Focus Area: Follow-up and Referral for Additional Testing and Treatment

Colorectal Cancer Screening Change Package

The follow-up and referral focus area includes tools and resources to—

  • Promote and support regular screening per USPSTF recommendations.
  • Ensure timely referral for diagnostic testing, treatment, and other appropriate next steps, such as genetic testing, when screening tests are abnormal.
Focus area, change concept, change idea, tools and resources
  • Change concepts are “general notions that are useful for developing more specific strategies for changing a process.”1
  • Change ideas are evidence-based or practice-based “actionable, specific ideas or strategies.”1
  • Each change idea is linked to tools and resources that can be used or adapted to improve cancer screening.


  • Tools and resources with a symbol may contain some information that does not reflect the current US Preventive Services Task Force (USPSTF) recommendations for colorectal cancer screening.
  • Tools and resources with a symbol are patient resources.

See a list of acronyms used in this change package.

Change Concept: Establish relationships with specialists for diagnostic testing and treatment.

Tools and Resources, by Change Idea

Identify and partner with referral services or specialists who can provide follow-up diagnostic tests and/or cancer screening.
Establish two-way communication with referral services or specialists to find out if patients followed up with referrals.
Develop written agreements with referral services or specialists to coordinate follow-up care.

Change Concept: Adopt policies and procedures for patient referral and follow-up for diagnostic testing and treatment.

Tools and Resources, by Change Idea

Develop protocols and workflows, such as reminder systems, to ensure follow-up referrals are made.
Implement best practices for notification of abnormal test results and follow-up instructions to the patient.
Create a tracking system for documenting patient follow-up after an abnormal test result.
Use EHR-based clinical decision management tools to guide follow-up care.

Change Concept: Overcome barriers to follow-up and treatment.

Tools and Resources, by Change Idea

Work with specialists and health care facilities to negotiate free or reduced-cost follow-up services or offer payment plans for patients experiencing financial disadvantage.
Identify sources for low-cost or free transportation services for follow-up care.
Offer same-day and open-access scheduling and services outside of traditional hours.
Use patient navigation to help individuals access follow-up services.

Change Concept: Facilitate genetic screening for patients and their relatives.

Tools and Resources, by Change Idea

Implement risk assessment tools such as family histories and genetic counseling tools during primary care visits.
    Educate patients regarding genetic risk and communication with family members.
    Refer patients and family members for genetic counseling and testing when appropriate.

      Change Concept: Implement follow-up processes for regular screening.

      Tools and Resources, by Change Idea

      Provide visit summaries and patient education on future regular screening.


      1Centers for Disease Control and Prevention. Tobacco Cessation Change Package. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2019.