- Indian Health Center of Santa Clara Valley
- Livingstone Community Development Corporation
- Mission Neighborhood Health Center
- Opsam Health
- Shasta Community Health Center
- Ventura County Community Health Center
- Western Sierra Medical Clinic
Indian Health Center of Santa Clara Valley
Project Director: Daniela Arcienega
Organization Headquarters: San Jose, CA
Amount Funded: $17,000
Project Title: Indian Health Center of Santa Clara Valley – BCCSIP Cycle 3
Priority Areas:
- Screening underserved populations, including AI/AN populations or others at disproportionately higher risk for BC and/or CRC
Indian Health Center of Santa Clara Valley (IHCSCV), founded in 1977 as a non-profit organization, serves the healthcare needs of the American Indian and Alaskan Native (AI/AN) community in the Santa Clara Valley. IHC’s mission is to ensure the survival and healing of AI/ANs and the greater community by providing high-quality, comprehensive health care and cultural services. In the 1990s, IHC gained an Urban Indian Health Program status and, in 1993, became a Federally Qualified Health Center (FQHC), expanding its services to low-income, non-AI/AN communities. Today, IHC serves approximately 20,000 patients, offering Medical, Dental, Counseling, Women, Infant, and Children (WIC), and Inter-tribal services.
Through the Breast and Colorectal Cancer Screening Improvement Project (BCCSIP), IHC seeks to address disparities in cancer screening rates within our patient population. Our main challenge is that patients are not completing their mammograms due to a lack of knowledge. Patients are aware that a mammogram order has been placed, however, more education about the importance of breast cancer screening is needed. Our goal is to improve breast cancer screening rates from our 2023 baseline of 42.84% and colorectal cancer screening rates from 30.31% by the end of 2025. To achieve this, we will implement a multi-faceted approach that leverages provider engagement, patient education, and SMS outreach. Provider reminders will encourage more proactive conversations about screening, while SMS campaigns and client reminders will be used to educate patients on the importance of screening and to ensure timely follow-up. This project will be supported by data-driven monitoring through the OCHIN Epic EHR system, allowing us to track progress and make adjustments as needed. Weekly staff meetings will ensure continuous evaluation and optimization of the interventions.
Livingstone Community Development Corporation
Project Director: Helen Jung, MPH, DPH
Organization Headquarters: Petaluma, CA
Amount Funded: $15,000
Project Title: Connection to Cancer Screening
Priority Areas:
- Screening underserved populations, including AI/AN populations or others at disproportionately higher risk for BC and/or CRC
- Recipient of < 2 rounds of prior BCCSIP funding (cycle 1 and/or cycle 2)
The sustainability of breast cancer (BC) and colorectal cancer (CRC) screening programs is critical to improving early detection and reducing mortality rates, particularly among underserved populations. This project focuses on integrating evidence-based interventions (EBIs) into existing screening services, utilizing the principles of the Patient Experience Improvement program to enhance patient-centered care, increase participation rates, and ensure long-term program viability.
For breast cancer screening, we implement EBIs such as provider reminders and client reminders to increase mammography rates. Provider reminders delivered through electronic health records ensure that healthcare providers consistently offer screening services during routine appointments. Client reminders, such as letters, text messages, or phone calls, prompt patients to schedule their mammograms. Additionally, patient navigation addresses barriers like transportation, language, and health literacy, further enhancing adherence to screening protocols. Another EBI, reducing structural barriers, will be applied by extending clinic hours, offering transportation assistance, and establishing mobile mammography units, making screening more accessible for hard-to-reach populations.
For colorectal cancer screening, the project utilizes fecal immunochemical test (FIT) kits as the primary EBI, alongside small media (brochures, flyers, and digital campaigns) to raise awareness and educate patients about the importance of screening. Patient navigators will ensure that patients understand how to properly use FIT kits and return them for analysis. In addition to offering flexible access to CRC screening, the project will focus on reducing structural barriers by providing screening at non-traditional locations (e.g., community centers, food pantries) and expanding screening hours. This EBI will significantly boost screening uptake, especially in underserved populations.
To further increase screening rates for both BCC and CRC, we will employ the EBI of provider assessment and feedback. Healthcare providers will receive regular performance reports on their screening rates and participate in workshops aimed at improving screening practices. This ongoing assessment and feedback loop fosters accountability and encourages providers to prioritize offering screening services during patient visits.
Methods to Achieve Goals
To achieve our goals of improving screening uptake and patient outcomes, we will implement a multi-faceted strategy. First, we will engage providers through continuous education, emphasizing the use of EBIs such as reminders, provider assessment, and reducing structural barriers. Regular feedback sessions will enable providers to track their performance and make necessary adjustments to their practice.
