, leaving 29 randomized sites. Successful recruitment required iterative outreach across time, with a range of 2 to 17 encounters per clinical practice. Facilitators to recruitment included multi-modal outreach, prior relationships, effective messaging, flexibility, and good timing. Recruiting health plans and rural clinical practices was complex and iterative. Leveraging existing relationships and allocating time and resources to engage clinical practices in pragmatic implementation research may facilitate more diverse representation in future trials and generalizability of research findings.

Comparison of social determinants of health in Medicaid vs commercial health plans.

Incorporating the measurement of social determinants of health (SDOH) into health care practice and US health policy reforms is a promising approach to improving population health nationwide. One way health care practitioners have started to incorporate consideration of SDOH in clinical care is by using International Classification of Diseases, Tenth Revision (ICD-10), Z-codes, a set of diagnosis codes spanning a range of social and economic circumstances. Our study summarizes Z-codes used by code type, setting, and patient demographics between Medicaid and commercial insurance to help identify strategies to optimize their use within each program and understand their differences. Overall, Z-code use was highly limited nationwide in Medicaid and commercial insurance between 2020 and 2021. Still, we found notable differences in the use of Z-codes between the programs; Medicaid beneficiaries were more likely to receive Z-codes related to financial and economic issues, while commercially insured beneficiaries were more likely to receive Z-codes indicating problems with social and familial relationships. Policy efforts focused on increasing the rate and ease of patient SDOH screening will potentially expand SDOH measurement and facilitate actions to address patient social needs.

Variation in Medicaid and commercial coverage of cell and gene therapies

Growth in the availability of cell and gene therapies (CGTs) promises significant innovation in the treatment of serious diseases, but the high cost and one-time administration of CGTs has also raised concern about strain on health plan budgets and inequity in access. We used coverage information from the Tufts Medical Center Specialty Drug Evidence and Coverage (SPEC) database for 18 large commercial health plans in the US and information from state Medicaid websites to examine variation in coverage of 11 CGTs in August 2021. We found that US commercial and Medicaid health plans imposed restrictions in 53.5 % and 68.3 % of their coverage policies for the 11 included CGTs, respectively. In addition, we identified significant variation in access to CGTs across commercial plans and across Medicaid plans. Coverage restrictions for certain CGTs were more common than others; clinical requirements were often (but not always) consistent with the inclusion criteria for the clinical trial central to the drug’s approval. We conclude that there is variation in access to CGTs, creating differential patient access.

Depressive and anxiety disorders and antidepressant prescriptions among insured children and young adults with congenital adrenal hyperplasia in the United States.

Dysfunction in the hypothalamic-pituitary-adrenal axis has been associated with depressive and anxiety disorders. Little is known about the risk for these disorders among individuals with congenital adrenal hyperplasia (CAH), a form of primary adrenal insufficiency. We investigated the prevalence of depressive and anxiety disorders and antidepressant prescriptions in two large healthcare databases of insured children, adolescents, and young adults with CAH in the United States. We conducted a retrospective cohort study using administrative data from October 2015 through December 2019 for individuals aged 4-25 years enrolled in employer-sponsored or Medicaid health plans. Adjusting for age, the prevalence of depressive disorders [adjusted prevalence ratio (aPR) = 1.7, 95% confidence interval (CI): 1.4-2.0, p<0.001], anxiety disorders [aPR = 1.7, 95% CI: 1.4-1.9, p<0.001], and filled antidepressant prescriptions [aPR = 1.7, 95% CI: 1.4-2.0, p<0.001] was higher among privately insured youth with CAH as compared to their non-CAH peers. Prevalence estimates were also higher among publicly insured youth with CAH for depressive disorders [aPR = 2.3, 95% CI: 1.9-2.9, p<0.001], anxiety disorders [aPR = 2.0, 95% CI: 1.6-2.5, p<0.001], and filled antidepressant prescriptions [aPR = 2.5, 95% CI: 1.9-3.1, p<0.001] as compared to their non-CAH peers. The elevated prevalence of depressive and anxiety disorders and antidepressant prescriptions among youth with CAH suggests that screening for symptoms of depression and anxiety among this population might be warranted.

