Colon cancer case

How a community hospital and physician teams worked together to increase colorectal cancer screenings throughout northeast Georgia: a case study

Streamlined and improved processes—and patient outreach and education—closed care gaps for patients due for colorectal cancer screenings.

Colorectal cancer is the third leading cause of death from cancer in the United States, mostly affecting adults ages 50 and older.

The good news is that there are a variety of tests used to detect colorectal cancer, and with early detection, most types are treatable or preventable. Since early colorectal cancer often has no symptoms, screening is extremely important. Yet, studies show that one-third of eligible adults are not up to date with their screening.

Cancer Screening Roadblocks

Despite convenient testing options, there are several reasons people don’t get screened as recommended:

  • Perceived pain of test
  • Not at risk/don’t need screening
  • Cost concerns
  • Convenience

Working Together to Close Care Gaps

Northeast Georgia Health System (NGHS) — a not-for-profit community health system serving Northeast Georgia — participates in the Northeast Georgia Health Partners Network. Health Partners brings regional physicians and hospitals together as a preferred provider organization (PPO) to serve managed care plans. Health Partners also created HP2, a physician-led, Clinically Integrated Network (CIN) that includes physicians and advanced practitioners from Northeast Georgia Medical Center, Longstreet Clinic, Georgia Heart Institute, Northeast Georgia Physicians Group, and other independent practices in the north Georgia area.

Recognizing the importance of early colorectal cancer (CRC) screening detection and prevention, HP2 initiated a screening campaign to:

  • Better identify patients due for CRC screening
  • Educate patients about the importance and effectiveness of screenings in early prevention and detection
  • Improve access and availability of screenings
  • Increase screenings to support improved patient outcomes

HP2 set out to increase CRC screenings among its eligible Medicare beneficiaries and Medicare Advantage Plan participants, most of whom were 50 and older.

HP2 began working more closely with its providers and now implements several measures to close gaps and increase CRC screening rates:

Identify patients due for screening: Since different tests have different recommended intervals for screening (examples: colonoscopy every 10 years, Cologuard® every three years, etc.), the team reviews data each month and alerts providers when it’s time for them to follow up with their patients who are due for screening.

Target patient outreach and education: Armed with more accurate data, provider offices were able to contact patients due for screening, educate them about colorectal cancer, inform them that they are due for a colonoscopy or other screening and encourage them to make an appointment with their physician.

Dr. Marti Gibbs, a family physician with Longstreet Clinic, a primary care and multi-specialty medical group with several locations across northeast Georgia, says this proactive outreach has been an important factor in closing gaps, especially in confirming records accurately reflect the patients’ screenings. It also ensures patients are contacted for future screenings at the correct date and time intervals, depending on which screening they last had.

“Now we must have official documentation of the patient’s colonoscopy or other acceptable screening, Dr. Gibbs says, “versus confirming it based on what the patient tells us.”

Cross Promote CRC Screening: A patient’s primary care physician plays an important role in preventative care and early detection, and HP2 has been working with its providers to promote the annual wellness visit or other appointments as effective opportunities for physicians to talk with their patients about recommended preventative health measures, including CRC screening. A screening test can be ordered during the appointment, the patient can take a test kit home, or the patient can schedule a follow-up test.

“We’re making it easier for the patients, and it’s much more seamless for us too,” Dr. Gibbs says.  


As a result of HP2’s CRC screening population health initiative, providers within the HP2 network have improved CRC screening rates.

Perhaps most impactful is what providers like Dr. Gibbs are seeing firsthand because of the CRC screening initiatives.

“Each time we identify a pre-cancerous polyp — which happens a lot — I consider it a success,” she says. “The evidence is there; we recommend the screening because we know it works.”

What is population health and why is it important?

Population health is an approach to care that promotes collaboration among all types of services and service providers (hospitals, physicians, community groups, etc.) that work together to deliver improved outcomes in the communities they serve. These partnerships help ensure people have the right care, at the right time, at the right place and – ideally – at the right cost.

Population health delivery has become more important as more health systems and providers seek better ways to improve the health of the people and communities they serve. Providers are focusing on preventative measures, interventions and incentives to promote health and wellness throughout the entire community.


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American Cancer Society. (2022, January 12). Key Statistics for Colorectal Cancer: How common is colorectal cancer? Retrieved from American Cancer Society:

Cancer Care. (2021). Colorectal Cancer: The Importance of Screening and Early Detection. Retrieved from Cancer Care:

Centers for Disease Control and Prevention. (2021, February 8). Colorectal Cancer Screening Tests. Retrieved from Centers for Disease Control and Prevention: (2020). Access to Primary Care. Retrieved from

Issa, I. A., & Noureddine, M. (2017, July 28). Colorectal cancer screening: An updated review of the available options. World J Gastroenterol, 23(28), 5086–5096.

U.S. Preventive Services Task Force. (2021, May 18). Colorectal Cancer: Screening. Retrieved from U.S. Preventive Services Task Force: