Department of Family and Community Medicine University of California, San Francisco CA 94143-0900

How To Do It:

Setting up a FluFIT Program is not hard, but it does require some careful planning.
1. Put Your FluFIT Team Together
  • Select a  FluFIT Champion to coordinate your efforts

This will usually be an enthusiastic physician, nurse, team leader, or quality improvement manager who has the time and skills to supervise the clinic staff who will carry out day to day FluFIT Program activities.

  • Select your  FluFIT Team Members and Determine Staffing Requirements

FluFIT Team members can be medical assistants or other health workers who enjoy working with patients and who are willing and able to be trained to to provide flu shots and FIT kits to patients.

Depending on your setup, you may have each team member carry out all aspects of the providing flu shots and FIT to your patients, or you may divide up the tasks.

To implement FluFIT activities successfully, you may need to adjust your staffing assignments. If you have a high volume clinical site, you may need to assign one or more additional persons above what is usually needed for flu shot season to help assess patient eligibility and dispense FIT kits when indicated.  In lower volume settings, it may be possible to create a successful workflow that does not require additional personnel.

  • Help your FluFIT team to be Successful

To ensure a successful program, start your planning process at least three months before the beginning of the flu shot season, and involve your team members in the planning process.

Once you have settled on the details of your program and who will be involved, set up a date for a final training session. This training should take place at least one or two weeks before the start of your Program. See link about Training

On the first day of the program, make sure that  team members  arrive early enough to check their supplies and systems for assessing patient eligibility and providing FIT before they greet the first patient. Assign at least one experienced team member who knows all aspects of the program to be on hand each day to help supervise and offer guidance to team members who are less experienced. Develop a coverage system for lunch breaks and a back-up plan to solve logistical challenges as they arise.

2. Choose Times and Places for FLU-FIT Program and Advertise
  • When to Start

The best time to start a FluFIT Program is on the first day of influenza vaccination season, usually in September.  The first several days and weeks of flu shot activities can be busy, but this is also the time when you have the opportunity to reach the largest number of patients who may be due simultaneously for colorectal cancer screening with FIT.

  • Where to do it

You can do FluFIT Programs wherever you provide flu shots, but the approach used may differ depending on the nature of your venue, your available resources, and your relationships with your patients.

FluFIT Programs are easiest to implement within integrated healthcare settings. For example, in settings with immediate access to documentation about prior screening history and with systems to provide test results to primary care physicians and to refer patients with abnormal tests to get follow-up.

FluFIT Programs can be implemented during dedicated “FluFIT Clinics” or integrated with routine primary care office visits.

FluFIT Programs can be implemented outside of integrated healthcare settings, such as in commercial pharmacies or in non-clinical community health settings, but the logistics of doing this successfully are more complex, because of payment, processing, and test reporting issues.

  • Advertise it

The first step is to advertise your plans at all levels of your organization, so that everyone can be on board and support your FluFIT Program activities as they develop, and so they will be ready to support you when you need help. 

How to  announce your FluFIT Program  patients depends on your resources. If you are in a primary care setting, you may choose to pass out flyers to your patients announcing the FluFIT  Program dates, send postcards, provide an automated phone call announcement, or place information about the program on your website or in a clinic newsletter.  If your electronic health record has an active patient portal, you may choose to use it to advertise your program, as well.

Important information to give to patients can include the following:

• Dates and times of your program

• Who should come in for their flu shot

• Explain that patients aged 50-75 who come in for flu shots will be offered a home colorectal cancer screening kit if they are due

• Provide a motivational message, such as “Yearly Prevention Saves Lives”

3. Patient Flow and Line Management Plan
  • Offer FIT in line BEFORE giving the flu shot

Anticipating  patient flow  in advance will help your program run smoothly. In busy settings, there may be a FluFIt line. When there is a line, the most efficient way to reach everyone who needs FIT is usually to provide it  before providing flu shots. Waiting until after the flu shot is given to offer the FIT kit may not work as well, since patients will often fail to wait for the FIT kit after the flu shot has been provided. 

  • Assess eligibility for flu shots and FIT

Most experienced flu shot clinics already have established protocols for screening for patients with allergies to egg or poultry products or other contraindications to flu shots. Guidelines for providing flu shots are provided here: http://www.cdc.gov/flu/index.htm

Annual FIT should be considered for all adults between the ages of 50 and 75.  However, patients who have had a colonoscopy in the last 10 years should not be offered FIT. 

There are other types of screening for colorectal cancer, but they are not yet widely available in most clinical settings.  In addition, healthy adults may choose to continue getting screening until the age of 85, but this is a decision best made between a patient and his or her primary care clinician.