It takes quality improvement to cross the chasm

Healthcare organisations in the USA rank significantly lower in quality of care compared with other developed nations. Research shows US performance emphasises expensive treatment over effective prevention programmes. This study...

Groundbreaking alliance formed to bid Kansas Medicaid contract

CareSource, a national nonprofit managed care organization, announced June 7 the first strategic alliance of its kind to compete in the upcoming procurement to serve KanCare members and transform the health care experience for vulnerable Kansans, according to an organization news release. The CareSource HealthAlliance uniquely combines CareSource — a national leader in nonprofit managed care with 30+ years of experience — with three prominent and well‐respected statewide organizations with deep Kansas roots, company officials stated. Interhab, the Children's Alliance, the Association of Community Mental Health Centers of Kansas and CareSource Kansas will collaborate to offer KanCare 3.0 recipients an innovative and unique Medicaid health plan option focused on the whole person. “We know that integrating the deep expertise of leading, influential organizations into the design and governance of Medicaid programs consistently improves health equity, member experience and health outcomes while managing the cost of care,” said Erhardt Preitauer, president and CEO of CareSource. “I'm confident that this alliance will reinvigorate health care in Kansas and become a national model.” To form the CareSource HealthAlliance, CareSource has partnered exclusively with: Interhab, a Topeka‐based nonprofit organization with over 50 years to enhancing the well‐being of individuals in Kansas who live with intellectual and developmental disabil‐ities; the Children's Alliance of Kansas, which spearheads the national preparation of kin, foster and adoptive parents through its development of certified trainers and leaders in the Model Approach to Partnerships in Parenting program; and the Association of Community Mental Health Centers of Kansas Inc., which advocates for the welfare of both community mental health centers and the individuals to whom they cater. The organization achieves this through legislative representation, providing leadership and professional education, and showcasing model practices and programs. All three organizations will collectively guide the CareSource HealthAlliance model of care, access to care, operational excellence and community reinvestment, while ensuring a high level of quality, transparency and accountability.

HPR19 Variation in Medicaid and Commercial Coverage of Cell and Gene Therapies

Cell and gene therapies (CGTs) are potentially curative treatments for a growing array of diseases. CGTs pose a particular challenge to health care payers due to their one-time administration, high costs and uncertain long-term benefits. Most patients who are eligible for CGTs are covered by Medicaid or Commercial health plans. In this study we assessed variation in Medicaid and Commercial coverage for 11 CGTs.

National Chlamydia Screening Rate in Young Sexually Active Women Using HEDIS Measures in the United States, 2011 to 2020.

National guidelines recommend sexually active women younger than 25 years be screened annually for chlamydia. Our objective was to estimate the chlamydia screening rate of sexually active women aged 16 to 24 years from 2011 to 2020. We analyzed the chlamydia screening rates among sexually active women aged 16 to 24 years from 2011 to 2020 using the chlamydia measures in the Healthcare Effectiveness Data and Information Set data set. The annual national chlamydia screening rates were further stratified by census region and by patient age. Chlamydia screening rates among sexually active women aged 16 to 24 years ranged from 55.0% to 61.8% in Medicaid health plans and from 46.9% to 52.4% in commercial health plans during 2011-2020. The Northeast consistently had the highest screening rates among 4 geographic regions. The chlamydia screening rate among sexually active women aged 16 to 24 years decreased from 2019 to 2020: from 61.8% to 57.9% in Medicaid plans and from 52.4% to 48.4% in commercial health plans. The number of sexually active women aged 16 to 24 years covered by commercial health plans decreased from 2019 to 2020, but the number covered by Medicaid increased from 2019 to 2020. The chlamydia screening rates in the target population have increased little from 2011 to 2019. The decrease in chlamydia screening rates between 2019 and 2020 could be related to the COVID-19 pandemic and the reduced use of health services during that period. With recently suboptimal chlamydia screening rates in the United States, interventions of improving and assessing chlamydia screening rates are needed.

