Michigan Colorectal Cancer Early Detection Program (MCRCEDP)

Program Manual

FY2020

Michigan Department of Health and Human Services

November 2019

Table of Contents

Overview Contact Information: Michigan Department of Health and Human Services 3

MCRCEDP Program Requirements Eligibility Requirements – Quick Reference Sheet Eligibility Requirements – Detailed Document Eligibility U.S. Citizenship Minimum Program Requirements CDC Service Quality Indicators MCC Clinical Protocol for the Early Detection of Colorectal Cancer (CRC) Conscious Sedation Policy (Propofol) Inadequate Bowel Preparation Guidelines Policy for Retention of Client Records

4 5 7 8

14 15 17 18 19

Patient Navigation Risk Assessment Script Templates Patient Navigation OC Light FIT Kits MDHHS Fecal Immunochemical Test (FIT) Instructions – English

22 28 32 34

MCRCEDP Forms MDHHS Agreement for Program Participation – formerly Informed Consent Form Enrollment Form Referral to Healthy Michigan Plan or the Health Insurance Marketplace Michigan Tobacco Quit Line Referral Form FIT Intake Form Colonoscopy Intake Form Secured Application User Agreement Access Form – MBCIS Application Provider/Facility Form

35 38 40 41 42 43 47 48

MCRCEDP Provider Documents Fax Template - Forms Tracking Provider Claim Submission and Reimbursement Quick Reference Sheet: Billable Codes

49 50 51

MCRCEDP Flowsheets, and Resources FIT Screening Flow Chart Colonoscopy Flow Chart (Diagnostic/Surveillance/Screening) FIT Supply Request Form FIT Kit Ordering Process & Expiring FIT Kits Provider Colorectal Cancer (CRC) Resources Client Colorectal Cancer (CRC) Resources

52 53 54 55 56 57

Budget Documents Annual Budget Instructions 60

MDHHS Contact Information

Michigan Department of Health and Human Services 109 W Michigan Avenue Washington Square Bldg. Cancer Section – 5th Floor

Lansing, MI 48933 Fax: (517) 335-8752

www.michigancancer.org/Colorectal

Dr. Nickell M. Dixon Program Director (517) 335-9349DixonN2@michigan.gov

Sharde’ Burton, BS, MPH Cancer Policy & System Change Consultant (517) 373-7226BurtonS4@michigan.gov

Susan Harris, PhD Data Manager MI Public Hlth Institute 2390 Woodlake Drive Suite 360 Okemos, MI 48864 (517) 324-7306SHarris@mphi.org

Robin L. Roberts Svcs Coordination Unit Manger (517) 335-1178RobertsR6@michigan.gov

Kanika S. Lewis, MPH, MSW, RNPublic Health Consultant (517) 335-9087(517) 763-0290 – Fax LewisK27@michigan.gov

Tory Doney Lay Patient Navigator, Billing & Reimbursement Specialist, and MBCIS Technical Assistance (517) 335-8854(517) 763-0290 – FaxDoneyT@michigan.gov

Colorectal Cancer Screening Program Eligibility Quick Reference Sheet

The Michigan Colorectal Cancer Early Detection Program (MCRCEDP) provides colorectal cancer (CRC) screening services in limited areas to eligible men and women:

• Ages 50-64• Low income (≤ 250% of the Federal Poverty Level)• Who have no symptoms• Who are underinsured and uninsured:• Colonoscopy for average and increased-risk clients• Fecal Immunochemical Test (FIT), optional for average risk clients

o Insured/underinsured clients may be eligible for the MCRCEDP if they have high out- of-pocketcosts for a colonoscopy.

o Clients who are not currently insured by the Healthy Michigan Plan are eligible for the MCRCEDP.

Average Risk Clients will be screened by colonoscopy or optional FIT, an at-home collection of stool. • Clients with a positive FIT found through the MCRCEDP will be referred for a diagnostic colonoscopy.• Average risk clients with positive (+) FIT results obtained from outside the program, may be eligible for

services.o Contact an agency for additional details as these enrollments will need to be approved by

MDHHS.

Increased Risk Clients will be screened by colonoscopy.

High Risk Clients are Not Eligible for the MCRCEDP. This includes men and women with: • Significant ongoing gastrointestinal symptoms.• Genetic, clinical or family history that places them at high risk for CRC.

Contact these agencies for MCRCEDP Enrollment

• District Health Department #10: (231) 876-3826 (Kalkaska, Crawford, Manistee, Wexford, Missaukee,Mason, Lake, Oceana, Newaygo, Montcalm, Mecosta Counties)

• Huron County Health Department: (989) 269-3323 (Huron, Sanilac, Tuscola, Bay, Saginaw, St ClairCounties)

• Health Department of Northwest Michigan: (231) 547-7677 (Antrim, Charlevoix, Emmet, OtsegoCounties)

• Grand River Gastroenterology: (616) 752-5297 (Grand Rapids/surrounding area, Kent County)

• Karmanos Cancer Institute & ACCESS Community Health Center: (313) 216-2206 or (248) 304-2301(Macomb, Oakland & Wayne Counties)

• Integrated Health Partners: (269) 425-7135 (Calhoun County)

# ppl in house

Annual Income

# ppl in house

Annual Income

1 $31,225 2 $42,275 3 $53,325 4 $64,375 5 $75,425 6 $86,475

Colorectal Cancer Screening Program Eligibility

The Michigan Colorectal Cancer Early Detection Program (MCRCEDP) provides colorectal (CRC) screening services to program eligible men and women who meet the following criteria:

• Asymptomatic, aged 50-64 yearso Average risk for CRC - screened by colonoscopy or optional at-home fecal

immunochemical test (FIT)o Increased risk for CRC – must be screened by colonoscopyo Positive FIT /FOBT from outside the program – Average risk clients with a positive FIT

or FOBT performed outside of MCRCEDP may be enrolled in the program on a limitedbasis. Contact the Michigan Department of Health and Human Services (MDHHS) forauthorization prior to enrolling these patients in the program for a diagnosticcolonoscopy.

• Low income (< 250% of the Federal Poverty Level)• Uninsured or underinsured:

o No health insurance: Enroll eligible clients who are not currently insured.o Inadequate health insurance: Enroll eligible clients who have high out-of-pocket CRC

screening expenses. For the underinsured, call the insurance company to verify deductible or out-

of-pocket expenses. Document insurance deductible on the enrollment form.Once CRC services are provided, the client’s insurance must be billed first withan Explanation of Benefit demonstrating a coverage gap. CDC funds must beused as the “funds of last resort” to pay for CRC services.

Clients enrolled in the Healthy Michigan Plan (HMP) are not eligible forMCRCEDP screening services.

Referrals for Insurance:

• All clients <138% of the Federal Poverty Levelo If not yet enrolled in the HMP, FIRST enroll the client in MCRCEDP and provide CRC

screening services.o Explain to the client that based on income, they may be eligible for HMP and other

valuable health services; provide HMP enrollment information.o Refer clients who are potentially eligible for the HMP to a certified health insurance

enrollment counselor at ENROLL MICHIGAN (http://enrollmichigan.com/) OR thewebsite www.michigan.gov/mibridges for HMP enrollment.

o Referrals to the HMP must be documented on the MCRCEDP enrollment form and inMBCIS.

• All clients 139% - <250% of the Federal Poverty Levelo In addition to enrolling these clients in the MCRCEDP, the LCA staff should encourage

clients to obtain health insurance through the Health Insurance Marketplace.

o All clients interested in obtaining health insurance through the marketplace should bereferred to a Patient Navigator at Enroll Michigan or the Health Insurance Marketplace.

o Referrals to the Marketplace must be documented on the MCRCEDP enrollment formand in MBCIS.

Referrals to Primary Care:

• If the client has no current provider, refer him/her to a PCP as a part of the enrollment process.

INELIGIBLE CLIENTS High Risk People who are symptomatic and those at high risk for colorectal cancer are NOT eligible for screening or surveillance services through the MCRCEDP. A process must be in place to refer clients who are ineligible for the MCRDEDP for additional services and/or evaluation. People at high risk include those with:

1. A genetic, clinical diagnosis or family history or suspicion of familial polyposis (FAP) or hereditarynon-polyposis colorectal cancer (HNPCC/Lynch Syndrome).

2. A history of inflammatory bowel disease, ulcerative colitis or Crohn’s disease.3. Significant gastrointestinal symptoms including, but not limited to rectal bleeding, bloody

diarrhea, blood in the stool within the past 6 months, prolonged change in bowel habits such asdiarrhea or constipation for more than two weeks that has not been clinically evaluated

4. Abdominal pain5. Unintentional weight loss of 10% or more of starting body weight6. Symptoms of bowel obstruction (e.g., abdominal distension, nausea, vomiting, severe

constipation).

Referral of Ineligible Clients: • This includes:

o High risk clientso Individuals who require CRC screening, but do not meet MCRCEDP eligibility

requirements (due to age, income or other eligibility criteria)o Individuals who may not benefit from CRC screening.

• All clients, who require screening but are not eligible for the MCRCEDP, must be referred to aPCP for CRC screening and/or diagnostic services utilizing community resources as needed.

• All uninsured clients who are not eligible for the MCRCEDP should be referred to a PatientNavigator to assist with enrollment in the HMP and the Health Insurance Marketplace.

Program Eligibility – U.S. Citizenship

Most legal immigrants are barred from Medicaid for their first 5 years in the U.S. and undocumented immigrants are eligible only for emergency Medicaid services.

Given this information, it has been determined:

If a client is not a citizen and has been in the country less than five years, they do not need to apply for the Healthy Michigan Plan and may be enrolled directly into the MCRCEDP.

If a client is a citizen or has been in the country legally for more than five years and they are <138% of the Federal Poverty Level they must be referred to Enroll Michigan or MI Bridges for enrollment in the Healthy Michigan Plan (HMP/ Medicaid Expansion).

• Clients eligible for HMP, but not enrolled, may receive MCRCEDP services.

Minimum Program Requirements

Introduction

This is a guidance tool for the Local Coordinating Agencies (LCAs) to ensure sites participating in the Michigan Colorectal Cancer Early Detection Program (MCRCEDP) are meeting the program requirements.

LCAs are required to maintain supportive documentation for all minimum program requirements listed below, and submit documentation as requested. Written documentation may be in the form of detailed flow sheets, schematics, or step-by-step policies and procedures. These documents should be compiled in a binder and be available to both the LCA and Michigan Department of Health and Human Services (MDHHS). This document should result in a step-by-step manual for the program policies and procedures in your local agency.

Minimum Program Requirements

Organizations funded by the MDHHS to implement the MCRCEDP must adhere to the following program requirements:

1) Project Coordination and Management

Identify one person at the LCA as the organization’s MCRCEDP Coordinator. This individual will be responsible for the administration of the local program, data collection, oversight of patient navigation and other duties as described in the MCRCEDP Policies and Procedures Manual.

LCAs are required to follow the MCRCEDP Program Manual per contract requirements.

Meet or show significant progress toward meeting performance indicators established by the Centers for Disease Control and Prevention (CDC) and MDHHS. These indicators will be provided to LCAs.

LCAs must receive authorization from MDHSS to begin screening clients through the MCRCEDP. LCA staff involved in the implementation of the MCRCEDP must attend training sessions, if offered by MDHHS.

All MCRCEDP staff changes (including extended sick leave) must be communicated to the MDHHS as soon as possible.

Contracts with program partners (i.e. health care providers, facilities, pathologists, and laboratory etc.) must be established prior to delivery of MCRCEDP services.

Ensure non-CDC resources (public or private funds) are in place to support treatment for persons diagnosed with cancer through the MCRCEDP or those experiencing medical complications from screening and diagnostic procedures.

2) Client Recruitment

Develop a work plan for how your organization will recruit eligible men and women to participate in the MCRCEDP, including women served by the Breast and Cervical Cancer Control Navigation Program (BCCCNP).

Develop a step-by-step policy to create linkages with health systems, providers and/ or community organizations for the referral of program eligible clients to the MCRCEDP.

Develop a step-by-step policy describing the local agency’s role in assisting clients who are ineligible for the MCRCEDP with providers and resources as detailed in the Eligibility Section of this manual.

3) Provision of Screening and Diagnostic Services

Develop a step-by-step policy for assessing and documenting MCRCEDP eligibility including age, income, insurance status and assessment of risk for colorectal cancer using the MCRCEDP Client Enrollment Form and the Michigan Cancer Consortium Guidelines for the Detection of Colorectal Cancer.

• When applicable, this process must include referrals to insurance (i.e. Healthy Michigan Planor the Marketplace) and documentation in MBCIS as detailed in the Eligibility Requirementssection of this manual.

Develop a step-by-step policy for patient navigation and support services for MCRCEDP clients beginning with client outreach and program enrollment, ending with the completion of screening and if necessary, follow-up services or treatment, as detailed in the Patient Navigation section of this manual.

A step-by-step policy for the referral of clients to colonoscopy services including: • Assessing the client’s readiness to screen utilizing colonoscopy.• Signed, approved informed consent forms.• Referral of clients for office visits/colonoscopy services within 2 weeks of program

enrollment.• Each client must be clinically evaluated prior to the procedure.• Discussion about the colonoscopy with the client, assessment of barriers to screening, and

tracking of the scheduled services through the completion of services.

• Ensure the provision of the colonoscopy prep and client understanding about how tocomplete the colonoscopy prep.

