Table 2 Implementation Challenges Experienced in the First Year of BeneFIT

 More time-consuming and complex to set up/start than anticipated

X

X

“At the very beginning we did have a few provider groups that opted out because they were already providing kits to their members. It was something we definitely had to deal with early on to weed out certain populations for provider groups who were already engaged in their own initiatives.” – Centralized

“There was a question of what to do with patients who hadn’t yet been seen in their clinic, and every clinic kind of dealt with that separately. In the end we had one health center just not process a bunch of FITs that came in because they couldn’t get those patients seen and they didn’t want to process FITs for them – so that was a pretty big challenge.” – Collaborative

 Some health centers/provider groups less interested as prefer to “do own thing” or had other CRC screening plans

X

X

 Lack of accurate electronic health record data for member information (e.g., address)

X

X

 Unestablished patients created unprocessed kits, extra time in outreach, or differing approaches to resolve

X

 Complexity and time working with vendors to get FIT kits ordered and distributed

X

X

“I would say the biggest challenge was the ordering of the FIT – there was a shortage for a while…and we had the whole issue of expired kits…Also, physically getting kits to the vendor so they could mail them out took tremendous coordination, effort, emails, reminding and tracking.” – Collaborative

“The largest barrier we encountered was around patients receiving the FIT kits from the vendor…it took longer than we anticipated for the pre-letter mailing to go out [from vendor]. And per our timeline we wanted the kits to be mailed about a week after that and unfortunately the kits were not mailed out [by vendor] until a month after the pre-letter went out.” – Centralized

 Delay in obtaining kits from vendor to mail them out (e.g., large quantity or out of date)

X

X

 Delay in vendor mailing introductory letter and kits

X

 Lack of sufficient oversight with vendor so difficult to know exactly how many reminder calls were being completed or if following script

X

 Current lab vendor requires a two-sample test which may be barrier to FIT completion for patients

X

 Lack of communication with other key departments (e.g., membership services) about mailed program so less able to address patient questions

X

X

“The customer service people at [health plan] didn’t really know about the program and should have because they would get [member] phone calls – so we should have written something up for them beforehand.” – Collaborative

“Once we started getting our first list in for members that needed to receive calls to make sure to follow-up with their provider on the positive screening, it was sort of a scramble to figure out who was going to make those calls. The department at the time of signing up for the BeneFIT project had staff to do it, but once we received the actual list they didn’t have time and staff - so that staffing barrier needed to be addressed.” – Centralized

 Lack of staffing for follow-up calls regarding positive results/initial staff designated for this work unavailable once call list was ready

X

 General patient resistance to completing a FIT and doing CRC screening

X

X

“The delays with the timeline and vendor also impacted members who were thinking they were going to receive the kit a week after the letter. And when members didn’t receive it, well, that’s when the calls started coming in…[members]saying ‘I haven’t received it in the mail.’” – Centralized

“There is still that resistance to using FIT out there in some areas…we had one health center group that had very little penetration of patients touched by the BeneFIT program, and [in those] we have a high percentage of clinics where provider groups are still pushing colonoscopy.” – Collaborative

 Patient calls asking about whereabouts of FIT due to delay of kit mailing

X

 Providers desiring response rates for their patients/teams but information not available at time of inquiry

X

 Provider/health center resistance to FIT screening in some locations

X

 Returned FIT kits not always processed

X

“A big challenge was making sure all the names and dates were on the collected samples so when sent to the lab we wouldn’t get any rejections…but there was a break in communication between the lab and the clinics. The lab would get the test but wouldn’t process it for one reason or another and they wouldn’t let the clinic know – so the clinic would never know, and the patient never knows…that kind of feedback loop was never closed.” – Collaborative

“We’ve seen some results, but we’re not sure on what the true [return] rates are at this point. The vendor had some issues [delays]…and we have some claims we are waiting on, so we don’t know what the real improvement will be [yet].” – Centralized

 Lack of workflow/process to ensure returned FIT kits were properly labeled before going to lab for processing

X

 No system in place to inform patient their completed FIT kit was not processed due to an issue (e.g., mislabeling)

X

 Some health centers were lower performers due to staff turnover or longstanding operational issues

X

 Assessing fully kit return rate outcomes hindered by delays and lag in claims data (e.g., up to 6 months)

X