Second, patient-centered communication strategies will be tailored to meet the cultural and linguistic needs of target populations. Client reminders will be adapted to language preferences, and trusted community partners will help disseminate information about screening services. Additionally, we will collaborate with community organizations to offer screening at easily accessible locations and distribute FIT kits in non-clinical settings.
Finally, robust data collection through electronic health records will track screening rates, and patient satisfaction surveys will assess impact of patient navigation services, reminders, and structural barrier reduction. Ongoing evaluation (quarterly reviews) will ensure that services are continuously improved to address emerging challenges.
By integrating these EBIs and focusing on reducing barriers to care, Livingstone aims to significantly increase BC and CRC screening rates, ultimately improving health outcomes for our underserved patients.
Mission Neighborhood Health Center
Project Director: Robert B. Williams, MD
Organization Headquarters: San Francisco, CA
Amount Funded: $15,000
Project Title: CHW-led Cancer Screening and Education Outreach Project
Priority Areas:
- Screening underserved populations, including AI/AN populations or others at disproportionately higher risk for BC and/or CRC
- Recipient of < 2 rounds of prior BCCSIP funding (cycle 1 and/or cycle 2)
MNHC plans to significantly improve our patients’ rates of breast cancer screening and increase patient awareness and understanding of breast cancer risks and prevention modalities via implementation of a protocol by which a Community Health Worker is dedicated to phone outreach involving providing education, ordering mammography by standing order (under direction of designated medical provider), autonomously verifying or registering patients in coverage programs, providing navigation for the various mammography centers (hospitals, mammogram van, etc.), and participating in tracking of appointments and results.
Opsam Health
Project Director: Archie Bella, MD, MBA
Organization Headquarters: National City, CA
Amount Funded: $18,000
Project Title: Evidence Based Interventions to Advance Opsam Health’s Progress on BC and CRC Screening Compliance
Priority Areas:
- Screening underserved populations, including AI/AN populations or others at disproportionately higher risk for BC and/or CRC
- Recipient of < 2 rounds of prior BCCSIP funding (cycle 1 and/or cycle 2)
Opsam Health worked in the prior cycle to improve risk stratification and to standardize screening processes–while implementing algorithms and EHR enhancements to assist care providers, while deploying call center reminders to promote patient utilization of screening services. This year, we will enhance past progress by implementing a mailed birthday cards EBI (in which we celebrate screening-eligible patient’s birth anniversary, whilst including a note that we “hope to be celebrating their birthday for many years to come,” and educating the patients that BC and/or CRC screening are key approaches to identifying cancer early–and creating excellent health outcomes. This project will increase client demand for screening. This EBI has been proven at multiple FQHCs, and in service to multiple ethnic groups. In fact, in a study by Watson and Tossas (2023), patients receiving a Birthday Card EBI completed their desired screenings at a higher rate than those who received an EBI (i.e. patient education) offered during their well-visits by their primary care provider (follow-through of 25% vs. 17%). Opsam will additionally provide lay Navigation outreach assistance as our second EBI to patients who are due for both BC and CRC screening during the grant funding period. This will increase community access, through facilitated assistance. Thanks to a recent AxCS grant from HRSA, Opsam is instituting a full-time Cancer Navigator within our care system. This individual will work with our Data Analytics team to identify ALL Opsam patients who are due for a cancer screening in the upcoming month, each and every month, and after the mailing and receipt of the Birthday Card EBI, the Navigator will outreach to every single patient who is due for screening. They will deploy techniques that they are being trained in by UC San Diego Moores Comprehensive Cancer Center community engagement staff, to have a thoughtful conversation around the importance of screening–and the existence of less-invasive screening modalities that exist for CRC, such as Cologuard and FIT testing. (Additional Notes: our providers additionally provide screening counseling during patient visits for all individuals flagged by the EHR as due for screening, and while this grant and our HRSA grant focus on BC and CRC, we are also using our Cancer Navigator to promote Cervical Cancer screening compliance, and monthly lists of individuals due for Pap Smears will also be pulled and queued up for EBIs in the same manner).
Shasta Community Health Center
Project Director: Rae Sanchez, MSA CPC
Organization Headquarters: Redding, CA
Amount Funded: $22,803
Project Title: SCHC Mobile Mammogram and Colorectal Cancer Screening Events 2025
Priority Areas:
- Screening underserved populations, including AI/AN populations or others at disproportionately higher risk for BC and/or CRC
- FQHC and LAL clinics located in the Central Valley or in rural census tracts
Project Overview: Shasta Community Health Center (SCHC) seeks funding to support evidence-based practices in breast and colorectal cancer screenings through a series of mobile mammogram events scheduled throughout the calendar year 2025. These events aim to increase access to preventive care for our patient population, particularly those with identified gaps in breast and colorectal cancer screenings.