• Systematic tracking of “no-show” colonoscopy appointments including follow-up phone call,assessment of barriers to screening and rescheduling of procedures.

• Adherence to national CLIA standards for processing pathology specimens.• Following the colonoscopy, obtain copies of completed, reimbursable MCRCEDP services

including final colonoscopy report, pathology, lab work, office visit (if applicable), and anyadditional testing or procedures reimbursed by the MCRCEDP. Enter CRC services in MBCISand FAX copies of all completed, reimbursable CRC services to MDHHS.

• Plan to ensure colonoscopy results, screening intervals and any next steps are documentedand communicated to clients:o Negative colonoscopy results and next screening interval.o Positive non-cancerous colonoscopy results and next screening interval.o Positive colonoscopy results (indicating cancer) including referrals for treatment within

60 days of diagnosis.

A step-by-step policy for those average risk clients who choose to complete the optional annual at-home FIT for colorectal cancer screening including:

• Assessing the client’s readiness to screen and understanding of “next steps’ if the FIT ispositive.

• Signed, approved informed consent forms.• Distribution of FIT kits to clients. Use only the FIT kits provided by MDHHS.• Follow-up within 10 days on unreturned FIT kits.• FIT kits must be processed in a laboratory meeting national CLIA standards.• Tracking of FIT results.• Notifying the client of FIT results within 1 week of receipt.• Notify MDHSS of all positive FITs.• Plan for communicating negative results and next screening interval.• Positive FIT - Referral of clients for office visits/colonoscopy services within 2 weeks of

positive FIT results. Clients with abnormal screening results must receive a final diagnosiswithin 90 days of the screening test.

• Follow-up on clients who have positive FIT results and are not responsive to requests tocomplete the diagnostic colonoscopy as recommended.

• Certified mail to clients with a positive FIT who have not completed their scheduleddiagnostic colonoscopy as recommended, requesting colonoscopy completion ortermination of program enrollment.

A step-by-step policy for enrollment of clients with a Positive FIT outside the MCRCEDP for Diagnostic/Follow-up Colonoscopy:

• Assessment of program eligibility including age, income, insurance status and CRC risk(must be average risk for CRC). MDHSS authorization is necessary prior to MCRCEDPenrollment as detailed in the Eligibility Section of this manual.

• Assess the client’s readiness to screen utilizing a colonoscopy.• Signed, approved informed consent forms.

• Documentation of a Positive FIT outside the MCRCEDP in MBCIS:o Under the CRC Services tab, enter the date of the completed Positive FIT, but mark it as

a non-paid clinical service.• Referral of clients for office visits/colonoscopy services within 2 weeks of program

enrollment.• Each client must be clinically evaluated prior to the procedure.• Discussion about the colonoscopy with client, assessment of barriers to the diagnostic

testing and tracking of the scheduled services through the completion of services.• Systematic tracking of “no-show” colonoscopy appointments including follow-up phone call,

assessment of barriers to screening and rescheduling of procedures.• Adherence to national CLIA standards for processing pathology specimens.• Following the colonoscopy, obtain copies of reimbursable MCRCEDP services including final

colonoscopy report, pathology, lab work, office visit (if applicable), and any additionaltesting or procedures reimbursed by the MCRCEDP. Enter CRC services in MBCIS and FAXcopies of all completed, reimbursable CRC services to MDHHS.

• Plan to ensure colonoscopy results, screening intervals and any next steps are documentedand communicated to clients:o Negative colonoscopy results and next screening interval.o Positive non-cancerous colonoscopy results and next screening interval.o Positive colonoscopy results (indicating cancer) including referrals for treatment within

60 days of diagnosis.

A step-by-step policy for timely, uncompensated care (such as treatment for complications from a colonoscopy, or treatment following the diagnosis of colorectal cancer) including the LCAs role assisting clients obtain necessary resources:

• Provider referral list and financial navigator if available.• Enrollment in community health plans or other appropriate resources.• Referrals to available community specific and national CRC resources.

A step-by-step policy for the training of provider agencies to ensure proper enrollment, patient education, referrals, data collection/reporting, appropriate, timely follow-up of all tests including rescreening and surveillance recommendations.

4) Patient Support/Case Management/Patient Navigation

A plan to ensure patient support services to those enrolled in the program in order to support screening adherence including:

• Referral to a primary care provider (PCP) if client has no current provider as part ofenrollment process.

• Client education about colorectal cancer, risk factors, screening recommendations (includingdiagnostic colonoscopy following FIT), and if necessary, treatment. The limits of theMCRCEDP program and what it can and cannot pay for should be included in clienteducation communication.

A step-by-step tracking system to assure appropriate follow-up and timely screening, diagnostic and treatment services as referenced in Provision of Screening and Diagnostic Services.

5) Provider Care Network

Agreements in place with providers and facilities to offer screening and diagnostic services through the MCRCEDP according to MCC Clinical Protocol for the Early Detection of Colorectal Cancer and acceptance of MCRCEDP Unit Cost Reimbursement Rate Schedule as payment in full. Please refer to MCRCEDP Unit Cost Reimbursement Rate Schedule.

Plan for ongoing communication with providers regarding, but not limited to: • Dissemination of and adherence to MCC Clinical Protocol for the Early Detection of Colorectal

Cancer.• Providers will be contacted, as needed, if a repeat colonoscopy is not ordered following an

incomplete colonoscopy due to inadequate bowel prep or failure to reach the cecum.• MCRCEDP program updates.• Ongoing MCRCEDP website access.• Provide copies of provider documentation of completed reimbursable MCRCEDP services

within two weeks of the procedure including:o Screening Services: final colonoscopy, sigmoidoscopy or DCBE report.o Claims: pathology, lab work, office visit, EKG.o Recommendations: CRC rescreening and next screening interval, follow-up services or

treatment, if necessary.• Prompt reporting of sentinel events/complications from procedures to the LCA for forward

to MDHHS within 21 days.

6) Data Collection and Quality Control

Develop and utilize a step-by-step tracking and reminder system for the screening of both new and recalled clients. This includes documentation of telephone, mailings and other efforts to improve compliance with:

• Completion of screening and additional diagnostic or follow-up procedures.• Compliance with CRC rescreening recommendations based on recommended screening

interval.

A step-by-step policy is in place, if necessary, for quality improvements to the tracking and reminder system.

A step-by-step policy for reporting complications experienced by clients who have received colonoscopy services (or MDHHS authorized sigmoidoscopy/DCBE) either during, or within 30 days after the procedure. All complications must be reported to MDHHS with 21 days of occurrence.

A step-by-step policy to maintain compliance with the collection of all data elements required by MDHHS including:

• Documentation of client enrollment and provided CRC services in MBCIS.• Copies of pathology, lab work, medical dictation, all reimbursable CRC services and claims to

MDHHS within 1 week of receipt.• FAX Enrollment forms of all clients with a positive FIT to MDHSS.• FAX Colonoscopy Intake and Enrollment forms to MDHHS.

A step-by-step policy for securing laboratories with documented adherence to national CLIA standard for the processing of FIT and pathology specimens. FIT kits cannot be processed by LCAs.

A step-by-step policy for maintaining annual recertification of the MCRCEDP staff in the areas of: • Cultural competency• Privacy and confidentiality protocols

Centers for Disease Control: Service Quality Indicators

*Subject to change based on input from CDC

Indicator Type, Number and Description CDC Benchmark

Adherence to Screening

1 Percent of clients scheduled for screening colonoscopy who complete the test (Screening colonoscopy adherence rate)

≥ 75%*

2 Percent of clients provided with a fecal test kit who complete the test (Fecal kit return rate)

≥ 80%*

Screening the Priority

Population

3 Percent of new clients screened who are at average risk for CRC

≥ 75%

4 Percent of average risk new clients screened who are aged 50 years and older

≥ 95%

5

Percent of clients enrolled for routine screening or surveillance

With MDHHS authorization, a limited number of clients may be enrolled for diagnostic colonoscopy as a follow-up to a positive screening test performed outside the program.

≥ 75%

Completeness of Clinical Follow-up

6 Percent of abnormal test results with diagnostic follow-up completed

≥ 90%

7 Percent of diagnosed cancers with treatment initiated ≥ 90%

Timeliness of Clinical Follow-up

8

Percent of positive tests (FOBT/FIT, sigmoidoscopy, or DCBE) followed-up with colonoscopy within 90 days (This measure will not apply to all programs)

≥ 80%

9 Percent of cancers diagnosed with treatment initiated within 60 days

≥ 80%

Colorectal cancer screening efforts should focus on average risk men and women between the age of 50 and 64 years:

• Screening for average risk clients by FIT should be completed annually.• Completion of screening by FIT every 12-18 months is considered an annual colorectal

cancer screening.

Clinical Protocol for the Early Detection of Colorectal Cancer (CRC) July 2019

This Clinical Protocol is based upon screening guidelines developed by the U.S. Preventive Services Task Force (2016), the American Cancer Society (2016), and the NCCN Guidelines (2016). Not all acceptable CRC

screening tests are utilized by the Michigan Colorectal Cancer Early Detection Program (MCRCEDP).

Table 1: AVERAGE RISK

Table 2: INCREASED RISK due to family history

INC

RE

ASE

D R

ISK

Family History: When to Begin Surveillance Type If negative findings: If positive

findings:

Colorectal cancer or

polyps

CRC or adenomatous polyp in one first degree relative (parent, sibling or child) before age 60 OR in two or more first degree relatives of any age

Age 40 or 10 years before the youngest case in the family, whichever is earlier

Colonoscopy Every 5 years Counseling to consider genetic counseling and testing for affected relative with referral to a specialist/specialty center

See:

Abnormal Test

Result Table (5)

\Or

History of Polyps

Table (6)

Colorectal cancer or adenomatous polyp in a first-degree relative > age 60 OR two second-degree relatives with colorectal cancer at any age

Age 40 years Any screening option as recommended for average risk individuals

As recommended for average risk persons, depending on type of screening procedure chosen

Table 3: INCREASED RISK due to personal history of curative-intent resection of CRC

Personal History of When to Begin

Surveillance Type If negative findings: If positive finding:

INC

RE

ASE

D

RIS

K

Colorectal Cancer

Colorectal Cancer Personal history of curative-intent resection of CRC

Within 1 year after resection

Colonoscopy - Colonoscopy in 3 years; if stillnormal, colonoscopy every 5 years- CRC or other visceral cancersunder age 50 should be consideredfor genetic counseling

See: Abnormal Test Result Table (5) Or History of Polyps Table (6)

Table 4: HIGH RISK SCREENING and SURVEILLANCE

HIG

H R

ISK

When to Begin Surveillance Type If negative findings: If positive

finding: Inflammatory bowel disease, colitis (ulcerative colitis or Crohn’s)

8 years after the start of colitis

Colonoscopy with biopsies for dysplasia

Every 1-2 years See:

Abnormal Result Test Table (5)

Or

History of Polyps Table (6)

Personal or Family History of FAP (familial adenomatous polyposis)

Puberty (Age 10-12 years)

Annual FSIG to determine if FAP is present

- If familial polyposis is confirmed,colectomy is indicated; otherwise,endoscopy every 1-2 years- Referral for genetic counseling tospecialist/specialty center

Personal or Family History of Lynch Syndrome (HNPCC)

Age 20-25 years Colonoscopy - Every 1-2 years until age 40, thenevery year- Referral for genetic counseling tospecialist/specialty center

AV

ER

AG

E R

ISK

Age Range

When to Begin Screening Type & Recommendation If negative findings: If positive

findings:

\Age 50-75

Age 50

At-Home Stool Based Tests - Guiac-based fecal occult blood test (*highsensitivity gFOBT)- Fecal Immunochemical Test (FIT)- DNA-FIT test (Cologuard)*FOBT or FIT obtained by DRE is not acceptablefor screeningDirect Visualization Tests ColonoscopyFlexible sigmoidoscopy plus FIT yearlyFlexible sigmoidoscopyComputed Tomographic Colonography (CTC)

Annual Stool Testing -*gFOBT (high sensitivity) annually or -FIT annually– DNA-FIT Manufacturerrecommended every 3 year-Colonoscopy every 10 years- FSIG every 10 years plus annualFITFSIG every 5 yearsCTC every 5 years

See:

Abnormal Test

Result Table (5)

Or

History of Polyps

Table (6) Age 76-85

The decision to screen should be individualized taking into account the patient’s overall health and prior screening history utilizing one of the above recommended CRC screening methods.

Clinical Protocol for the Early Detection of Colorectal Cancer (CRC) July 2019

This Clinical Protocol is based upon screening guidelines developed by the U.S. Preventive Services Task Force (2016), the American Cancer Society (2016), and the NCCN Guidelines (2016). Not all acceptable CRC

screening tests are utilized by the Michigan Colorectal Cancer Early Detection Program (MCRCEDP).

Table 5: ABNORMAL TEST RESULT Abnormal Test Follow-up Recommended Procedure Future Screening Protocol

Positive Fecal Occult Blood Test (gFOBT/FIT or Stool DNA/FIT)

Colonoscopy

NEVER repeat a + FIT/gFOBT/ or Stool DNA/FIT

Reassess risk status based upon results of colonic exam and follow appropriate future screening protocol.

