Three years ago, St. Louis-based Ascension set out to close gaps in breast and colorectal cancer screenings, with a focus on communities facing medium-to-high social vulnerability. The effort was part of a broader strategy to use community and clinical data to determine where the health system should focus its work.
Over those three years, more than 500,000 patients received recommended screenings, including nearly 180,000 in communities with high social vulnerability. During the initiative, late-stage breast cancer diagnoses fell 35% and late-stage colorectal cancer diagnoses fell 23%.
“Those are significant outcomes, and they were very intentional, because we had the data and made sure we were going where there was great need,” said Stacy Garrett-Ray, MD, senior vice president and chief community impact officer at Ascension. “If it was transportation, assistance with scheduling or any navigation support, that’s what we provided to get to those results.”
The screening effort is one of Ascension’s systemwide clinical priority goals, which run in three-year cycles and grow out of the system’s broader community and population health strategy. Dr. Garrett-Ray told Becker’s how Ascension chooses those priorities, measures their effectiveness, and keeps successful programs going after the goal period ends.
Ascension uses community health needs assessments, focus groups, clinical data and social determinants of health screenings to determine where to focus efforts. The system has completed more than 5.4 million screenings over the past five years.
“That gives us insight not only to identify the barriers, but also to stratify the data and understand which ZIP codes we need to reach,” Dr. Garrett-Ray said. “We take a data-driven and community informed approach to move insights into action.”
The system also considers whether it can measure the results.
“We look at what we can quantifiably say moves the needle,” she said. “Are we reaching more people? Are we enhancing clinical outcomes? Are we improving utilization so people are getting preventive care in the right areas?”
With the cancer screening goal complete, Ascension is now working on one for maternal health, aimed at reducing severe obstetric complications and disparities.
Beyond the three-year cancer screening cycles, Dr. Garrett-Ray also touted the system’s ability to connect older patients with resources. She pointed to annual wellness visit outreach as an example. Ascension began testing a digital outreach campaign in a small number of primary care practices in 2022, and it went on to reach nearly 180,000 Medicare patients across 12 states, according to the system.
“It’s something we track and bring to our care teams, so it does not become a check-the-box exercise at all,” Dr. Garrett-Ray said. “Our care teams continue to do this because it was about how they identify patients, how they reach out, how they optimize scheduling care and how they track it.”
She compared the three-year goals to building strength and muscle memory through increased repetitions at the gym: The repetition builds lasting habits for the organization to grow stronger and better.
“These aren’t one-offs,” she said. “These are lifting the bricks to build the house we need.”
For leaders at smaller hospitals and systems with tighter resources, Dr. Garrett-Ray’s first piece of advice was to look outside their own walls.
“We don’t have to build everything within our own organization,” she said. “Partnership is foundational.”
She also urged leaders to define the goal before choosing the program. “Start with the end in mind,” Dr. Garrett-Ray said. “Understand your why and how it attaches to the mission, but start with where you want to go.”
At Ascension, that has meant changing how the system invests in its local markets. It built a prioritization process that weighs each community investment against a list of core strategic priorities and initiatives to achieve greatest impact and improved outcomes.
“Does this align with the strategic imperative? Does it help with the clinical priority goal? Are there KPIs associated with it? Is it supporting the social determinants of health needs in the community?” she said.