Project Rationale: Breast and colorectal cancer screenings are critical components of preventive healthcare, yet many patients face barriers to accessing these services, including transportation issues, limited availability of services, and financial constraints. SCHC is committed to overcoming these barriers by bringing the services directly to our community through mobile mammogram events.
Proposed Plan: SCHC plans to hold one mobile mammogram event per quarter in 2025, totaling four events over the year. Each event will be strategically scheduled and located to maximize patient access and engagement. During these events, SCHC will conduct targeted outreach to patients who are overdue for breast cancer screenings. Additionally, while patients are onsite, we will address colorectal cancer screening needs by offering a variety of options, including Cologuard, Fit Kits, and referrals for colonoscopy consultations.
- Impact: These mobile mammogram events will significantly enhance SCHC’s ability to provide high-quality, accessible healthcare to our community. By focusing on evidence-based practices and addressing both breast and colorectal cancer screening gaps, SCHC will continue to lead in delivering preventive care that meets the needs of our patients. The inclusion of Patient Navigators to discuss colorectal cancer screening options ensures a comprehensive approach to cancer prevention, further improving patient outcomes.
- Conclusion: The proposed quarterly mobile mammogram events for 2025 are a vital component of SCHC’s ongoing commitment to improving women’s health and reducing cancer-related disparities in our community. We are hopeful that with your support, SCHC can continue to expand access to life-saving screenings and contribute to the overall well-being of our patients.
Ventura County Community Health Center
Project Director: Chaya, M, Blum, MPA
Organization Headquarters: Oxnard, CA
Amount Funded: $25,000
Project Title: SCHC Mobile Mammogram and Colorectal Cancer Screening Events 2025
Priority Areas:
- Screening underserved populations, including AI/AN populations or others at disproportionately higher risk for BC and/or CRC
The Ventura County Community Health Center (VCCHC) Program is organized around 18 FQHCs, serving over 95,300 patients, over 5,000 are within the Health Care for the Homeless program. In 2023, fewer than 50% of patients within the targeted age received the breast cancer screening and colorectal cancer screening that is recommended for optimal care. Throughout the past few years, there has been a big push for our clinics to get each patient within the age range screened. Our team’s goal for breast cancer screenings is to reach 60.39%, and 51.43% for colorectal cancer screenings. Some of the previous efforts include providing a mobile unit to more rural locations, as well as providing incentives to our patients to come in for their annual, or bi-annual well visit. The proposed requested funding would allow our team to increase their outreach efforts to patients through text campaigns, mailers, as well as dedicated staff scheduling appointment and follow up calls to patients. Once our patients receive the screening, they will then be referred, if needed, to additional care. Furthermore, by patients coming in for various health screenings, our team is then able to schedule future visits for patients, providing more consistent health care and creating a healthier community.
Western Sierra Medical Clinic
Project Director: Kirsten George, PA-C
Organization Headquarters: Grass Valley, CA
Amount Funded: $15,000
Project Title: Better Quality Health Together
Priority Areas:
- Screening underserved populations, including AI/AN populations or others at disproportionately higher risk for BC and/or CRC
- Clinics with baseline CRC screening rates below 25%
Western Sierra Medical Clinic, Inc. is a 501(c) 3 non-profit federally qualified health center in rural California, operating seven locations that serve Nevada, Sierra, Placer, and Yuba counties. During its over 40 years in operation, Western Sierra has provided high-quality primary care services in a manner responsive to the needs of our communities. Western Sierra has a QI process that involves a QI team to create action plans, implement plans, and reports on them, creates documentation of progress on specific measures that are shared with staff, board members, granters, and insurance companies. We use the Plan, Do, Study, Act (PDSA) method for all quality measures. We will use a PDSA for both BCS and CCS measures to measure the baseline of each measure and track all progress and through each stage of the improvement process of our implementation plan. We will monitor our progress through our monthly reporting process, this will allow us to evaluate our workflows and make necessary adjustments to achieve outcomes. Our plan includes enhancing the infrastructure built over the last two funding cycles to implement a closed loop process to improve patient outcomes and mitigate risk of potential life-changing patient outcomes. Our PDSA for both BCS and CCS measures will include patient outreach and education, closed loop workflows to address the open orders for both BCS and CCS screening orders, staff training on new workflows, analyze top provider/staff performers of both BCS and CCS measures and model their workflows as standardized documentation practices, document new workflows, create training plans and train staff in new workflow, and add new workflows to existing training platforms. Continue with community partnerships and identify new partnerships to allow for new low-cost access points for screening sites, and collaboration with managed care health plan and Cologuard for patient outreach program for CCS screenings. Our mission is to provide quality care to all regardless of their ability to pay, their race, ethnicity, religion, self-identity, or creed.