Data Challenges in Identifying Patients Due for Colorectal Cancer Screening in Rural Clinics.

Colorectal cancer (CRC) incidence and mortality are disproportionately high among rural residents despite the availability of effective screening methods. Outreach activities can improve CRC screening rates but rely on accurate identification of patients due for screening. We report on data challenges in rural clinics and Medicaid health plans in Oregon in identifying patients eligible for CRC screening, in a large project implementing mailed fecal immunochemical tests (FIT) and patient navigation. We analyzed data from clinic intake surveys and administrative claims. Clinics were asked to identify total population numbers relevant to CRC screening and follow-up. Health plans also identified enrollees eligible for CRC screening in Spring, 2021. Clinic staff validated patient lists for eligibility using their electronic health records (EHR). EHR features varied across the 29 participating and 28 responding clinics. Among the 28 responding clinics, 21 were able to report their Medicaid population (75%), 19 reported the number of patients aged 50 to 75 (68%) and the number screened for CRC in the last year (68%). Only 8 (29%) were able to report screening details such as number screened by FIT and 9 were able to report on patients with an abnormal FIT or colonoscopy completed after FIT (32%). Health plans had challenges properly identifying where enrollees received care and had missing data for race and ethnicity (range 22 to 34% unknown race, <1% to 24% unknown ethnicity). Most participating rural primary care clinics and Medicaid health plans experienced challenges identifying the population due for a CRC screening outreach program. Better EHR functionality and data reporting capabilities could help rural clinics apply population-based strategies and ultimately attenuate disparities in cancer screening and follow-up.

LOS ANGELES COUNTY BOLD INITIATIVE: LAYING THE GROUNDWORK FOR STRATEGIC PLANNING ON DEMENTIA

Abstract Funded by the Centers for Disease Control and Prevention’s Building Our Largest Dementia Public Health Program through U.S. Congressional appropriations for the BOLD Infrastructure for Alzheimer’s Act, the Los Angeles County BOLD initiative (LA BOLD) was established in 2021 with the goal of addressing the silent but burgeoning epidemic of Alzheimer's disease and related dementias (ADRD) in Los Angeles County (LAC). In 2019, approximately 166,857 LAC residents were living with Alzheimer’s disease; this number is expected to increase 150% by 2040. The initiative brings together a diverse group of multi-sector stakeholders, including two Area Agencies on Aging, two major academic centers, the largest Medicaid health plan in the region, the county’s safety net health agency (Public Health, Health Services, Mental Health), and other key community partners. The primary objectives of LA BOLD are: (i) establish a countywide coalition to address ADRD locally, and (ii) develop a strategic plan to guide the coalition’s efforts. The present study describes the first year of this initiative, highlighting the formation of the coalition’s steering group, identifying the three focus areas for strategic planning – risk reduction, early detection, advance care planning – and sharing lessons learned from navigating the contextual realities of ADRD care and prevention in LAC’s diverse communities. Data and program accomplishments for this early phase of LA BOLD are discussed within the context of medical advancement, the financial realities of ADRD programming and services, and the geo-political factors that are being considered as part of the strategic planning and implementation processes.

Improving screening, treatment, and intervention for unhealthy alcohol use in primary care through clinic, practice-based research network, and health plan partnerships: Protocol of the ANTECEDENT study.