Abnormal Flexible Sigmoidoscopy If polyp found and biopsied: Adenoma: colonoscopy Hyperplastic polyp: no colonoscopy, return to screening guidelines OR If no biopsy done: colonoscopy

Reassess risk status based upon results of biopsy and follow appropriate protocol.

Abnormal CT Colonography* (*Limited reimbursement in Michigan)

Colonoscopy Reassess risk status based upon results of the colonoscopy and family/medical history. Follow appropriate protocol.

Abnormal Double Contrast Barium Enema

Colonoscopy Reassess risk status based upon results of biopsy and follow appropriate protocol.

Abnormal Colonoscopy Biopsy or Polypectomy Reassess risk status based upon results of biopsy and follow appropriate protocol.

Incomplete Colonoscopy Repeat colonoscopy, Double Contrast Barium Enema or CT Colonography

Reassess risk status based upon results and follow appropriate protocol.

Table 6: HISTORY OF POLYPS at Prior Colonoscopy

Type/Number of Polyps Time of next screening:

Recommended Procedure Future Screening Protocol

Small, rectal hyperplastic polyps Time of initial diagnosis

Any screening option as recommended for average risk individuals

Follow average risk recommendations, unless hyperplastic polyposis syndrome

Single, small (< 1 cm) adenomatous polyp OR 1-2 small tubular adenomas with low grade dysplasia

5 years after initial polypectomy

Colonoscopy If normal, consider following average risk recommendations

People with one large (> 1 cm) adenoma or 3-10 adenomas of any size or any adenoma with villous features or high-grade dysplasia

3 years after initial polypectomy

Colonoscopy If normal or 1-2 small tubular adenomas with low-grade dysplasia found, interval may be 5 years

People with more than 10 adenomas on a single exam

< 3 years after initial polypectomy

Colonoscopy Consider possibility of familial syndrome

Persons with sessile adenomas that are removed piecemeal

2-6 months toverify completeremoval

Colonoscopy Based on endoscopist’s judgment. Completeness of removal should be based upon both endoscopic and pathologic assessments

Table 7: SYMPTOM REPORTED by Patient Symptom

Reported by Patient

Age Recommended Procedure Future Screening Protocol

Bright red rectal bleeding, on tissue, in bowel, or on stool

Age 50 and up: Colonoscopy Reassess risk status based upon results of colonic exam and follow appropriate future screening protocol.

Age 40-50: Colonoscopy Below age 40: If obvious anal source, and no risk factors:

treat symptomatically. If recurrent symptoms, then colonoscopy or flex sigmoidoscopy.

Burgundy blood marbled into the stool

Any age Colonoscopy Reassess risk status based upon results of colonic exam and follow appropriate future screening protocol.

Table 8: INADEQUATE BOWEL PREPARATION Guidelines at Prior Colonoscopy Recommendations from the American Gastroenterology Association and the US Multi-Society Task Force (2014)

Inadequate Bowel Preparation Time of next screening:

Recommended Procedure Future Screening Protocol

The inability to detect polyps > 5 mm, after adequate bowel cleansing attempts have been made

1 year after initial colonoscopy

Colonoscopy with more aggressive bowel prep

If normal, consider following average risk recommendations

Colonoscopy Sedation Policy

The purpose of the Michigan Cancer Early Detection Program (MCRCEDP) is to provide colorectal cancer (CRC) screening to Michigan men and women who are 50-64 years of age, average risk, asymptomatic, low income, underinsured or uninsured. Due to limited program funding, the MCRCEDP Medical Advisory Committee encourages that moderate sedation be used routinely during a colonoscopy. Although moderate sedation is encouraged during a colonoscopy, anesthesia services provided during the administration of propofol will be reimbursed at the agreed upon reimbursement rate.

Situations that may warrant use of propofol: • A history of a failed colonoscopy due to inadequate sedation.

• Inability to sedate using conscious sedation.

• History of past trauma (physical or psychological) making conscious sedation difficult orundesirable.

• Co-morbidities such as chronic obstructive lung disease or heart disease.

o An individual’s life-limiting co-morbidities should be assessed prior to CRCscreening. The risk to each client with limited-life expectancy should beevaluated prior to CRC screening and the decision for screening based upon thisevaluation. Only appropriate candidates should proceed with CRC screening.

Payment of anesthesia provider services during a colonoscopy will follow the MCRCEDP Unit Cost Reimbursement Rate Schedule Codes. Refer to these codes for a list of claims covered by the MCRCEDP. In all cases, it is hoped that the MCRCEDP provider reimbursement for anesthesia services will be accepted as payment in full and the client will not be billed for any additional charges incurred during the colonoscopy.

To expedite payment of anesthesia provider services, please forward documentation indicating the use of anesthesia services during a colonoscopy to the Local Coordinating Agency.

Revised December 16, 2016

July 2019

Inadequate Bowel Preparation Guidelines

The MCRCEDP Medical Advisory Committee encourages the following clinical protocol guidelines for colonoscopies completed in the program with inadequate bowel preparation:

Per the American Gastroenterological Association (AGA) with recommendations from the US Multi-Society Task Force (USMSTF) on Colorectal Cancer (Johnson et al., 2014), “If the colonoscopy is complete to the cecum, and the preparation ultimately is deemed inadequate, then the examination should be repeated, generally with a more aggressive preparation regimen, within 1 year; intervals shorter than 1 year are indicated when advanced neoplasia is detected and there is inadequate preparation.”

After completion of repeat colonoscopy, reassess risk status based on results of colonic exam and follow appropriate future screening protocol. If more aggressive bowel preparation is required, this same regimen should be used for all future colonoscopies.

The MCRCEDP will provide payment for a repeat colonoscopy at approved program rates with nurse consultant authorization for colonoscopies that meet these guidelines.

Adequate Bowel Preparation (excellent and good):

Defined as the ability to detect polyps > 5 mm, after additional bowel cleansing attempts have been made.

According to the AGA (Johnson et al.,2014), “If the preparation is deemed adequate and the colonoscopy is completed then the guideline recommendations for screening or surveillance should be followed.”

Inadequate Bowel Preparation (poor):

Defined as the inability to detect polyps > 5 mm, after additional bowel cleansing attempts have been made.

Please Refer to Table 8 on page 16: Clinical Protocol for the Early Detection of Colorectal Cancer (CRC) July 2019.

References

Johnson, D. A., et al. (2014). Optimizing Adequacy of Bowel Cleansing for Colonoscopy: Recommendations From the US Multi-Society Task Force on Colorectal Cancer. American Gastroenterology Association, 147, 903-924. doi: 10.1053/j.gastro.2014.07.002

Michigan Colorectal Cancer Early Detection Program (MCRCEDP)

Policy for Retention of MCRCEDP Client Records Effective Date October 1, 2015

Purpose: Provide guidelines for local coordinating agencies on time frames for retention of MCRCEDP clinical program data.

Time Frame for Retention of MCRCEDP Clinical Program Data

1. Clinical program data for MCRCEDP clients who receive colorectal cancer screening and/ordiagnostic services are to be retained by the local coordinating agency for the specified time periodas stated in # 4 below.

2. These guidelines pertain ONLY to MCRCEDP local coordinating agencies, NOTsub-contracted providers (See page 2 – Public Health Code Act 368 of 1978 for Michigan lawregarding provider record retention). Agencies that have clinical data retention policies shouldcontinue to follow those policies unless the time frames stated in those policies are LESS than theguidelines stated in # 4.

3. For agencies using Electronic Medical Records (EMRs):• Clinical data must be verified for accuracy and completeness prior to being entered in the

Michigan Breast and Cervical Information System (MBCIS) and authorized for reimbursementby MCRCEDP.

• Agencies that document client care in EMRs DO NOT need to print paper copies of medicalrecords as long as these records can be accessed to verify care/test results for MCRCEDP clients.

4. The following clinical data/forms must be retained at the MCRCEDP agency for the time periodspecified below.

a. Informed Consent: All signed current informed consent forms for the client, for each yearenrolled in the program.

NOTE: To eliminate the number of paper copies, the agency can add separate client “initial anddate” lines to the bottom of current consent forms. This can be reviewed with the client ateach renewal period.

b. MCRCEDP Client Enrollment form: Current year and two years previous (3 years).

c. Results of MCRCEDP screening/diagnostic tests:• Normal Results (requiring NO follow-up): Retain all copies of results and reports on file for 3

years from the original date of service.o The use of MBCIS data is acceptable for monitoring interval screening >3 years.

• Abnormal Results (NO Cancer Diagnosis): Retain all copies of tests, pathology reports, consultnotes, progress notes, forms, etc. for 3 years from the date of the final follow-upprocedure for the abnormal result. **

o The use of MBCIS data is acceptable for monitoring interval screening >3 years.• Abnormal results (CANCER DIAGNOSIS): Retain all copies of tests, pathology reports, consult

notes, progress notes, forms, etc. for 3 years from the date of the final diagnosis. **o The use of MBCIS data is acceptable for monitoring interval screening >3 years.

** Please refer to the MCC Clinical Protocol for the Early Detection of Colorectal Cancer – Recommendations for Colorectal Cancer Screening (March 2017) for screening and follow-up intervals. **

Michigan Colorectal Cancer Early Detection Program (MCRCEDP)

Policy for Retention of MCRCEDP Client Records Effective Date October 1, 2015

Public Health Code Act 368 of

1978

Section 333.16213 – Retention of Records (1) An individual licensed under this article shall keep and maintain a record for each patient for whomhe or she has provided medical services, including a full and complete record of tests andexaminations performed, observations made, and treatments provided. Unless a longer retentionperiod is otherwise required under federal or state laws or regulations or by generally acceptedstandards of medical practice, a licensee shall keep and retain each record for a minimum of 7 yearsfrom the date of service to which the record pertains. The records shall be maintained in such amanner as to protect their integrity, to ensure their confidentiality and proper use, and to ensure theiraccessibility and availability to each patient or his or her authorized representative as required bylaw. A licensee may destroy a record that is less than 7 years old only if both of the following aresatisfied:

(a) The licensee sends a written notice to the patient at the last known address of that patientinforming the patient that the record is about to be destroyed, offering the patient theopportunity to request a copy of that record, and requesting the patient's writtenauthorization to destroy the record.

(b) The licensee receives written authorization from the patient or his or herauthorized representative agreeing to the destruction of the record.

(2) If a licensee is unable to comply with this section, the licensee shall employ or contract, arrange, orenter into an agreement with another health care provider, a health facility or agency, or a medicalrecords company to protect, maintain, and provide access to those records required under subsection(1).

(3) If a licensee or registrant sells or closes his or her practice, retires from practice, or otherwiseceases to practice under this article, the licensee or the personal representative of the licensee, if thelicensee is deceased, shall not abandon the records required under this section and shall send awritten notice to the department that specifies who will have custody of the medical records and howa patient may request access to or copies of his or her medical records and shall do either of thefollowing:

(a) Transfer the records required under subsection (1) to any of the following:

(i) A successor licensee.

(ii) If requested by the patient or his or her authorized representative, to the patientor a specific health facility or agency or other health care provider licensed underarticle 15.

(iii) A health care provider, a health facility or agency, or a medical records companywith which the licensee had contracted or entered into an agreement to protect,maintain, and provide access to those records required under subsection (1).

(b) In accordance with subsection (1), as long as the licensee or the personal representative ofthe licensee, if the licensee is deceased, sends a written notice to the last known address ofeach patient for whom he or she has provided medical services and receives writtenauthorization from the patient or his or her authorized representative, destroy the recordsrequired under subsection (1). The notice shall provide the patient with 30 days to request acopy of his or her record or to designate where he or she would like his or her medical records

Michigan Colorectal Cancer Early Detection Program (MCRCEDP)

Policy for Retention of MCRCEDP Client Records Effective Date October 1, 2015

transferred and shall request from the patient within 30 days written authorization for the destruction of his or her medical records. If the patient fails to request a copy or transfer of his or her medical records or to provide the licensee with written authorization for the destruction, then the licensee or the personal representative of the licensee shall not destroy those records that are less than 7 years old but may destroy, in accordance with subsection (4), those that are 7 years old or older.

(4) Except as otherwise provided under this section or federal or state laws and regulations, recordsrequired to be maintained under subsection (1) may be destroyed or otherwise disposed of after beingmaintained for 7 years. If records maintained in accordance with this section are subsequentlydestroyed or otherwise disposed of, those records shall be shredded, incinerated, electronicallydeleted, or otherwise disposed of in a manner that ensures continued confidentiality of the patient'shealth care information and any other personal information relating to the patient. If records aredestroyed or otherwise disposed of as provided under this subsection, the department may take actionincluding, but not limited to, contracting for or making other arrangements to ensure that thoserecords and any other confidential identifying information related to the patient are properlydestroyed or disposed of to protect the confidentiality of patient's health care information and anyother personal information relating to the patient. Before the department takes action in accordancewith this subsection, the department, if able to identify the licensee responsible for the improperdestruction or disposal of the medical records at issue, shall send a written notice to that licensee athis or her last known address or place of business on file with the department and provide the licenseewith an opportunity to properly destroy or dispose of those medical records as required under thissubsection unless a delay in the proper destruction or disposal may compromise the patient'sconfidentiality. The department may assess the licensee with the costs incurred by the department toenforce this subsection.

(5) A person who fails to comply with this section is subject to an administrative fine of not more than$10,000.00 if the failure was the result of gross negligence or willful and wanton misconduct.

