Gaps-in-Care Cancer Screening

Project Overview: 

Penobscot Community Health Care (PCHC), the largest Federally Qualified Health Center (FQHC) in Maine, will hire an Outreach Medical Assistant (Outreach MA) to lead our Gaps-in-Care program for the purpose of proactively reaching out to any PCHC patient who may be overdue for three, specific cancer screenings: breast, cervical, and colorectal. The Outreach MA will: 1) schedule appropriate tests (if the patient is willing); 2) work to identify barriers that may be preventing a patient from obtaining such tests (inadequate insurance, transportation, fear, etc.); 3) collaborate with care managers to reduce those barriers; and 4) help the patient explore alternative test options and care management strategies. The Outreach MA will first delve into the patient’s chart to locate any test results that may not have been entered, and will contact local pathologists or surgical providers to obtain reports that may not have been documented in the patient’s electronic health record at PCHC. This will ensure that every patient receives necessary follow-up screening and treatment.

The Challenge:

In late 2012, cancer screening rates for PCHC were lower than either the U.S. or Maine averages before we began implementing outreach strategies using a medical assistant (based on 2014 American Cancer Society/Surveillance Research, see details below). This data demonstrates the need for ongoing Gaps-in-Care outreach so we can build upon our past success and achieve the stated goals (75% compliance for mammograms, 75% compliance for Pap smears, and 65% compliance for colorectal cancer screenings).

Screenings at recommended intervals (%):

  • Mammogram 58.6 (US) 65.0 (ME) 63.1 (PCHC Current) 75 (PCHC Goal)
  • Pap Smear 84.3 (US) 87.9 (ME) 64.0 (PCHC Current) 75 (PCHC Goal)
  • Colorectal 63.2 (US) 71.7 (ME) 55.5 (PCHC Current) 65 (PCHC Goal)

Project Benefits:

In this calendar year, through October of 2014, PCHC served 41,589 adult patients, of whom 55% were female and 45% were male. Adult female patients (22,874) will benefit from increased screening for breast and cervical cancer. All adult patients ages 50 and over will benefit from increased screening for colorectal cancer.

Penobscot Community Health Care
Grant Amount Given: 
Year Issued: 
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Types of Cancer: 

Maine Cancer Foundation Grants to this Organization:

Year Program Amount Category Organization
2017 Expanding Systems to Increase Colorectal Cancer Screening through Patient Outreach and Recall $100,000 Screening Penobscot Community Health Care
2016 Peer-Led Tobacco Cessation Training at Unlimited Solutions Clubhouse $26,116 Prevention Penobscot Community Health Care
2016 Provide a Reminder and Recall System for Colorectal Cancer Screening $30,000 Screening Penobscot Community Health Care
2015 Gaps-in-Care Cancer Screening $38,500 Screening Penobscot Community Health Care
2015 Eliminating Barriers to Cancer Screening through Use of Navigator Medical Assistants $164,000 Navigator Penobscot Community Health Care