BackgroundUnhealthy alcohol use (UAU) is a leading cause of morbidity and mortality in the United States, contributing to 95,000 deaths annually. When offered in primary care, screening, brief intervention, referral to treatment (SBIRT), and medication-assisted treatment for alcohol use disorder (MAUD) can effectively address UAU. However, these interventions are not yet routine in primary care clinics. Therefore, our study evaluates tailored implementation support to increase SBIRT and MAUD in primary care.MethodsANTECEDENT is a pragmatic implementation study designed to support 150 primary care clinics in Oregon adopting and optimizing SBIRT and MAUD workflows to address UAU. The study is a partnership between the Oregon Health Authority Transformation Center—state leaders in Medicaid health system transformation—SBIRT Oregon and the Oregon Rural Practice-based Research Network. We recruited clinics providing primary care in Oregon and prioritized reaching clinics that were small to medium in size (<10 providers). All participating clinics receive foundational support (i.e., a baseline assessment, exit assessment, and access to the online SBIRT Oregon materials) and may opt to receive tailored implementation support delivered by a practice facilitator over 12 months. Tailored implementation support is designed to address identified needs and may include health information technology support, peer-to-peer learning, workflow mapping, or expert consultation via academic detailing. The study aims are to 1) engage, recruit, and conduct needs assessments with 150 primary care clinics and their regional Medicaid health plans called Coordinated Care Organizations within the state of Oregon, 2) implement and evaluate the impact of foundational and supplemental implementation support on clinic change in SBIRT and MAUD, and 3) describe how practice facilitators tailor implementation support based on context and personal expertise. Our convergent parallel mixed-methods analysis uses RE-AIM (reach, effectiveness, adoption, implementation, maintenance). It is informed by a hybrid of the i-PARIHS (integrated Promoting Action on Research Implementation in Health Services) and the Dynamic Sustainability Framework.DiscussionThis study will explore how primary care clinics implement SBIRT and MAUD in routine practice and how practice facilitators vary implementation support across diverse clinic settings. Findings will inform how to effectively align implementation support to context, advance our understanding of practice facilitator skill development over time, and ultimately improve detection and treatment of UAU across diverse primary care clinics.

Mailed fecal testing and patient navigation versus usual care to improve rates of colorectal cancer screening and follow-up colonoscopy in rural Medicaid enrollees: a cluster-randomized controlled trial

BackgroundScreening reduces incidence and mortality from colorectal cancer (CRC), yet US screening rates are low, particularly among Medicaid enrollees in rural communities. We describe a two-phase project, SMARTER CRC, designed to achieve the National Cancer Institute Cancer MoonshotSM objectives by reducing the burden of CRC on the US population. Specifically, SMARTER CRC aims to test the implementation, effectiveness, and maintenance of a mailed fecal test and patient navigation program to improve rates of CRC screening, follow-up colonoscopy, and referral to care in clinics serving rural Medicaid enrollees.MethodsPhase I activities in SMARTER CRC include a two-arm cluster-randomized controlled trial of a mailed fecal test and patient navigation program involving three Medicaid health plans and 30 rural primary care practices in Oregon and Idaho; the implementation of the program is supported by training and practice facilitation. Participating clinic units were randomized 1:1 into the intervention or usual care. The intervention combines (1) mailed fecal testing outreach supported by clinics, health plans, and vendors and (2) patient navigation for colonoscopy following an abnormal fecal test result. We will evaluate the effectiveness, implementation, and maintenance of the intervention and track adaptations to the intervention and to implementation strategies, using quantitative and qualitative methods. Our primary effectiveness outcome is receipt of any CRC screening within 6 months of enrollee identification. Our primary implementation outcome is health plan- and clinic-level rates of program delivery, by component (mailed FIT and patient navigation). Trial results will inform phase II activities to scale up the program through partnerships with health plans, primary care clinics, and regional and national organizations that serve rural primary care clinics; scale-up will include webinars, train-the-trainer workshops, and collaborative learning activities.DiscussionThis study will test the implementation, effectiveness, and scale-up of a multi-component mailed fecal testing and patient navigation program to improve CRC screening rates in rural Medicaid enrollees. Our findings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings.Trial registrationRegistered at clinicaltrial.gov (NCT04890054) and at the NCI’s Clinical Trials Reporting Program (CTRP #: NCI-2021-01032) on May 11, 2021.