Table 1 Adaptations in Lung Cancer Screening Delivery by Program Site and Year Utilizing FRAME
Location | Year | Modification planned? | Who made the decision to modify? | Modification goal | What process was modified? | At what level of delivery? | Nature of modification | Reasons for adaptations | Baseline | Modification description |
|---|---|---|---|---|---|---|---|---|---|---|
Site A | 2020 | Planned and reactive | Executive leadership | Meet COVID-19 precautions | Shared decision-making and smoking cessation | Patient and practitioner (program navigator) | Substituting | Organization/setting competing demands and mandates | Navigator meets with Veteran in-person for smoking cessation/shared decision-making | Navigator uses virtual/telehealth for shared decision-making/smoking cessation |
2021 | Unplanned | Program site director and specialty clinician (pulmonary chief) | Improve feasibility or efficiency | Patient identification and eligibility confirmation | Individual practitioner (program navigator) | Tailoring/refining | Provider resources (time) | Navigator receives screening consult, verifies Veteran’s eligibility from chart, and checks for duplicate consult. Navigator meets with Veteran to initiate screening process | 1. Medical support assistant receives consults and checks age and for duplicate consults 2. Medical support assistant schedules Veteran to meet with navigator for eligibility determination | |
Site B | 2020 | Not eligiblea | ||||||||
2021 | Unplanned | Program navigator and program site directors | Increase, decrease Reach or engagement | Patient identification and eligibility confirmation | Patient and practitioner (program navigator) | Tailoring/refining | Resources (technology) | The navigator uses the VA’s Corporate Data Warehouseb to identify Veterans for screening | No longer identifying eligible Veterans through the VA’s Corporate Data Warehouse Site is now using VA’s National Lung Cancer Screening Care Platform software to conduct screening and data tracking | |
2021 | Unplanned | Program navigator and program site directors | Feasibility | Communication of results | Patient and practitioner (program navigator) | Removing elements | Provider resources (time) | Navigator calls Veterans when screening results are negative/benign | Communication of results via mailed letter to Veterans for negative/benign screening results | |
Site C | 2020 | No reported changes | ||||||||
2021 | Unplanned | Screening program team | Decrease reach or engagement | Patient identification and eligibility confirmation | Patient and practitioner (program navigator) | Removing elements | Sociopolitical (funding or resource allocation/availability) Provider resources (time) | Navigators send letters to all eligible Veterans for recruitment | Program no longer sends letters to Veterans for recruitment | |
Site D | 2020 | Planned and reactive | Executive leadership | Meet COVID-19 precautions | Shared decision-making and smoking cessation | Patient and practitioner (program navigator) | Substituting | Organization/setting competing demands and mandates | Navigator meets with Veteran in-person for group shared decision-making/smoking cessation | 1. Navigators use virtual/telehealth for shared decision-making/smoking cessation 2. Temporarily stopped referral process 3. Changes made to scheduling in-person visits for COVID-19 precautions |
2021 | Planned and reactive | Screening program team | Improve feasibility or efficiency | Patient identification and eligibility confirmation | Patient and practitioner (program navigator) and clinic unit level | Shortening/condensing | Provider resources (time) | Navigator responsible for eligibility verification (pack year calculation) of Veterans in the screening program | Lung cancer screening (LCS) consult modified to include tobacco pack year calculator and require referring provider to enter pack years and confirm eligibility | |
Site E | 2020 | Not eligiblea | ||||||||
2021 | Planned and reactive | Program navigator and program site directors | Increase engagement | Screening and eligibility confirmation | Patient and practitioner (program navigator) and clinic unit level | Adding elements | Organization/setting (location/accessibility) | Veterans only identified and enrolled if the navigator recruits from primary care clinics | Tobacco cessation program and pulmonary department trained and refer to lung cancer screening program | |
2021 | Planned and reactive | Program navigator and program site directors | Increase engagement (primary care) | Communication of results | Patient and practitioner (program navigator) and clinic unit level | Removing elements | Provider preferences | Primary care alerted to all screening results | Primary care no longer alerted with negative/benign screening results | |
Site F | 2020 | Not eligiblea | ||||||||
2021 | Planned and reactive | Screening program team | Increase engagement | Patient identification | Patient and practitioner (program navigator) and clinic unit level | Adding elements | Organization/setting (location/accessibility) | Primary care is the main clinic to refer Veterans to lung cancer screening | Partnered with infectious disease to increase referrals of all eligible Veterans | |
2021 | Planned and reactive | Screening program team | Improve feasibility or efficiency | Communication of results | Patient and practitioner (program navigator) | Substituting | Provider resources (time) | Navigator sends letters to all Veteran with screening results. | 1. Changed results communication process to eliminate mailing 2. Add phone call to Veteran for all screening results | |
Site G | 2020 | Planned and reactive | Executive leadership | COVID-19 precautions | Shared decision-making and smoking cessation | Patient and practitioner (program navigator) | Substituting | Organization/setting competing demands and mandates | Navigator meets with Veteran in-person for shared decision-making and smoking cessation | Stopped in-person shared decision-making and smoking cessation visits |
2021 | Unplanned | Navigator | Improve feasibility or efficiency | Communication of results | Patient and practitioner (program navigator) | Substituting | Provider resources (time) | Navigator calls Veterans when screening results are negative/benign | Communication of results via mailed letter to Veterans with negative/benign screening results | |
Site H | 2020 | No navigatora | ||||||||
2021 | Planned and reactive | Screening program team | Improve feasibility or efficiency | Follow-up of screening results | Patient and practitioner (program navigator) | Tailoring/refining | Provider resources (time) | Navigator uses the date the screening is scheduled and checks electronic health record to see if completed | Navigator receives an alert within electronic health record when screening is completed. Avoids delays in communication of results | |
Site I | 2020 | No reported changes | ||||||||
2021 | No reported changes | |||||||||
Site J | 2020 | No reported changes | ||||||||
2021 | Unplanned | Navigator | Improve feasibility or efficiency | Patient identification, eligibility confirmation | Patient | Substituting | Provider resources (time) | Navigator calls Veteran eligible for screening | Navigator sends letters to Veterans eligible for screening | |
2021 | Planned and proactive | Research stakeholder and collaboration group | Improve feasibility or efficiency | Communication of results | Patient and practitioner (program navigator) | Tailoring/refining | Organization/setting competing demands and mandates | Navigator waits for recurring meetings to discuss non-definitive screening results with providers. | Unclear screening results are discussed in a new lung nodule conference that occurs weekly. | |
2021 | Planned | Navigator | Improve feasibility or efficiency | Follow-up | Patient | Tailoring/refining | Provider resources (time) | Navigator schedules 6-month and 12-month follow-up and 3 months post-initial screening | Navigator schedules 3 months and 6 months at initial screening and 12-month and 3-month follow-up | |