(6) Nothing in this section shall be construed to create or change the ownership rights to anymedical records.

(7) As used in this section:

(a) "Medical record" or "record" means information, oral or recorded in any form or medium,that pertains to a patient's health care, medical history, diagnosis, prognosis, or medicalcondition and that is maintained by a licensee in the process of providing medical services.

(b) "Medical records company" means a person who contracts for or agrees to protect,maintain, and provide access to medical records for a health care provider or health facilityor agency in accordance with this section.

(c) "Patient" means an individual who receives or has received health care from a health careprovider or health facility or agency. Patient includes a guardian, if appointed, and a parent,guardian, or person acting in loco parentis, if the individual is a minor, unless the minorlawfully obtained health care without the consent or notification of a parent, guardian, orother person acting in loco parentis, in which case the minor has the exclusive right toexercise the rights of a patient under this section with respect to his or her medical recordsrelating to that care.

History: Add. 2006, Act 481, Imd. Eff. Dec. 22, 2006 Popular Name: Act 368 © 2015 Legislative Council, State of Michigan

http://www.legislature.mi.gov/(S(jwr0ria54iaxveblvbtc4qo0))/mileg.aspx?page=GetObject&objectname=mcl-333-16213

Risk Assessment Script Templates

Eligible Clients: Average Risk: Client, Age 50-64 - MCRCEDP Screening Options Script:

You are 50-64 years of age and eligible for the MCRCEDP.

This program offers a colonoscopy for colorectal cancer screening or you may choose to complete an at-home stool (poop) test called a FIT.

If you choose a colonoscopy, the colonoscopy must be completed in a hospital (or out-patient center). There is a special “prep” you must drink before the test to clean out your bowel (gut). Someone will need to drive you to the hospital because you will receive medicine to “sleep” during the procedure and you may be drowsy after the test. The program staff will schedule the colonoscopy for you with doctors and hospitals who have agreed to work with us. If the colonoscopy is normal (no growths are found), the colonoscopy should be repeated in 10 years as long as no other new problems or symptoms develop. Always share any changes in your health with your doctor.

The at-home stool/poop test (FIT) is easy to complete. We will talk with you about how to complete the test and give you a “special” envelope to return the FIT kit back to the lab. The at-home stool test looks for tiny amounts of blood in your stool/poop that you cannot see. If no blood is found in your stool/poop, the test is normal, and the staff will ask you to come back in a year for another at-home stool test.

If there is no blood detected in your stool, the at-home stool test must be completed every year.

If blood is found in your poop/stool, it is not normal, but it does not have to mean you have cancer. The only way to find out why you have the blood in your stool/poop is to have a colonoscopy. It is important you understand that if blood is found in your stool you need to complete a colonoscopy as soon as possible.

While the at-home stool test (FIT) and colonoscopy are covered by the program, you may require more tests or medical services that are not covered by the program. These services, including treatment for colorectal cancer are not covered through the program. We will help you find agencies and/or providers who will work with you if you need more help getting services not covered by the program.

Average Risk – Eligible Average Risk Client, Aged 50-64 With Positive FIT Results Script: Recommend diagnostic colonoscopy

The result of your FIT is positive, meaning there was blood in your stool that you may not be able to see. The blood in your stool might be because of something simple like hemorrhoids, or

it could be colorectal cancer. The only way to be certain of why you are bleeding is to schedule a colonoscopy. The colonoscopy is paid for through the program. If you need other testing not covered by this program, we will help you find local resources.

During the colonoscopy you will be given medication that makes you sleepy. While you are “put-to-sleep” during the test, a lighted tube – like a long skinny flashlight - will be put in your “bottom” and moved along through your colon/bowel (gut). There is a camera on the end of the tube that the helps the doctor look at your entire gut/colon. If there are any growths in your colon (tumor/polyps) or anything that does not look normal, the doctor can remove it during the test. All growths that are removed will be sent to the lab to test for testing. The doctor will let you know the results of any testing.

You may need other tests that are not covered by the program. These tests, including treatment for colorectal cancer, surgery, chemotherapy, radiation, and medications are not covered by the program. We will help you find agencies and/or providers who will work with you if you need more testing.

Increased Risk – Eligible Client, Aged 50 – 64: Colonoscopy Script Personal or family history of colorectal cancer or precancerous polyps

You are considered at increased risk for colorectal cancer because you have a family or personal history of pre-cancerous growths (adenomas) or colorectal cancer. Because you are 50-64 years of age, are uninsured or under insured, have a limited income and are not enrolled in the Healthy Michigan Plan, you are eligible for the Michigan Colorectal Cancer Early Detection Program.

This program offers a colonoscopy for colorectal cancer screening. Because of your increased risk for colorectal cancer, a colonoscopy is the only recommended test for screening. A colonoscopy must be completed in a hospital (or patient center) and requires a special prep that you must drink before the test to clean out your bowel (gut). The program staff will schedule the colonoscopy for you with doctors and hospitals who have agreed to work with us and the staff will provide the prep for the colonoscopy.

You will be given medication that makes you sleepy during the colonoscopy. While you are “put-to-sleep” during the test, a lighted tube – like a long skinny flashlight - will be put in your “bottom” and moved along through your colon or bowel (gut). There is a camera on the end of the tube that the helps the doctor look at your entire gut/colon. If there are any growths in your colon (tumor/polyps) or anything that does not look normal, the doctor can remove it during the test. All growths that are removed will be sent to the lab to test for testing. The doctor will let you know the results of any testing.

You may need other tests that are not covered by the program. These tests, including treatment for colorectal cancer, surgery, chemotherapy, radiation, and medications are not covered by the program. We will help you find agencies and/or providers who will work with you if you need more testing.

Ineligible Clients Low Risk - Under age 50 Script (No personal or family history): No Colorectal Cancer (CRC) Screening Recommended

You must be 50 to be eligible for the Michigan Colorectal Cancer Early Detection Program (MCRCEDP). Because you are less than 50 years of age and have no personal or family history of colorectal cancer or precancerous growths (polyps) or colorectal cancer symptoms, you are at low risk for colorectal cancer. We recommended that you talk to your provider about when you should be screened for colorectal cancer and decide which test is best for you:

- An at-home stool test every yearo Fecal Occult Blood Test (high sensitivity FOBT)o Fecal Immunochemical Test (FIT)

OR - Flexible Sigmoidoscopy every 10 years with a yearly FIT

OR - Colonoscopy every 10 years

Average Risk – Client, Aged 50 – 64: Ineligible for Program Script - No Enrollment

• You are not yet due for your next colorectal cancer screening,OR

• You have health insurance that covers colorectal cancer screening

You are not eligible for the colorectal cancer screening program. We recommend that you talk with your doctor about when you should be screened for colorectal cancer and decide which test is best for you:

- An at-home stool test every yearo Fecal Occult Blood Test (high sensitivity FOBT)o Fecal Immunochemical Test (FIT)

OR - Flexible Sigmoidoscopy every 10 years with a yearly FIT

OR - Colonoscopy every 10 years

Increased Risk – Client, Aged <50 years: Ineligible for Program Script - No Enrollment

• You have a personal history of CRC or precancerous polyps• You have a family history of CRC or precancerous polyps

You are not eligible for the MCRCEDP because you are less than 50 of age. Because of your personal/family history, you may need to begin screening for colorectal cancer before the age of 50. It is important to share your personal and family medical history with your provider anddecide when you should be screened for colorectal cancer.

High-Risk - Client, Aged? – 64 - Symptomatic Script: Ineligible for Program Script - No Enrollment (Recommend follow up and provide resources.)

You have been having some symptoms: e.g., unexplained belly pain, thinner stools (pencil-size), unexplained weight loss, ongoing changes in bowel habits such as diarrhea or constipation for more than two weeks, black or bloody stools/diarrhea, or blood from your rectum. These symptoms might be something simple such as hemorrhoids, but it could be an early warning sign of colorectal cancer. Please talk with your doctor about your symptoms. If you have no doctor, we will give you a list of doctors and community resources.

High Risk Category Script - Client, Aged? – 64: Ineligible for Program Script – No Enrollment (Recommend follow-up and give resources)

You shared that you have a history of inflammatory bowel disease (ulcerative colitis or Crohn’s disease), or personal/family history of a genetic or clinical diagnosis of familial adenomatous polyposis (FAP) or Lynch Syndrome (hereditary non-polyposis colon cancer/HNPCC) which is associated with a higher risk for colorectal cancer. You are not eligible for the MCRCEDP, but it is important that you be screened at the right times for colorectal cancer. We encourage you to talk to a doctor about your personal/family history and decide when you should be screened for colorectal cancer. If you do not have a provider, we will give you a list of providers and community resources.

Definitions of Commonly Used Terms:

Colonoscopy – A test that allows your doctor to look at the inside lining of the large intestine (rectum and colon). While you are “put-to-sleep” during the test, a lighted tube – like a long skinny flashlight - will be put in your “bottom” and moved along through your colon or bowel (gut). There is a camera on the end of the tube that the helps the doctor look at your entire gut/colon. If there are any polyps (mushroom-like growths), or anything that does not look normal, the doctor can remove it during the test. A colonoscopy may be completed for different reasons:

Diagnostic Colonoscopy- Colonoscopy following a positive FOBT. Surveillance Colonoscopy – A follow-up colonoscopy for people with a personal

history of pre-cancerous growths or colorectal cancer in order to reduce the riskof colorectal cancer developing.

Screening Colonoscopy – A colonoscopy that is performed as a screening test onperson without symptoms.

Polyps – Colon polyps are growths that develop in the colon or the rectum. The cause of most colon polyps is unknown.

Polyp Shape: • Pedunculated polyps: mushroom-like in appearance with a stalk.• Sessile polyps: flat and sitting on the surface of the intestine.

Crohn’s Disease – Crohn's Disease causes inflammation in the small intestine. Crohn's Disease usually occurs in the lower part of the small intestine, called the ileum, but it can affect any part of the digestive tract, from the mouth to the anus. The inflammation extends deep into the lining of the affected organ. The inflammation can cause pain and can make the intestines empty frequently, resulting in diarrhea. Crohn's Disease is an inflammatory bowel disease (IBD), the general name for diseases that cause inflammation in the intestines.

Colorectal Cancer – Cancer is an abnormal and uncontrolled growth of cells in the body. "Colorectal" refers to the colon and rectum, which together make up the large intestine. Colorectal cancer can originate anywhere in the large intestines. The majority of colorectal cancers develop first as polyps, abnormal growths inside the colon or rectum that may become cancerous. Colorectal cancer develops with few, if any, symptoms at first. However, if symptoms are present, they may include blood in or on the stool, a change in bowel habits, stools that are narrower than usual, general, unexplained stomach discomfort, frequent gas, pains, or indigestion, unexplained weight loss, chronic fatigue. These symptoms can also be associated with other health conditions.

Double Contrast Barium Enema – This test is an x-ray of the colon. An enema is given with liquid called barium. Then the doctor takes an x-ray. The barium makes it easy for the doctor to see the outline of the colon on the x-ray to check for polyps of other abnormalities.

Fecal Occult Blood Test/Fecal Immunochemical Test – Also called a FOBT/FIT and is an at-home stool test. The FOBT/FIT can find tiny amounts of blood that might be from an intestinal polyp or very early cancer. If blood is found an additional test will done to find out why the blood is there. The follow up test for a positive result on the stool test is called a colonoscopy.

Inherited Syndromes – There are inherited syndromes that may put an individual at a higher risk for colorectal cancer. Examples of inherited syndromes:

• Familial Adenomatous Polyposis or FAP: This is a syndrome that runs in families in whicha gene mutation can cause the development of colon, rectal or other cancers. Peoplewith FAP usually have a hundred or more of precancerous or benign polyps. Over time these polyps can become cancerous.

• Lynch Syndrome (Hereditary Non-Polyposis Colorectal Cancer/HNPCC) - This is aninherited disorder in which there is an increased tendency to develop colorectal cancerwithout a large amount of polyps. It is the most common hereditary cause of colon

cancer.

Screening Tests – Medical tests used to find colorectal cancer. Screening tests can find polyps before they turn into cancer. Screening tests can also find colorectal cancer early, when the chance of being cured is good. There are several screening tests that can be used to find polyps or colorectal cancer. Fecal Occult Blood Test, Flexible Sigmoidoscopy, Colonoscopy and Double Contrast Barium Enema are screening tests. Sometimes these tests are used in combination with each other.

Sigmoidoscopy (or Flexible Sigmoidoscopy) – A test in which a doctor passes a lighted scope (sigmoidoscope) through the anus in order to view the inner lining of the large intestine's terminal portions, known as the sigmoid colon and rectum. The test is often used to detect cancer or investigate gastrointestinal disorders. This test allows the doctor to look inside the anus, rectum, and the lower part of the large intestine (colon) for abnormal growths (such as tumors or polyps), inflammation, bleeding, hemorrhoids, and other conditions (such as diverticulosis). This test does not visualize the right side of the colon.

Stool – A medical word for poop or bowel movement.

Type of polyps: Two Major Classes of Polyps

• Serrated Polypso Hyperplastic Polyp (HP): Benign polyp, almost no malignant potentialo Sessile serrated polyp (synonymous with sessile serrated adenoma) (SSA/P) and

traditional serrated adenoma (TSA) TSAs are easy to detect SSA/P - 5X more likely to be incompletely removed due to indistinct

edges. Endoscopists may not realize the entire lesion has not beensnared. SSA/Ps maybe with or without cytological dysplasia. Less than10% of the SSAP’s have a dysplastic region and the remainder of thelesions looks like a typical SSA/P.

• Adenomas: Colon polyps that are considered precancerous. May cause no symptomsand should be removed during a colonoscopy before they turn into a colorectal cancer.

o Tubular, Villous or Tubulovillous: More serious type of polyp and frequentlysessile/flat. Sometimes difficult to remove and if removed in pieces, they mayrequire a second colonoscopy/sigmoidoscopy or surgery for total removal of thepolyp.

• Adenomatous polyps can be any one of the following: tubular, sessile serrated advancedadenoma, adenocarcinoma, traditional serrated adenoma, or other adenomatous.

Patient Navigation I. Definition of MCRCEDP Patient Navigation:

MCRCEDP patient navigation starts with the outreach and recruitment of eligible clients. It ensuresthat all eligible clients understand and receive appropriate and timely colorectal cancer educationand care, including screening, diagnostic services and referrals for treatment, when indicated,regardless of their ability to pay for such services. Patient navigation assists clients with completingscreening and diagnostic services by reducing barriers to quality care.

Possible barriers to the completion of CRC screening may include:o Transportationo Financialo Physical needso Trust (medical system/personnel)o Lack of symptoms (I feel fine)o Lack of physician referral (provider never told them about this screening)o Fatalistic view of cancer: cultural and personal beliefso Fear (procedure/cancer diagnosis)

III. Process of MCRCEDP Navigation:

The Local Coordinating Agency is responsible for providing navigation services to all MCRCEDPclients to ensure CRC screening completion and appropriate rescreening. Although many of thescreening and follow-up services are subcontracted with community providers, the agency remainsresponsible for overseeing the provision of timely services to MCRCEDP clients in the subcontractedcommunity clinics. Navigation can be completed by professional or paraprofessional staff within thelocal agency, according to his or her scope of practice.

The MCRCEDP has categorized PN interventions into the following categories:

A. Outreach & Recruitment:• Recruitment of eligible, underserved men and women for colorectal cancer screening.

B. Assessment and Enrollment:• Determine program eligibility (age, CRC risk, income, and insurance) and assist client

with completion of enrollment form as needed.• Document patient’s Primary Care Provider (PCP). If the client has no PCP, refer them to

a PCP as a part of the enrollment process.• Assess every client’s smoking history during MCRCEDP enrollment. The LCA staff will

refer all clients who are interested in smoking cessation to the Tobacco Quitline usingthe consolidated BCCCNP/MCRCEDP/WW fax form.

• Educate clients about colorectal cancer and risk appropriate screening.• Assess readiness for colorectal cancer screening.• Offer average risk clients screening test choice:

o Inform clients that MCRCEDP offers a colonoscopy for colorectal cancerscreening. Average risk clients have the option of an “at-home” FIT. Provideeducation for both screening options including screening intervals and the needfor a diagnostic colonoscopy for a positive FIT.

• During MCRCEDP enrollment, educate increased risk clients about the importance ofinterval appropriate screening by colonoscopy based on family or personal history.NEVER give an increased risk client a FIT; they must be screened by colonoscopy.

• Positive FIT/FOBT outside the program: Following MDHHS approval, average riskclients who have a positive FIT/FOBT outside the program AND meet MCRCEDPeligibility requirements may be enrolled in the MCRCEDP for a diagnostic colonoscopy. Referrals for a diagnostic colonoscopy must be made within two weeks of

program enrollment.• Documentation of the positive FIT outside the program must be entered

in MBCIS as a non-paid clinical service.

C. For Clients completing the FIT option:• Provide the client with education on how to complete the FIT• Assess the actual or potential barriers that might interfere with FIT completion.• Assist patients with overcoming identified barriers through education, referral and/or

acquisition of additional resources.• Track the timely completion the FIT kit, communicating with clients as needed.• For clients with negative FIT results: Communicate the screening result and next

screening interval to the client.o Complete the FIT Intake Form documenting the completeness of the test,

results, and next recommended screening interval.• For clients with positive FIT results:

o A referral for a diagnostic colonoscopy must be made within two weeks of thepositive FIT results. The FIT Intake Form must be sent via fax to MDHHSindicating a referral was made for a diagnostic colonoscopy.

o If, after multiple attempts to contact a client or schedule the procedure, theclient declines services or the LCA is unable to reach the client to schedule thediagnostic colonoscopy, a certified letter will be sent to the client terminatingprogram enrollment.

D. For Clients completing a Screening, Surveillance or Diagnostic Colonoscopy:• Schedule colonoscopy services with subcontracted agencies.• Provide information about the colonoscopy and prep and/or coordinate with

subcontracted agencies to assure the client receives this information.

• Assess the actual or potential barriers that interfere with colonoscopy completion.• Assist patients with overcoming identified barriers through education, referral and/or

acquisition of additional resources.• Implement psychosocial interventions with the client or family members (i.e.

counseling, active listening and empathy) to assist in problem solving.• Use a tracking and reminder system to ensure timely delivery and completion of clinical

services.• Communicate colonoscopy results and next screening interval to the client.• All complications either during the procedure or within 30 days of the procedure must

be reported to MDHHS within 21 days of the event.• Clients with abnormal screening results (positive FIT) must receive a final diagnosis

within 90 days of the screening test (or enrollment in the program if the FIT wascompleted outside of the program).

• Documentation:o Complete a Colonoscopy Intake Form, documenting test completeness, results,

next screening interval or recommended procedure and final diagnosis. It isimperative for the client to understand current screening results and theimportance of future screening/surveillance recommendations for theprevention of colorectal cancer. Enter data in MBCIS.

o Upon completion of the colonoscopy, obtain and fax the following to MDHHSwithin one week of receipt: pathology reports, final colonoscopy report, and ifindicated, any reimbursable MCRCEP services including office visits, EKG and labwork, if ordered. Screening results, any follow-up testing and the next screeninginterval must be documented and communicated with the client.Documentation of this communication between the provider and/or LCA withthe client must be faxed to MDHHS.

E. Treatment and Follow-up services not paid for by the program:• Facilitate timely referrals to and appropriate use of community resources for any

necessary follow-up services or treatment of colorectal cancer.• Treatment for cancer must be started within 60 days of diagnosis. All clients must be

provided assistance obtaining providers, and the necessary resources for cancertreatment.

F. Re-Screening• Educate clients on the importance of timely rescreening/surveillance.• Educate clients about the next screening interval.• Utilize client reminders to promote adherence to screening intervals.

G. Ineligible clients:• Develop a plan for the referral of clients who are ineligible for the MCRCEDP, to

providers and community resources.

H. Insurance referrals:• Refer all uninsured or underinsured clients:

o Refer all clients <138% of the Federal Poverty Level to the Healthy Michigan Plan.o Encourage all MCRCEDP clients >139% - 250% of the Federal Poverty Level to obtain

health insurance through the Health Insurance Marketplace. Refer interested clientsto a Patient Navigator at Enroll Michigan or the Health Insurance Marketplace.

• Document insurance referrals in MBCIS.

III. Documentation of Patient Navigation Services

Appropriate documentation of MCRCEDP services must be submitted to the Cancer Prevention andControl Section of the Michigan Department of Health and Human Services (MDHHS). MCRCEDPservices will not be considered complete until data is entered in the MCRCEDP database (MBCIS).

IV. MDHHS Responsibilities• MDHHS staff will review data submitted by agencies and complete any required data entry

authorized by MDHHS.• MDHHS will notify the MCRCEDP Coordinators when data is available for review through the

secure file transfer system.• It is the responsibility of the LCA to ensure completeness of data entry in MBCIS and accuracy of

caseload count.

OC Light FIT Kits Polymedco’s OC-Light® S FIT kits is an optional CRC screening test for average risk clients enrolled in the Michigan Colorectal Cancer Early Detection Program (MCRCEDP).

• All eligible clients may choose to be screened for colorectal cancer through the MCRCEDPby completing a colonoscopy.

• Average risk clients may choose a colonoscopy or an at-home test OC-Light® S FIT.

For clients choosing an at-home CRC screening:

Patient must be instructed to immediately return the sample bottle (with stool) in the specially provided, self-addressed envelope (found in the kit). The manufacturer recommends that collected stool samples are only stable for these specified times:

• Bottle with stool sample may be stored at room temperature for up to 15 days• Bottle with stool sample may be refrigerated at 2-8°C for up to 30 days.

More information about the OC-Light® S FIT kit may be found on the Polymedco website. Patient instruction video for the OC FIT testing procedure:

• http://www.polymedco.com/products.php Click this photo on the Polymedco website

See how FIT-Check is saving lives: Patient video from Kaiser Permanente

Patient instruction sheets for the OC Light FIT kits are available in the following languages:

English Chinese--traditional Hmong Portuguese Arabic Tagalog Somali Somoan Hindi Russian Cantonese French Haitian Spanish Vietnamese Russian Polish

Copies of the patient instruction sheets for the OC FIT in various languages may be found on the MCRCEDP website: http://www.michigancancer.org/colorectal/LocalAgencyInformation/Forms.html

Package Insert for Personal Use Kit Read all package insert directions carefully before sample collection. Test results may be invalid if test is not performed properly.

Sample Deposit

1. Place supplied collection paper inside toilet bowl on top of water.2. Deposit stool sample on top of collection paper.3. Collect sample from stool before paper sinks and stool sample touches water.4. Flush. Collection paper is biodegradable and will not harm septic systems.

Sample Collection

1. Fill in all required information on the sampling bottle.

Open green cap by twisting and lifting.

2. Scrape the surface of the fecal sample with the sampling probe.

Cover the grooved portion of the sampling probe completely with stool sample.

3. Close sampling bottle by inserting the sampling probe and snap green cap on tightly. Donot reopen.

Return the sampling bottle to your doctor or laboratory in envelope provided. Please do not mail to Polymedco.

Fecal Immunochemical Test (FIT) Kit

PATIENT INSTRUCTIONS

MCRCEDP

June 2019

1. Remove sample bottle from kit and labelwith your first name, last name, and date ofbirth.

2. Place collection paper inside toilet bowl ontop of water. Poop on top of the collectionpaper.

3. Open green cap by twisting and lifting.Do not empty liquid in sample bottle out.

4. Scrape the surface of the poop with thecollection stick. Cover the tip of thecollection stick with a small amount of poop.

5. Close the sample bottle by inserting thecollection stick into the sample bottle andtwist the green cap on tightly.

6. Flush the collection paper and the rest ofthe poop down the toilet.

7. Place the sample bottle into the plastic bagwith the absorbent pad inside and seal thebag.

8. Return the sample bottle to the clinic siteor if postage is provided mail the samplebottle.

Alberta Health Services. 2018. Laboratory Patient Collection Instructions: Fecal Immunochemical Test (FIT). Retrieved from https://www.albertahealthservices.ca/assets/wf/lab/wf-lab-fit-patient-collection-instruction-sheet.pdf

University of California, San Francisco Departments of Pathology and Laboratory Medicine. 2018. Colon Cancer Stool Screening Kit Instructions. Retrieved from http://labmed.ucsf.edu/labmanual/db/resource/FOBT-PatientInstructionsEnglish.pdf

Michigan Colorectal Cancer Early Detection Program

AGREEMENT FOR PROGRAM PARTICIPATION

The (agency) offers the Michigan Colorectal Cancer Early Detection Program (MCRCEDP, also referred to as the “program”). This screening program, supported by the Federal Government and the Michigan Department of Health and Human Services, is part of a national plan to increase colorectal cancer screening among people who are uninsured or underinsured and not currently enrolled in the Healthy Michigan Plan.

Purpose of This Program The purpose of the MCRCEDP is to prevent or find out if I have colorectal cancer. Colorectal cancer is cancer of the of the colon or the rectum (large intestine or gut). Regular cancer screening tests can help prevent cancer by finding and removing polyps before they can become cancer. Regular screening can also find cancer that may be present when it is still very small and easier to treat. Finding cancer before it spreads to other parts of the body increases the chance for survival.

If I meet program eligibility requirements, I can receive one of the two services below, depending on my current risk for colorectal cancer The MCRCEDP staff will determine my risk for colorectal cancer.

1. Fecal Immunochemical Test (FIT kit)

• I can choose a FIT kit if I am at average risk for colorectal cancer.

• I complete this test at home.

• A FIT kit checks for blood in my stool (poop) that I may not be able to see with my eyes.

• Blood in my stool is not normal. It can be there because of cancer or other problems.

• If the FIT kit finds blood in my stool, I will need to have a colonoscopy to find out why thereis blood in my stool.

2. Colonoscopy

• I can choose a colonoscopy if I am at average risk for colorectal cancer.

• If I am at increased risk for colorectal cancer, a colonoscopy is my only option in theprogram to test for colorectal cancer.

• I will go to a surgery center or hospital to complete this test.

• A colonoscopy is a procedure that allows a doctor to look at the inside lining of my rectumand colon. If there are any polyps (mushroom-like growths that can cause colorectalcancer), the doctor can remove them during the procedure.

