Brief history of the organization, the community to be served, and the target population: North End Waterfront Health (NEW Health) is a free-standing FQHC practicing as a Patient-Centered Medical Home and has been recognized as a PCMH by the Joint Commission and NCQA, level 3. Our primary care practice features physician-led patient-focused teams working with each patient to provide primary care, prevention, and wellness services. We serve low-income and public housing residents in the Boston neighborhoods of Charlestown (PHPC) and the North End (CHC). As low income, minority, and immigrant residents, our target populations suffer high levels of poverty, distrust and instability. One critical result is the lack of utilization of health care and a corollary increase in poor health status overall and health disparities of the most disabling kind for these communities. In terms of colorectal cancer, our target population has lower rates of screening and higher rates of mortality when compared to citywide, statewide, and nationwide data. How the proposed project will increase access and address barriers to cancer screening and referral to care and treatment: NEW Health proposes to address colorectal cancer screening and treatment through this project. We will increase the number of patients who receive stool-based and direct visual methods of screening as well as increase the number of patients who receive follow-up care within 30 days of an abnormal screening result. The project’s priority is to increase equitable access to colon cancer screening and referral for treatment by enhancing outreach, patient education, and case management. The health center and partners will use a multicomponent intervention approach as recommended by the Community Preventative Services Task Force (CPSTF). Aspects of the interventions will include outreach and education, care coordination, home visits, eligibility assistance, enhancing virtual care capabilities, tr
ansportation, patient navigation, patient engagement and activation, collaboration with families and caregivers, tracking patient screening, referrals, and follow-up, diversifying availability of screening, workforce recruitment, workforce training, and workforce engagement. As demonstrated by the CPSTF, we expect that the combination of these interventions over two years will result in an 18% increase in patients screened for colorectal cancer and a decrease in the amount of time between positive screen and linkage with care and treatment. Description of proposed partnerships: NEW Health will increase equitable access to colorectal cancer screening and referral for care and treatment by enhancing patient education, case management, outreach, and other enabling services in coordination with The Dana-Farber Cancer Institute, an NCI-designated Cancer Center that will deploy outreach specialists and patient navigators for populations served by NEW Health and help build capacity within the health center systems and workforce. AxCS activities will specifically address the unmet needs, barriers to screening and care, strategies to improve patient experience, equity, impact of COVID-19, and telehealth resources for our patients. NEW Health will add screening hours, assist patients with scheduling, and provide transportation and translation services. Additionally, NEW Health will work with Harvard T.H. Chan School of Public Health to leverage their expertise in implementation and evaluation through partnership with The Implementation Science Center for Cancer Control Equity (ISCCCE).