A Scalable, Digitally Enabled, Trauma-Informed Approach to Cancer Screening in Long-Stay Psychiatric Inpatients

Background :Despite well-established and effective cancer screening approaches, individuals with serious mental illness (SMI) experience significantly lower rates of breast, cervical, and colorectal cancer screening compared to the general population. To address these disparities, a tertiary mental health hospital in Toronto implemented a quality improvement initiative integrating cancer screening into inpatient psychiatric care through a co-located “reverse integration” model. The aim of the project was to increase the uptake of colorectal, breast, and cervical cancer screening among long-stay inpatients with SMI.

Approach: Using a co-design approach, an interdisciplinary team of hospitalists, nurses, psychiatrists, and allied health clinicians developed trauma-informed, electronic health record (EHR)-integrated care pathways to improve breast, cervical, and colorectal cancer screening for long-stay inpatients with SMI. For colorectal cancer, the team identified barriers to screening and implemented a fecal immunochemical testing (FIT) workflow with standardized procedures for FIT kit storage, distribution, sample handling, result reporting, patient consent and education. For breast cancer, a partnership was established with an external imaging center to enable coordination of mammograms for patients, which was supported by co-developed educational resources.

Patients received handouts explaining the mammography process and were also shown a desensitization video that provided a narrated virtual walkthrough of the entire screening experience to reduce anxiety and increase familiarity with the screening process. Breast imaging technologists received training in trauma-informed communication and accommodation strategies for patients with SMI. For cervical cancer, educational sessions were provided to patients, and a dedicated “Pap blitz” was conducted to increase access to screening.

Eligible participants were long-stay inpatients continuously admitted for at least one year who met the age criteria for the respective cancer screenings and were overdue for screening. The EHR was optimized to generate reminders and capture screening completion. Screening uptake, timeliness to follow-up, and associated patient characteristics were assessed through a retrospective two-year chart review.

 

 

Results: Implementation of the co-designed, trauma-informed care pathway with EHR integration led to substantial improvements in cancer screening among long-stay inpatients with SMI. Colorectal cancer screening using FIT increased from 4.9% to 33.3%, while cervical cancer screening completion rose from 35% to 50%. Although breast cancer screening declined from 50% to 36%, this was primarily due to a change in provincial age eligibility criteria, which expanded the number of patients eligible for screening during the study period. Key enablers included offering screening directly within psychiatric units, defining staff roles with targeted training, embedding reminders and results tracking in the EHR, and establishing structured follow-up processes.

 

Implications: This initiative shows that breast, cervical, and colorectal cancer screening can be  effectively integrated into inpatient mental health care for patients with SMI through a scalable, trauma-informed, and EHR-supported model. Success relied on interdisciplinary collaboration, co-design, staff training, and digital tools that automated reminders and follow-up tracking. Key lessons include engaging clinicians in co-design, addressing trauma-related barriers through education, and coordinating with community providers to ensure continuity of care. Overall, the project demonstrates how collaborative, digitally enabled pathways can advance equity and improve preventive screening in mental health settings.