Table 2 Criteria and contextual factors that guided selection of CRC screening EBPs

1. The intervention should act across the screening care continuum and at multiple levels

• CRC screening is a complex process involving several steps along a continuum of care

• Screening includes identifying eligible populations to screen, diagnostic follow-up, and subsequent treatment and surveillance

• Multiple patient-, provider-, and system-level factors affect how and if patients move through each step

• This complexity suggests that interventions operating only at a single point along the screening continuum or at a single level would have limited impact on screening [24]

2. The intervention should account for clinical staff time constraints in primary care

• The inner context of CHCs is characterized by substantial clinician and staff time constraints

• Time constraints represent a major barrier to delivering guideline-recommended clinical services, including CRC screening [21,22,23]

3. The intervention should focus on non-visit-based (outreach) approaches to screening

• Partner CHCs had made significant progress in improving CRC screening among patients who attended regular clinic visits, maximizing screening rates using visit-based approaches

• Visit-based approaches to screening are missing the sizeable number of patients who visited the clinic infrequently or only when acutely ill

4. The intervention should facilitate follow-up colonoscopy after abnormal FIT

• Most CHC providers were using FIT-based screening

• Effective FIT-based screening requires that individuals with abnormal stool tests undergo follow-up colonoscopy

• Partner CHCs reported financial, transportation, and other barriers to completing these follow-up colonoscopies, consistent with published evidence of low rates of colonoscopy completion after abnormal FIT for socio-economically challenged populations [25]

• Endoscopy access is limited and varied across regions

• Facilitating colonoscopy completion for the uninsured was seen as especially important as North Carolina is one of 12 states that has not, as of this writing, implemented Medicaid expansion, contributing to high rates of uninsured [26]

• One of our partner CHCs serves a large undocumented immigrant population that is ineligible for Medicaid or federal health insurance subsidies

• Partner CHCs had limited navigation support for FIT + patients

5. The intervention should be replicable and adaptable across multiple CHCs to address service fragmentation and reduce process variation

• NC CHCs are not integrated, operate independently of each other, and use a variety EHR systems, fecal test kits, clinical laboratories, and independent endoscopy providers

• CHCs serve patients with varying insurance types, including government, private, and no insurance