Integrating proactive health screening and referral into 2-1-1

Matthew W. Kreuter, PhD, MPH*Kate Eddens-Meyer, MPH*

Kay Archer†

AIRS 2009 I & R Training & Education Conference; Reno, NV; June 3, 2009

*Washington University in St. Louis†United Way 2-1-1 Missouri

Kay Archer1962-2009

Overview

• Health disparities

•2-1-1 as a solution

• Pilot study results

• The current study

• Strategic thinking

• A grand vision

Eliminating health disparities by increasing the reach and effectiveness of health information in low-income and minority populations.

Health disparities

Cancer death ratesMen, by county poverty rate

Dea

th r

ate

246deaths per

100,000

282deaths per

100,000

Cancer death ratesLow income men, by race

Dea

th r

ate

270deaths per

100,000

366deaths per

100,000

St. Louis, MO

St. Louis, MOAfrican American population by census tract, 2000

St. Louis, MOIncidence of late-stage breast cancer 2X expected rates for MO, by census tract

Why are there cancer disparities?Known differences include…

• Cancer risk behaviors

• Early detection

• Treatment quality

• Adherence and follow-up care

Why are there cancer disparities?Known differences include…

• Cancer risk behaviors

• Early detection

• Treatment quality

• Adherence and follow-up care

Why are there cancer disparities?Known differences include…

• Cancer risk behaviors

• Early detection

Why are there cancer disparities?Known differences include…

• Cancer risk behaviors

• Early detection

Proven strategies

Why are there cancer disparities?Known differences include…

• Cancer risk behaviors

• Early detection

Proven strategies

Free programs

Linking populations with servicesWhat have we done to date?

• Public access computer kiosks

• Outreach through Laundromats

• News service for minority serving newspapers

• Food Stamps, Public Housing

•FQHCs, CMHCs

2-1-1 as part of the solution

The promise of 2-1-1A perfect fit?

• High reach

• Common mission

• Existing infrastructure

• Disadvantaged populations

Financial assistance (rent, utilities) 71%

Material resources (clothes, furniture) 9%

Housing (shelter, home repair) 5%

Food (pantries) 3%

Health 1%

Why do people call?

Women 73-90%

Unemployed 54-59%

Household income < $15,000 45-64%

Disproportionately minorities

Who calls?

Pilot study

Pilot studyNovember, 2007 – February, 2008

• Aim 1: Estimate cancer control needs of callers

• Aim 2: Determine feasibility of cancer referrals

Mammography

Pap testing

Colonoscopy

HPV vaccine

Smoking

Smoke-free home policies

Assessing six cancer control actions

Disparities associated with all of them

Effective tests or interventions for all

Programs available that provide them for free

Why these six?

Need at least one 85%

Need two or more 54%

Need three or more 30%

Current cancer control needs of 2-1-1 callers

Eddens K, Kreuter MW, Archer K. J of Hlth Care Poor & Underserved (under review).

No health insurance2-1-1 callers (n=297) vs. Missouri vs. U.S.

Current cigarette smoker2-1-1 callers (n=297) vs. Missouri vs. U.S.

Has a smoke-free home policy2-1-1 callers (n=297) vs. Missouri vs. U.S.

Ever had a colonoscopy (ages ≥ 50)2-1-1 callers (n=107) vs. Missouri vs. U.S.

Getting a mammogram* (women 40+)2-1-1 callers (n=146) vs. Missouri vs. U.S.

Getting a Pap test (women 18+)2-1-1 callers (n=255) vs. Missouri vs. U.S.

Pilot studyNovember, 2007 – February, 2008

•Aim 1: Estimate cancer control needs of callers

•Aim 2: Determine feasibility of cancer referrals

Mammograms

Pap smears

Colonoscopies

HPV vaccination

Smoking cessation

Smoke free home policy

Telephone follow-up 2 weeks later- What did they think of the mailed referrals?- Did they make a call and/or schedule an appointment?

Reactions to mailed referrals (n=39)

Outcome %

Recall getting referral 92%Recall getting mailing 54%Read all of mailing 41%Liked mailing a lot 62%Very easy to understand 67%Called referral agency 26%Made an appointment 13%

Willingness to participateAmong 2-1-1 callers in pilot study

• 58% agreed to answer cancer risk questions

• 91% agreed to participate in randomized trial

• 81% could be contacted at 2-week follow-up

Appropriateness of health questionsAmong 2-1-1 callers in pilot study

• 56% said 2-1-1 should be asking about health

• Only 5% felt health questions were too private

• 81% were comfortable with mailed health info

• 100% said health referrals made 2-1-1 more appealing

How is call length affected?

Administer risk assessment and provide verbal referrals

• Mean = 4:54 minutes

Enroll into study

• Mean = 2:52 minutes

Conclusions

• High level of need among 2-1-1 callers

• Proactive health referrals are feasible via 2-1-1

• Mailed reminder referrals seem promising

What do we still need to learn?

• Is it scalable?

• How strong a referral is needed?

• Does it work equally well for all callers?

Current study

5-year project, randomized trialOctober, 2008 – September, 2013

• NCI-funded

•$250,000 to United Way 2-1-1 Missouri

Telephone follow-up 1 and 4 months later- Did they contact referrals?- Did they obtain needed services?

Telephone follow-up 1 and 4 months later- Did they contact referrals?- Did they obtain needed services?

Telephone follow-up 1 and 4 months later- Did they contact referrals?- Did they obtain needed services?

Coach

Help callers act on referrals by:

• Making appointments

• Providing reminders

•Arranging transportation

• Answering questions

•Addressing barriers

• Explaining systems

1. Which approach works best?

2. What’s the impact on 2-1-1 quality indicators?

3. What factors influence effectiveness?

Key questions

1. Problem resolution

2. Unmet basic needs

3. Sense of coherence

- comprehensibility- manageability- meaningfulness

Factors that could affect outcomes

What will we learn?

• Need for cancer prevention in 2-1-1 callers

• Effectiveness of 2-1-1 referrals for health

• Added benefit of mailed referrals vs. coaches

• Effects when original problem is solved by 2-1-1

• Effects by level of basic needs, SOC

Some strategic thinking

Five stages of 2-1-1 awarenessWhat do health researchers know?

• Never heard of it

• Surprised

• Interested

• Excited

• Love

Health researchers will love 2-1-1Here’s why:

• Populations served

• Call volume

• Existing infrastructure

• Data system

Who’s already in love?Some recent recruits to 2-1-1 health research

• UCLA

• Harvard

• Wisconsin

• U. of Washington

• UNC-Chapel Hill

• U. of Texas at Houston

2-1-1 Cancer research consortiumTwo primary goals:

• Describe opportunity for collaborative research

• Lay out guiding principles for collaboration

Collaborating with researchersWhat’s in it for 2-1-1 systems?

• Rigorous evaluation

• Data analysis

• Health programs & services

•New sources of funding

Five big trends that favor 2-1-1New priorities for research and funding

• Translational research

• Social impact

• Prevention

• Disparities

• Cancer

A grand vision

10-year goals for 2-1-1The “three pillars”

• Education

• Income

•Health

• Reduced risk

• Improved health

• Disease prevention

Mission of 2-1-1…

• Excellence, Everywhere, Always

• Proactive, Comprehensive, Evidence-based

Thank you!