What to know
The follow-up and referral focus area includes tools and resources to ensure timely referral for diagnostic testing, treatment, and other appropriate next steps (such as genetic testing) when screening tests are abnormal.
Introduction
This page is part of the Colorectal Cancer Screening Change Package.
Change concepts are "general notions that are useful for developing more specific strategies for changing a process."1 Change ideas are evidence-based or practice-based "actionable, specific ideas or strategies."1 Each change idea is linked to tools and resources that can be used or adapted to improve cancer screening.
Note: See a list of acronyms used in this change package.
Change concept: Establish relationships with specialists for diagnostic testing and treatment.
Identify and partner with referral services or specialists who can provide follow-up diagnostic tests and/or cancer screening.
- CDC, NACDD, and Kaiser Permanente CHR — Mailed FIT Implementation Guide, pages 25-26
- IOM — Primary Care and Public Health: Exploring Integration to Improve Population Health
- NACHC — Value Transformation Framework: Cancer Screening, pages 9–10
- Nekhlyudov L, Latosinsky S, 2010 — The Interface of Primary and Oncology Specialty Care: From Symptoms to Diagnosis
Establish two-way communication with referral services or specialists to find out if patients followed up with referrals.
- AHRQ — Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms
- Nekhlyudov L, Latosinsky S, 2010 — The Interface of Primary and Oncology Specialty Care: From Symptoms to Diagnosis
Change concept: Adopt policies and procedures for patient referral and follow-up for diagnostic testing and treatment.
Develop protocols and workflows, such as reminder systems, to ensure follow-up referrals are made.
- AICAF and NIHB — Advancing Health Systems Toolkit,A pages 12 and 15
- CDC, NACDD, and Kaiser Permanente CHR — Mailed FIT Implementation Guide, pages 26, 39
- Evidence-Based Cancer Control Programs (EBCPP) — Fecal Immunochemical Test and Colonoscopy Outreach — Colonoscopy Strategy Workflow
- Kaiser Permanente CHR — Health Plan: Clinic Workflow for Unestablished Patient (When FIT Results Arrive)
- Nekhlyudov L, Latosinsky S, 2010 — The Interface of Primary and Oncology Specialty Care: From Symptoms to Diagnosis
Implement best practices for notification of abnormal test results and follow-up instructions to the patient.
- CDC, NACDD, and Kaiser Permanente CHR — Mailed FIT Implementation Guide, pages 26, 39
- Evidence-Based Cancer Control Programs – Against Colorectal Cancer In Our Neighborhoods (ACCION) — FIT Abnormal Results LetterA B [English and Spanish]
- Evidence-Based Cancer Control Programs – Against Colorectal Cancer In Our Neighborhoods (ACCION) — FIT Positive Results LetterA B [English and Spanish]
- NCCRT and ACS — How to Assure Follow Up Colonoscopy for Positive FIT from the Process Side
- ONC — SAFER: Self-Assessment Test Results Reporting and Follow-Up, pages 5–7
Create a tracking system for documenting patient follow-up after an abnormal test result.
- CDC, NACDD, and Kaiser Permanente CHR — Mailed FIT Implementation Guide, pages 9–10, 26, and 35
- ECRI on behalf of HRSA — Using the EHR for Care Management and Tracking
- Evidence-Based Cancer Control Programs (EBCCP) — Smart Options for Screening (SOS),A see Program Materials: SOS Quality Assurance for Positive FOBT-FIT
Use EHR-based clinical decision management tools to guide follow-up care.
- CDC, NACDD, and Kaiser Permanente CHR — Mailed FIT Implementation Guide, page 9
- ECRI on behalf of HRSA — Using the EHR for Care Management and Tracking
Change concept: Overcome barriers to follow-up and treatment.
Work with specialists and health care facilities to negotiate free or reduced-cost follow-up services or offer payment plans for patients experiencing financial disadvantage.
Identify sources for low-cost or free transportation services for follow-up care.
- ACS — Road to Recovery [English and Spanish]
- AHA — Social Determinants of Health Series: Transportation and the Role of Hospitals
- CMS — Non-Emergency Medical Transportation (NEMT)
- Livestrong — Transportation and Other Cancer Support Services
Offer same-day and open-access scheduling and services outside of traditional hours.
- The Community Guide — Cancer Screening: Reducing Structural Barriers for Clients – Cervical Cancer
Use patient navigation to help individuals access follow-up services.
Change concept: Facilitate genetic screening for patients and their relatives.
Educate patients regarding genetic risk and communication with family members.
Change concept: Implement follow-up processes for regular screening.
Provide visit summaries and patient education on future regular screening.
- CDC, NACDD, and Kaiser Permanente CHR — Mailed FIT Implementation Guide, page 39
- Evidence-Based Cancer Control Programs – Against Colorectal Cancer In Our Neighborhoods (ACCION) — FIT Normal Results Letter [English and Spanish]
- This resource may contain some information that does not reflect the current US Preventive Services Task Force recommendations for cervical cancer screening.
- Indicates a patient resource.
- Centers for Disease Control and Prevention. Tobacco Cessation Change Package. US Department of Health and Human Services; 2019.