Program Eligibility: (Initial ) 1. I am between the ages of 50 and 642. My household income is at or below 250% of federal poverty level3. One of these three statements about my health insurance is true:

• I do not have health insurance OR• My health insurance DOES NOT pay for colorectal cancer screening OR• My health insurance has a large deductible that I cannot afford

4. If I get insurance after I’ve enrolled in the program, I will notify the MCRCEDP agency andaccurately report this information, because it may change my eligibility.

• If I report my change in insurance status, the MCRCEDP may be able to work with theinsurance company to pay any costs the insurance company does not cover

• If I fail to report a change in insurance status that makes me ineligible, I will beresponsible for the costs that result from any program services I receive

Notification of Test Results and Follow-Up for Any Abnormal Results: (Initial ) 1. I give permission for MCRCEDP staff to obtain my test results.2. The MCRCEDP staff will inform me of the results of these screening tests and of any

additional follow-up services that may be needed. Follow-up services are needed when acolorectal cancer screening result is considered abnormal (not normal).

3. It is my choice whether or not to follow the recommendations for follow-up of any teststhat are considered abnormal.

4. If any screening test shows something that is considered abnormal, the MCRCEDP agencywill help me schedule follow-up services through health care providers participating in theprogram.

Services Paid by the MCRCEDP: (Initial )

1. The program will pay for a FIT kit if I am at average risk for colorectal cancer. If blood isfound in my stool (poop), I will need a colonoscopy. The MCRCEDP agency staff will helpschedule the colonoscopy and the program will pay for this follow-up procedure.

2. The program will pay for a colonoscopy and “prep” to clean out my colon (gut) before theprocedure.

3. The program will pay for biopsies (tissue removed during colonoscopy) and to have polyps(small mushroom-like growths that can cause cancer) removed during the colonoscopy, ifneeded.

4. The program will pay for anesthesia (medication that “makes me sleep”) during thecolonoscopy.

Services NOT Paid by the MCRCEDP: (Initial )

1. It is possible my health care provider in the MCRCEDP may recommend other follow-upservices, such as tests, exams, or procedures.

• MCRCEDP will only pay for pre-approved follow-up services.

• If I choose to have the follow-up services not approved by the program, and I cannotafford to pay for them, the MCRCEDP agency will work with me to help find a way topay for the follow-up services (This may include finding financial assistance or settingup a payment plan with the health care provider).

2. The MCRCEDP does not pay for any treatment services for colorectal cancer.

• If colorectal cancer is diagnosed, the MCRCEDP agency will refer me to a health careprovider who specializes in colorectal cancer to get the cancer treatment I need(Treatment may include surgery, chemotherapy, and/or radiation).

• The MCRCEDP agency will help me find a way to pay for treatment. When possible,they will find public or private funds to pay for the full cost of my treatment.

Confidentiality: (Initial ) 1. Any personal information obtained about me will be treated as confidential.2. Signing this form grants permission for the program health care providers who care for me

to share my information and test results with MCRCEDP staff. (Continued on next page)

3. Information about me that does not identify me will be used in grouped reports or forother reporting purposes concerned with controlling colorectal cancer.

4. I may be asked sometime in the next several years to answer questions about mycolorectal health, or my experiences with this screening program. I understand I am notrequired to answer such questions. If I choose to do so, I do not have to identify myself.

Program Participation: (Initial __________)

• Provide the MCRCEDP agency and staff administering the program with informationabout me, including my health history and reports of screening, follow-up tests, andprocedures.

• Allow the MCRCEDP staff to assist me as needed in obtaining colorectal cancer screeningservices.

• Have the MCRCEDP staff contact me in the method I prefer (phone or email) and leave amessage for me about my care.

• Allow the MCRCEDP staff to give information regarding my care to:o My health care providero Any health care provider helping with my careo Any clinic or hospital to which I may be referredo Any other individual or agency designated by me

Program Services I Agree To: (Initial )

□ Follow the MCRCEDP agency recommendation and complete the FIT Kit.

□ Follow the MCRCEDP agency recommendation and complete colonoscopy.

• I understand I will be contacted when it is time to schedule my next screeningappointment.

• I agree to repeat these screening tests at the times recommended by the MCRCEDPagency.

• I understand I will be contacted if more testing or appointments are necessary.

This program has been explained to me and my questions have been answered. Based on my understanding of this colorectal cancer screening and follow-up program, I have decided to participate and wish to enroll.

The MCRCEDP agency phone number is ( /________-___________).

Signature of Client Date

Michigan Colorectal Cancer Early Detection Program

(MCRCEDP) ENROLLMENT FORM

Enrollment Site or Clinic Name: ______________________________ Date: ____________________ Client Contact Information – Please PRINT

Last Name * First Name * M.I.

Maiden Name Date of Birth *

Gender Identity □ Male □ Female □ Prefer Not to Answer □ Other ____________________

Street Address

Social Security # Apt. # PO Box

City State * Zip Code

County * Preferred Language

Phone Number * ( ) Ext. * □ Home □ Work □ Cell □ Other __________

Alt Phone # ( ) Ext. □ Home □ Work □ Cell □ Other ____________

Email Address

Race & Ethnicity * Are you Hispanic or Latino? □ Yes □ No □ Unknown □ Prefer Not to Answer

□ White □ Black/African American □ Asian □ American Indian/Alaskan Native □ Unknown/Did not Answer□ Native Hawaiian/Other Pacific Islander □ Arab/Middle Eastern □ Prefer Not to Answer □ Other ______________________

Household Members & Income * (Must be completed for program eligibility)

* Client Yearly Income * Number of people that the client’s yearlyincome supports (including client)

Relationship Status □ Single □ Married □ Separated □ Divorced □ Widowed □ Partner □ Other _________________

Employment Status: □ Full-time □ Not Employed □ Part Time □ Retired □ Prefer Not to Answer □ Other ________________

Level of Education: □ Less than high school □ High school graduate □ Some college □ College graduate □ Prefer Not to Answer

Provider (Primary Care) Information

Do you have a regular Primary Care Provider (doctor/nurse practitioner/clinic)? □ No* □ Yes – fill out information below * If NO, client MUST BE provided with referral resources for enrollment with a PCP.May we send results of your tests to your Primary Care Provider(s)? □ Yes □ No □ Other ______________________________

Provider Name

Address

Phone

INSURANCE INFORMATION (bring ALL cards with you) – Please copy both sides of card(s) & retain in patient medical record.

□ None □ Insurance Name:

Contract #: Group # Insurance Deductible Amount: $

HOW DID YOU LEARN OF THE PROGRAM? □ Primary Care Doctor □ TV/Radio □ Family/Friend □ 2-1-1 Website

□ Google/Other web search □ Other ________________________________________

□ Yes □ No Referral to HMP/Medicaid Expansion □ Yes □ No Referral to Marketplace Insurance

Comments:

MBCIS #

____________

Michigan Colorectal Cancer Early Detection Program

(MCRCEDP) MEDICAL HISTORY Clint Name: _____________________________________ Date: ________________

Signature of person filling out this form: _______________________

MEDICAL HISTORY (Staff must Review this Section with Client)

Have you ever had any of the following colorectal screening tests: Yes No Unknown

TEST DATE (MM/DD/YYYY) RESULTS (check one)

At home FOBT / FIT / Cologuard / / Normal/Negative Abnormal/PositiveUnknown

Colonoscopy / / Normal Polyp(s)/Tumor(s)/CancerUnknown

Sigmoidoscopy / / Normal Polyp(s)/Tumor(s)/CancerUnknown

Double Contrast Barium Enema (DCBE) / / Normal Polyp(s)/Tumor(s)/CancerUnknown

Other _______________ / / Normal Polyp(s)/Tumor(s)/CancerUnknown

Have you ever been told by a Health Professional that you have: Crohn’s Disease Familial Adenomatous Polyposis (FAP) Lynch Syndrome (HNPCC) Inflammatory Bowel Disease (IBD)

Ulcerative Colitis

Yes No Unknown Yes No Unknown Yes No Unknown Yes No Unknown Yes No Unknown

Have you ever been told you have/had colorectal cancer? Yes No Unknown If yes, Date of Diagnosis? (MM/DD/YYYY) _____/_____/______ Age:___________

Have you ever been told you have/had colorectal polyps? Yes No Unknown If yes, Date (MM/DD/YYYY): _____/_____/_______ Were any of the polyps precancerous? Yes No Unknown

Do you have an immediate family member who has ever been diagnosed with colorectal cancer, or precancerous polyps? Yes No Unknown1) Please check relative: Mother Father Sister Brother Child Other: _______________

Relative(s) Age at Diagnosis: _________ Colorectal Cancer Precancerous Polyps2) Please check relative: Mother Father Sister Brother Child Other: _______________

Relative(s) Age at Diagnosis: _________ Colorectal Cancer Precancerous Polyps3) Please check relative: Mother Father Sister Brother Child Other: _______________

Relative(s) Age at Diagnosis: _________ Colorectal Cancer Precancerous Polyps

Are you currently experiencing any of the following? If YES, the client is not eligible for the screening program.

Rectal Bleeding (in the past six months)? Yes No Unknown Blood in your stool (in the past six months)? Yes No Unknown Diarrhea (lasting more than 1-2 weeks)? Yes No Unknown

Constipation (lasting more than 1-2 weeks)? Yes No Unknown Unexplained weight loss? Yes No Unknown

Lower abdominal pain? Yes No Unknown

Comments:

TOBACCO HISTORY: Do you use any tobacco or smokeless tobacco products? □ Every Day □ Some Days □ Not At All

Interested in quitting tobacco? □ Yes □ No □ I Don’t use Tobacco Michigan Tobacco QuitLine Referral (FAX sent) □ Yes □ No

PROGRAM STAFF USE ONLY: Scheduling: Indication for this test: Screening Surveillance Diagnostic (MDHHS Authorization)

Test: At home FIT Colonoscopy Other ___________________

Date FIT kit distributed to client: (MM/DD/YYYY) _______/_______/___________

** MUST complete a FIT or Colonoscopy Intake Form **

MBCIS #

____________

Referral to the Healthy Michigan Plan (HMP) or Health Insurance Marketplace (ACA)

Clients enrolling in the MCRCEDP must be low income (≤ 250% of the Federal Poverty Level). During the MCRCEDP client assessment and enrollment, the LCA staff will encourage clients to obtain health insurance available to them and promote “whole body health:

• Clients ≤ 138% of the Federal Poverty Level must be referred to Enroll Michigan or MI Bridgesfor enrollment in the Healthy Michigan Plan (HMP/ Medicaid Expansion).

• Clients eligible for HMP, but not enrolled, may receive MCRCEDP services.• The referral of the client to the HMP must be noted on the MCRCEDP Enrollment Form and

documented in MBCIS (snapshots of both documents below).o Clients who are not currently insured by the Healthy Michigan Plan are eligible for the

MCRCEDP.

NOTE – HMP Referral:

NOTE – Marketplace Referral: • Clients 139% - ≤ 250% of the Federal Poverty Level are eligible for the MCRCEDP if all other

MCRCEDP eligibility criteria are met.o Clients with incomes 139-250% of the Federal Poverty Level should be referred to a

Patient Navigator at Enroll Michigan or the Health Insurance Marketplace for assistancewith obtaining health insurance.

A referral to the HMP must be checked on the bottom of page1 on the MCRCEDP Enrollment Form

PATIENT FAX REFERRAL FORM Fax to: 1-800-261-6259

Today’s Date ____________________

Use this form to refer patients who are ready to quit tobacco in the next 30 days to the Michigan Tobacco Quitline.

Provider name Contact Name

Clinic/Hosp/Dept E-mail

Address Phone ( ) -

City/State/Zip Fax ( ) -

Does patient have any of the following conditions: pregnant uncontrolled high blood pressure heart disease

If yes, please sign to authorize the Michigan Tobacco Quitline to send the patient free, over-the-counter nicotine replacement therapy if available. If provider does not sign and the patient has any of the above listed conditions, the Michigan Tobacco Quitline cannot dispense medication.

Provider Signature

Please Check: Patient agreed with clinician to be referred to the Michigan Tobacco Quitline.

_____ Yes, I am ready to quit and ask that a quitline coach call me. I understand that the Michigan Tobacco Quitline will inform

Initial my provider about my participation.

Best times to call? morning afternoon evening weekend

May we leave a message? Yes No

Are you hearing impaired and need assistance? Yes No

Date of Birth? / / Gender M F

Patient Name (Last) (First)

Address City State

Zip Code E-mail

Phone #1 ( ) - Phone #2 ( ) -

Language English Spanish Other

Patient Signature Date

PLEASE FAX TO: 1-800-261-6259 Or mail to: Michigan Tobacco Quitline., c/o National Jewish Health®, 1400 Jackson St., S117A, Denver, CO 80206

Confidentiality Notice: This facsimile contains confidential information. If you have received this in error, please notify the sender immediately by telephone and confidentially dispose of the material. Do not review, disclose, copy or distribute.