There are some patients who should be offered colonoscopy instead of FIT.  This includes individuals who have ever had an abnormal FIT in the past but not yet completed colonoscopy.  It also includes individuals with rectal bleeding or a family history of a parent or sibling who has been diagnosed with colorectal cancer before the age of 60.

Therefore, the goal of most FluFIT Programs is to offer FIT to the following patients:

Age 50-75

• No colonoscopy in the last 10 years

• No stool testing for colorectal cancer in the last year

• No recent rectal bleeding

• No parents or siblings diagnosed with colorectal cancer before the age of 60

• No history of abnormal testing that has not yet been followed up with colonoscopy

When it is determined that a patient has had recent rectal bleeding, a history of an abnormal FIT that has not yet been followed up with colonoscopy, or a parent or sibling with colorectal cancer before the age of 60, the FluFIT Team should make sure that the patient receives appropriate follow up with their primary care clinician.

In many cases, this information can be found in electronic health records or in a health maintenance log sheet in the patient’s paper medical chart. Team members who are unfamiliar with where to find this information may need training from a physician or clinic manager.

When information about colorectal cancer screening is not readily available in the health record, you can ask patients between the ages of 50 and 75 to provide this information and proceed as appropriate based on their answers. 

If there is both no information in the health record and patients are uncertain about when they had their last tests, you may still consider offering FIT if it seems possible that they have not had testing in the recommended time intervals.

One time-saving approach for clinics with electronic health records is to print out a list of patients who are due for FIT at the beginning of the flu shot season, and use it as a reference to select appropriate patients for FIT as they come in for their flu shots.

4. Develop Systems to Support Follow-Up of FIT Kits Dispensed
  • Consider ease of test completion when selecting a FIT kit

There are many FIT kit brands  on the market. When possible, select a brand that has been tested and proven effective in clinical trials.  Single sample test kits, as opposed to those that require multiple stool specimens, may be easier for patients to complete. Some stool kits on the market recommend changes in diet prior to test completion. These should usually be avoided because they are more difficult for patients to complete, resulting in lower return rates. Test kits that patients can mail to a lab for processing and resulted directly into your electronic health record are usually preferred by both patients and clinic staff, as patients do not have to return to the clinic in person with their completed test kit and clinic staff does not have to handle or process the specimens in the clinic. 

  • Provide clear instructions for completing and returning kits

Most test kits come with manufacturer-recommended instructions, and they can be given to patients as part of the FIT kit.

You may want to insert additional instructions (such as multilingual instructions, simpler instructions for low literacy patients, a special reminder to date the kit when completed, and/or or a phone number to call if they have questions) if you believe this would be helpful.

  • Provide a return envelope for kits to be mailed back to your clinic or to the lab

Most test kits come with return envelopes to allow kits to be mailed back to your clinic or laboratory. Providing envelopes with paid postage will increase your return rates on FIT kits dispensed.

  • Reminder phone calls or postcards to encourage test completion by those who are given FIT

Often, less than 50% of people who are given FIT kits will return them without reminders, especially if it is the first time they are completing the test.

Providing reminders within 2 or 3 weeks of providing patients with a home FIT kit, either by phone or by postcard, has been shown to increase test completion rates in some settings.

  • Help patients with abnormal FIT results to get colonoscopy and additional treatment when needed

Develop a system for FIT results to get to both the patient and their primary care clinician.

Patients with normal FIT test results should receive the message that this is good news and that they should repeat the test in a year. Their primary care clinicians should also receive these results.

Patients with abnormal FIT test results should be called and told that they require colonoscopy to check for polyps or cancer. Their primary care clinician should also be called with this message so they can assist with arranging a colonoscopy for the patient.

Keep a log of patients with abnormal test results and check it periodically to verify that everyone on the list has gotten needed follow-up.

5. Final Preparations
  • Gather Your Supplies Well in Advance

Order flu shot supplies, FIT kits with return envelopes and stamps

Written patient education materials, posters, and algorithms for your team can be downloaded from this website, edited for use in your patient population and printed up for your use:  link to materials

  • Two Weeks Before FluFIT Program Activities Start

Recheck to be sure you have all your supplies.

Make sure everyone involved is ready and knows what to do.

Do a walkthrough with your FluFIT Team.

Consider doing a role play with your FluFIT Team, checking your workflow and procedures for providing flu shots and FIT kits.

  • Your first day of your FluFIT Program

Whatever happens on the first day, or even the first season you try it, don’t give up – FluFIT Programs  programs get easier with experience.

And… don’t forget to congratulate yourselves for getting to this point!!!