PROVIDER(S): Complete this section

PATIENT: Complete this section

Michigan Colorectal Cancer Early Detection Program (MCRCEDP)

Fecal Immunochemical Test (FIT) - Intake Form

Last Name: _______________________________ First Name: _________________________

LCA Name: _______________________________ MBCIS ID: _________________

FIT Distribution Date (MM/DD/YYYY): _______/_______/___________

2. Screening Adherence: Test Performed/Complete No Test Performed:

FIT kit not returned Client refused Lost to follow-up

3. Screening Completed: Negative FIT Recommended test:

*FIT*Rescreen in 1 year – offer CRC screening options

Positive FIT Recommended test: Diagnostic ColonoscopyReferral date: _______/_______/______________

*Must Complete Colonoscopy Intake form*

Positive FIT / DiagnosticColonoscopy not Performed

Client refused Appointment(s) not kept Client lost to follow-up Certified letter sent to client informing

him/her of results and the need for follow-up or program termination will occur.(MM/DD/YYYY): ______/______/____________

Select the specialty of the person who distributed the FIT Kit (check one):

General Practitioner NP (Nurse Practitioner) Family Practitioner PA (Physician Assistant) Internist Administrator, if FIT is mailed by non clinician LPN (License Practical Nurse) OB/GYN RN (Registered Nurse) Unknown

Completed by: _______________________________________ Date: ____________________

1. FIT Information:

Date FIT Processed: (MM/DD/YYYY): _______/_______/___________ * Note * This will also be the Date of Service (DOS) used for billing purposes

Michigan Colorectal Cancer Early Detection Program (MCRCEDP)

Colonoscopy Intake Form (Must complete one form for each procedure needed to reach a Final Diagnosis)

NOTE: Attach copies of all reimbursable CRC services including: office visit, colonoscopy report, pathology, laboratory, and EKG

Last Name: _______________________________ First Name: _________________________

LCA Name: _______________________________ MBCIS ID: _________________

Procedure Date (MM/DD/YYYY): _______/_______/___________

1. Colonoscopy Information:Pre-Colonoscopy Office Visit (MM/DD/YYYY): _______/_______/______________

Was patient cleared for colonoscopy? Yes No if No, reason:____________________ Date of test (MM/DD/YYYY): _______/_______/___________ Colonoscopy Sigmoidoscopy (MDHHS authorization required) DCBE (MDHHS authorization required) Other: __________________

Physician performing the procedure: _________________________________________ Specialty of Physician performing the procedure:

Was the cecum reached? Yes No

Was bowel prep considered adequate? Yes No *Procedure should be

rescheduled*

If bowel prep was inadequate, has procedure been rescheduled? Yes – Date (MM/DD/YYYY):

_____/_____/______ If No, reason:

_______________________

General Practitioner Internist Family Practitioner Radiologist

Gastroenterologist General Surgeon Colorectal Surgeon

Completeness of Test and Test Results: Test is complete and adequate with: Normal/Negative/Diverticulosis/Hemorrhoids Polyp Lesion suspicious for cancer Other finding (not suggestive of polyps/cancer)

___________________________________

Test is incomplete or inadequate with:

No finding Polyp/Polyp fragments Lesion suspicious for cancer Other finding:

__________________________(Note: Incomplete test should be repeated)

Report any complications during or within 30 days of the procedure requiring observation or treatment. Date of complication (MM/DD/YYYY):______/______/_______

(Must be reported to MDHHS within 21 days)

No complications reported Bleeding requiring transfusion Bleeding not requiring transfusion Cardiopulmonary event Complications related to anesthesia

Bowel perforation Post-polypectomy syndrome/excessive

abdominal pain Death Other: __________________________

Michigan Colorectal Cancer Early Detection Program (MCRCEDP)

Colonoscopy Intake Form (Must complete one form for each procedure needed to reach a Final Diagnosis)

NOTE: Attach copies of all reimbursable CRC services including: office visit, colonoscopy report, pathology, laboratory, and EKG

Last Name: _______________________________ First Name: _________________________

LCA Name: _______________________________ MBCIS ID: _________________

2. Polyp/Lesion Information from Endoscopic Biopsy or Surgery to Complete Diagnosis(Must be completed if biopsy, polypectomy or surgery is performed)

Was a biopsy or polypectomy performed? *Yes No *If biopsy or polypectomy performed, include pathology report and medical dictationNumber of specimens sent to pathology: __________________

Were all polyps completely removed? Yes No

Histology of most severe polyp/lesion: Normal or other non-polyp histology Non-adenomatous polyp Hyperplastic polyp Adenoma, NOS (no high grade dysplasia noted) Adenoma, tubular (no high grade dysplasia noted) Adenoma, mixed tubular villous (no high grade dysplasia noted) Adenoma, villous (no high grade dysplasia noted) Adenoma, serrated (no high grade dysplasia noted) Adenoma with high grade dysplasia (includes in situ) Adenocarcinoma invasive Cancer, other Unknown/other lesions ablated, not retrieved or confirmed

Adenomatous Polyp/Lesion Information (Complete if any of the shaded histologies above are indicated)Total number of adenomatous polyps/lesions:

Less than 97: Enter the number ______ 97 or more adenomatous polyps/lesions Adenomatous polyps removed, exact number unknown

Size of largest adenomatous polyp/lesion: __________ cm

3. Surgery to Complete DiagnosisDate of surgery: (MM/DD/YYYY) _____/_____/__________ Surgery recommended, but not performed

Facility:__________________________________________________

Michigan Colorectal Cancer Early Detection Program (MCRCEDP)

Colonoscopy Intake Form (Must complete one form for each procedure needed to reach a Final Diagnosis)

NOTE: Attach copies of all reimbursable CRC services including: office visit, colonoscopy report, pathology, laboratory, and EKG

Last Name: _______________________________ First Name: _________________________

LCA Name: _______________________________ MBCIS ID: _________________

4. Next Steps (Must be completed) Screening/Surveillance/Diagnostic Completed – (Go to Final Diagnosis Section)

Next Screening test in _____ months Next Surveillance test in ______months

Recommended test: Screening: Any recommended CRC

screening test Surveillance: Colonoscopy

Screening/Diagnostic incomplete Recommended test: Colonoscopy Sigmoidoscopy (MDHHS authorization

required) DCBE (MDHHS authorization required) Surgery to complete diagnosis Other:________________________

5. Status of Final Diagnosis (Must be completed within 90 days of screening exam) Completed: Date of the Final Diagnosis: (MM/DD/YYYY) ______/______/__________

Pending, additional tests needed Client refused diagnostic testing Client lost to follow-up/deceased Certified letter sent to client informing him/her of results and the need for follow-up or

program termination will occur.Date: (MM/DD/YYYY) ______/______/__________

6. Final Diagnosis Normal/Negative Hyperplastic Polyps Adenomatous polyp, no high grade dysplasia Adenomatous polyp with high grade dysplasia Cancer (Complete Cancer Treatment Information) New CRC Cancer Recurrent CRC Cancer Non-CRC Cancer

Completed by: ________________________________ Date: ______/______/_______

Michigan Colorectal Cancer Early Detection Program (MCRCEDP)

Colonoscopy Intake Form (Must complete one form for each procedure needed to reach a Final Diagnosis)

NOTE: Attach copies of all reimbursable CRC services including: office visit, colonoscopy report, pathology, laboratory, and EKG

Last Name: _______________________________ First Name: _________________________

LCA Name: _______________________________ MBCIS ID: _________________

7. Cancer Treatment Information• Must be completed if Final Diagnosis = Cancer• Treatment must be started within 60 days of diagnosis

Treatment start date: (MM/DD/YYYY) ______/______/__________

Treatment pending, additional tests needed Treatment started Treatment not indicated due to polypectomy Treatment not recommended Treatment refused Lost to follow-up

Additional treatment planned: Chemotherapy Radiation Surgery Other: ______________________

Completed by: ________________________________ Date: ______/______/_______

Secured Application User Agreement Access Form

As a user of one, two or all three (BCCCNP, WW, and MCRCEDP) I accept and agree to the following: • I will handle information or documents obtained through all Secured Program Applications in a confidential manner. • I will restrict my use of Secured Program Applications to accessing information and generating documentation only as

necessary to properly conduct the administration and management of my duties as they relate to all the relevantprograms.

• I understand that my transactions on MBCIS are logged and subject to being audited. • I will not furnish information or documentation obtained through Secured Program Applications to individuals for

personal use nor to any individuals not directly involved with the conduct of my duties as they relate to all therelevant programs.

• I will not alter or falsify any document or data obtained through the Secured Program Applications. • I will not attempt to copy all or part of the database or the software used to access the Secured Program Applications in

any unauthorized fashion. • I will carefully safeguard my access privileges and password for MILogin and will not permit the use of my access

privileges by any other person. • I will report any threat to or violation of the Secured Program Application security. • I will strive to enter accurate and timely data into the MBCIS.

User Information (Please print): Please select one of the following options and complete the information below:

New access to the following Applications Update my current access Discontinue my current accessMBCIS DCH File Transfer

□□□ BCCCNP Clinical □□□ WISEWOMAN □□□ Wise Choices □□□ Colorectal (MCRCEDP)

□□□ BCCCNP Clinical VIEW ONLY □□□ WISEWOMAN VIEW ONLY □□□ Colorectal VIEW ONLY

** Applications requiring additional “Subscribe to Application” process Discoverer DCH-File Transfer DCH Cancer Mapper

_ MILogin ID

Full Name EMAIL

Job Title Local Coordinating Agency

( _) ( _) Telephone Number Fax Number

I have read the above security agreement and the prohibited acts provided on the reverse side of this form. I understand this information, and I agree to comply with the above provisions. Further, I understand any violation of these provisions may result in termination of access privileges and/or recommendation for prosecution.

Date User’s Signature

Supervisor’s Name (Print) Supervisor’s Signature Date

REMINDER – There are 2 STEPS!! You must SUBSCRIBE TO

APPLICATIONS and select Michigan Breast and Cervical Cancer Control System before

you will be given access to MBCIS.

Please fax completed form to Tory Doney

Fax # (517) 763-0290 ** THIS FORM EXPIRES 12/31/2019 **

* Name - as you would like it to appear in MBCIS (Example: John A Smith, MD OR Smith Pathology, PC)

BILLING CONTACT INFO to receive PAYMENT DETAIL REPORTS (EOBs)

** Please remember to include your LCA ID, Billing Start Date, and LCA Coordinator Signature **

* SIGMA Vendor ID ~ 9 digits ~ SIGMA Address ID MBCIS Provider ID

SIGMA Information --- to be filled out by MDHHS Staff

* Contact Name (1) Contact Email Address (1)

Phone # with area code (1) Phone Ext. * Fax # with area code (1)

NPI ~ 10 digits ~

Contact Email Address (2)

* Federal Tax ID ~ 9 digits ~

Termination Date

Phone Ext.

** LCA Coordinator Signature:** Billing Start Date

* Contact Name (2)

Phone # with area code (2)

LCA

Information

** LCA ID

&

Fax # with area codePhone # with area code

Check ONE □ NEW □ CHANGE □ TERMINATION

City

Suite # or P.O. Box #Address (physical address)

* State

Check all that apply □ BCCCNP □ WISEWOMAN/Wise Choices □ Colorectal (MCRCEDP)

PROVIDER/FACILITY Information

* County

INSTRUCTIONS: This form needs to be completed for each Provider and/or Facility that participates in the

BCCCNP, WW, and MCRCEDP - including local health departments and sub-contracted providers.

All bolded fields must be completed.

Billing Info MUST be on file with the State of Michigan Budget Office (Vendor Self-Service)

www.michigan.gov/SIGMAVSS For more information regarding VSS, call 517-636-5270.

Does the Provider use a CLEARINGHOUSE for electronic submission of claims?? □ NO □ YES

If YES please provide Clearinghouse Name: __________________________________________

Check all that apply □ Facility □ Enrollment Site

Zip Code

Phone Ext. * Fax # with area code (2)

LCA: Please fax completed forms to Tory Doney @ Fax # (517) 763-0290

MCRCEDP – FAX TRANSMISSION

Date: _________________

Secure FAX: Kanika Lewis (517) 763-0290

IMPORTANT Fax required documents to MDHHS:

Enrollment forms:o On all clients receiving a colonoscopy INCLUDING positive (+) FIT

from outside the MCRCEDP.

FIT Intake Forms (only positive FITs)

Colonoscopy Intake Forms - ALL

Colonoscopy Reports – Final Report requested

Pathology Reports – ALL

Office Visits – ALL

Labs, EKG, other

Authorized CRC reimbursable services; e.g., anesthesia record

Follow-up letter/s to client with screening results (Provider and LCA)

Recommendation for the client’s next CRC screening test and recommendedinterval. (Provider and LCA)

Provider – Claim Submission and Reimbursement

The Michigan Department of Health and Human Services (MDHHS) must authorize all Michigan Colorectal Cancer Early Detection Program claims prior to reimbursement.

Only approved CPT and revenue codes for the MCRCEDP will be paid • MCRCEP Billing Claims Quick List

Electronic Claim Submission Requested: Please submit all MCRCEDP claims electronically to the State of Michigan

• Payer ID D00111 and Application ID 5495.• Electronic claim submission can be found by clicking here.

Paper claims accepted:

MDHHS - Claims 109 Michigan Ave WSB, 5th Floor Lansing, MI 48933

If you have not received a payment or rejection of a claim within 60 days please call Toll-free: (866) 930-6324 or fax a copy of your claim to (517) 763-0290 to status your claim.

A copy of the following reports or completed service must be sent to the Local Coordinating Agency (LCA) to ensure prompt payment of MCRCEDP claims.

Required documents include: • Final Colonoscopy Report• Recommendation for next CRC screening interval• Pathology Reports• Reimbursable MCRCEDP services: office visits, EKG, and lab work.• Post colonoscopy communication with the patient:

o Letter with results/next screening interval

All direct service claims must be billed through MDHHS for claims processing. The LCA and/or direct service providers with contracts or letters of agreement with the LCA will be responsible for billing.

Service(s)

Entered &

Auth'd in

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82274 45378 88305 99213 93000 80048 00811 AA 99152 74270 4533045380 93005 80053 00811 AD 99153 7428045381 93010 82962 00811 QK 9915645382 93040 85025 00811 QX 9915745384 93041 85027 00811 QY G050045385 93042 85730 00811 QZ4538845390 00812 AAG0105 00812 ADG0121 00812 QK

00812 QX00812 QY00812 QZ

00810 + modifiers valid 10/01/2017 through 12/31/2017

FIT & Pathology

Office Visits

Ambulatory

Surgical

Centers (ASCs)

Only 1 (ONE) office visit (CONSULT) is payable on any given date of service …

Procedure

codes (CPT)

that will be

paid … if billed

CORRECTLY by

the provider(s)

** REMINDER**

- ALL services must be billed with MCRCEDP-approved ICD-10 codes, REVENUE codes and/or

PLACE OF SERVICE codes.

Ambulatory Surgical Centers (ASC) must bill with the -SG modifier in order to be correctly reimbursed for services at the

rates indicated on the MCRCEDP rate schedule. Not billing with the appropriate modifier may lead to rejection or

incorrect reimbursement rates.

When billing for FIT and Pathology - billers must use the date of COLLECTION of the speciman, not the date the results

are read. Mismatch of dates will result in rejection and non-payment.

Complete MCRCEDP Enrollment Form: Average Risk Client

See Colonoscopy

Lost to Follow Up

(Within 10 days) FIT Kit Returned/Completed

Completed Kit Not Returned (Within 4 Weeks)

Completed Kit Not Returned (Within 4 Weeks)

Reminder Phone Call #1

Reminder Phone Call #2

Reminder Letter Sent

FIT Analyzed/Lab

Negative Positive

Completed Kit Not Returned (Within 4 Months)

Client Notified Rescreen -

Provide FIT Kit, CRC Education and Patient Navigation

(Instruct Client To Return Kit In 1 Week)

Results to LCA

Michigan Colorectal Cancer Early Detection Program (MCRCEDP) Average Risk - Optional FIT Screening

Final Diagnosis/ Complete Colonoscopy

Intake Form

Lost to Follow Up/ Complete

Colonoscopy

Colonoscopy Completed Client Cancelled Appointment or No

Show

Reschedule

Completed

Call Client to Reschedule

(Within 1 week)

CRC Diagnosed

Cancerous Polyp(s) Removed Negative

Examination or Pre-Cancerous Polyps No Response

No Response

Place Second Call (Within 1 week)

Certified Letter to Clients with (+) FIT

to Complete Screening or

Terminate Program (Within 1 Week)

Provide Education / Patient Navigation Surveillance/Rescreen

per MCC Guidelines

Provide Referral for Community Resources

No Response

Colonoscopy Screening & Surveillance

Diagnostic Colonoscopy 1) Positive FIT Result – MCRCEDP

Call Client Within 1 Week of Positive FIT ResultsMust receive a final diagnosis within 90 days of screening

2) MDHHS Authorization prior to enrollment:ALL Positive FITs outside the MCRCEDP

Initiate Colonoscopy Intake Form

Schedule Colonoscopy Appointment/Office Visit Provide Patient Education and Navigation

(Within 2 weeks of enrollment)

Results to LCA

Referral For Additional Treatment

(Treatment must begin within 60 days of

diagnosis)

Michigan Colorectal Cancer Early Detection Program (MCRCEDP) Colonoscopy Flowsheet

FIT Supplies Request

Organization Name

Contact Person

Shipping Address

Contact Phone

Contact Email

When Needed

Item Packaged Amount Needed Product #

Test Kit 20 per box _____ Boxes 873089

Test Strip 50 per box _____ Boxes 873086

Control 1 per box _____ Boxes 868599

Fax to (517) 335-9397, Attention: Tracy Solis or e-mail to SolisT2@michigan.gov

FIT Kit Ordering Process

• MDHHS contact person for ordering FIT kits:o Tracy Soliso solist2@michigan.govo FAX: 517-335-9397o Phone: 517-335-6403

• Sites will complete the FIT kit order form and either fax or email requests to MDHHSo Kits will be received within a week, so large quantity orders are not necessary

• MDHHS will place the order with the supplier

• Supplier will ship kits directly to the requesting site

• Sites will confirm receipt of kits by faxing or emailing the packing slips to MDHHS as soon asreceived

• NOTE: If there are any issues with orders (not received, wrong item delivered, wrong quantity,etc.), notify MDHHS right away. MDHHS will follow-up with the supplier.

Expiring FIT Kits

All FIT kits should be used and analyzed by the expiration date found on the kit.

If FIT kits have expired, please follow this process:

• If the collection device (tube) is un-used, the unused tube may be disposed of in the regulartrash.

• If the fecal specimen has been collected in the tube and it has gone past the 15 day room tempor the 30 day refrigerated specifications, the collection device (tube) should be disposed of in abiohazard bag or container. Do not discard the tube, bottle or contents in a basket, toilet orclinic receptacle.

• Per clinic policy: The remainder of the FIT kit should be recycled or disposed of in the trash.

Colorectal Cancer Provider Resources

U.S. Preventive Services Task Force (USPSTF) Recommendations for Colorectal Cancer Screening (2008)

CDC Science Clips: Volume 5, Issue 38, November 4, 2013 – Key Scientific CRC Articles

Centers for Disease Control (CDC) The CDC is focused on increasing CRC awareness and screening to reduce colorectal incidence and mortality rates. The recent CDC Vital Signs Report and CRC Inforgraphics encourages the use of all risk appropriate CRC screening options to increase CRC screening. The Screen for Life Campaign offers free CRC small media and public service announcements. Links to basic CRC information found on the CDC Website.

3-part CRC Webinars Series: Overview of CRC Screening, Strategies and Systems for Expanding CRCScreening at Health Centers MI Primary Care Association, MI Department of Community Health Website –Clinical Quality. (1 hr. sessions)

The Community Guide The Community Preventive Services Task Force released provider and client evidence-based strategies that have been researched and are known to increase CRC screening rates.

Make It Your Own (MIYO) Develop FREE CRC small media for patient or provider reminders. Small media includes flyers, posters, patient office reminder cards, brochures and fact sheets that have been researched and tested by Washington State University through a CDC grant.

Michigan Cancer Consortium Guidelines for the Early Detection of Colorectal Cancer A two-page clinician’s reference to CRC screening guidelines based on the 2008 Joint Guideline from the American Cancer Society, the U.S. Multi-Society Task Force, and the American College of Radiology, and the U.S. Preventive Services Task Force (2008)

Clinician’s Reference: Fecal Occult Blood Testing (FOBT) for Colorectal Cancer Screening A 2-page resource developed by the National Colorectal Cancer Roundtable is designed to introduce (or reintroduce) clinicians to the value of stool blood testing. It explains stool blood testing in general, the differences between a guaiac-FOBT and an FIT, why different kinds of FOBTs are superior and outlines some of the things that need to go into a stool blood testing screening program, if it is to be done in a quality way.

Screening for Colorectal Cancer: Optimizing Quality (CME) This continuing education activity provides guidance and tools for clinicians on the optimal ways to implement screening for colorectal cancer to help ensure that patients receive maximum benefit. There are two versions of this course: one for primary care providers and one for clinicians who perform colonoscopy. Continuing education is available for both versions.

Adherence to Colorectal Cancer Screening: A Randomized Clinical Trial of Competing Strategies Apr 9, 2012, Vol 172, No. 7

American Gastroenterological Association Polyp Surveillance Measures

CRC Navigation: Increasing CRC Screening Rates in Michigan A how-to -guide for implementing patient navigation to increase CRC screening rates.

Cancer-Related Educational Opportunities and CRC Disparities in Michigan Webinar

Colonoscopy Screening after the ACA: Cost Barriers Persist for Medicare Beneficiaries CRC Screening Services Covered by Medicare

Colonoscopy Screening after the Affordable Care Act: (50)

Colorectal Cancer, Health Disparities, and Policy WEBINAR

An Update of the Lynch Syndrome in the Quest for Reducing its Morbidity and Mortality

NCI Gut-Check: Why Should I Care About CRC Screening?

National Institutes of Health: Colorectal Cancer

American Cancer Society (ACS) Call: 1-800-227-2345 ACS provides information about the prevention and early detection of CRC as well as Support Programs and Services for patients diagnosed with CRC and their family members. A Primary Care Clinician’s Evidence-Based Toolbox and Guide (2008) is designed to improve office practice and ensure patients are provided necessary CRC screening recommendations.

American Society for Gastrointestinal Endoscopy Colorectal Cancer Educational Videos

Michigan Cancer Consortium (MCC)

MDHHS Information Clearinghouse

Michigan Colorectal Cancer Early Detection Program (MCRCEDP) Manual

Colorectal Cancer Patient Resources

CRC SCREENING & PREVENTION RESOURCES • Centers for Disease Control: Screen for Life - free information and brochures

CDC Vital Signs and Choosing the Right Test

• National Cancer Institute:Gut Check - Why should YOU care about colorectal cancer screening?

WHAT IF I AM DIAGNOSED WITH COLORECTAL CANCER? • Cancer Survivorship Resources

A list of national resources for cancer survivors.

CRC TREATMENT RESOURCES • Patient Access Network Foundation

Eligible Medicare clients may apply for financial assistance for colorectal cancer treatment.

• Drug Company Patient Assistance Programs for CRC Treatment

CRC FINANCIAL RESOURCES • MI Bridges or Enroll Michigan

Certified Application Counselors assist individuals and families with health insurance including enrollingin health plans offered in the new Health Insurance Marketplace, Medicaid, MIChild and the HealthyMichigan Plan (Medicaid Expansion).

• Health Insurance Marketplace – Health Insurance coverage website

• Colonoscopy Assist Program (Low Cost Colonoscopies in Michigan)A program that helps uninsured or underinsured men and women obtain a colonoscopy screening at adiscounted rate.

• Colon Cancer Alliance (CCA) Patient Navigator ProgramNavigation assistance for patients at all stages of cancer care, from screening and diagnosis totreatment and survivorship. The CCA is collaborating with partners nationally to provide assistance toclients requiring CRC screening.For qualifying individuals, there is financial support for screening related expenses such as cost ofscreening, transportation, child care and lost wages through Colon Cancer Alliance’s Blue HopeFinancial Assistance Grant: (877) 422-2230, Monday – Friday 9:00 a.m. – 5:00 p.m.

• Patient Advocate Foundation (866) 657-8634Assistance to clients with financial and medical access issues, arbitration, medication, medical debt,insurance access, and job retention.

• SCBN for uninsured American who cannot afford Meds – (888) 331-1002

• Rx Advocates – uninsured and cannot afford meds? – (844) 559-8331

• Non-Profit Financial Assistance Programso Advocacy Connector (search for financial assistance near you)o Cancer Care Financial Assistance or call (800) 813-4673 (for men, women & children)o Cancer Care Co-Payment Assistance Foundation or call (866) 552-6729 (afford co-pay for chemo &

targeted therapies) o HealthWell Foundation or call (800) 675-8416 (funds to help patients)o Needy Meds or call (800) 503-6897 (help with the cost of medicine)o Partnership for Prescription Assistance or call (888) 447-2669 (helps patients without prescription

drug coverage)

CRC GENERAL INFORMATION RESOURCES • 2-1-1 – a free and confidential service that helps people across North America find the local resources

they need. 24 hours a day. 7 days a week. (enter your zip code in STEP 1 and enter “colorectal” in the“Search by Service Keyword” for services in your area)

• CancerCareProvides free, professional support services including counseling, support groups, financial assistance,workshops and publications for anyone affected by cancer.

• Benefits Check-UpBenefits Check Up is free service of the National Council on Aging (NCOA) that assists adults over 55with help to pay for prescription drugs, health care, utilities, and other basic needs.

• Michigan Department of Health & Human Services (MDHHS) ClearinghouseThe Health Promotions Clearinghouse is funded by the Michigan Department of Health and HumanServices. The Clearinghouse provides printed materials produced by the MDHHS to promote healthierlifestyles for a healthier Michigan.

• National Institutes of Health: Colorectal Cancer

• NIH Senior Health: Colorectal Cancer

Annual Budget (Instructions) For the Local Coordinating Agencies

The Michigan Colorectal Cancer Early Detection program (MCRCEDP) budget is to be developed in the following ways:

1. This budget is intended to cover all staffing and coordination for the program. Allallowable expenses will be reimbursed through the Comprehensive agreement.

2. All direct service claims must be billed through the Michigan Department ofHealth and Human Services (MDHHS) Cancer Prevention and Control Sectionfor claims processing. The Local Coordinating Agency (LCA) and/or directservice providers with contracts or letters of agreement with the LCA will beresponsible for billing.

3. Performance reimbursement will be based upon the understanding that a certainlevel of performance is met. There is a 90% performance requirement for thisprogram, which is measured by caseload completion and the total number ofclients screened. Failure to meet the minimum performance requirement willresult in a reduction in funding at year-end.

4. For specific program requirements, including current direct servicereimbursement rates and other documentation refer to the most currentMCRCEDP manual.