Method in Action

Utilizing nurse wellness visits for cancer family history risk assessment

Figure 4. Workflow with 2-tiered risk assessment utilizing nurse appointment and secondary provider review of family history and paper family history collection and risk assessment tools. CRA = cancer risk assessment. FH = family history. EHR = Electronic Health Record.

Family Care USA is a large family medicine residency program in a rural setting.Staff include attending physicians, physician assistants, family medicine residents, and nurses. The practice recognized a need to improve the identification of at-risk individuals for hereditary cancer syndromes, including hereditary breast and ovarian cancer syndrome and Lynch syndrome. A new telegenetics satellite office recently opened in the community, reducing access barriers for patients to be seen in cancer genetic clinic.

Family Care developed a cancer risk assessment model that utilized an existing clinic infrastructure for nurse wellness visits. The RN received specialized training on collecting and assessing family health history information for cancer. To systematize the risk assessment criteria, the practice, in collaboration with the genetic clinic, developed a Red Flags Checklist for the nurse and a Genetic Referral Checklist for the provider.

There are two points of entry into the Cancer Family History Nurse Wellness visit: (1) the provider recognizes a potential concern and refers the patient for more thorough family history collection and risk assessment or (2) the patient initiates the appointment request after receiving education through materials in the waiting room.

In the Wellness Visit, patients complete a paper family history questionnaire that elicits structured family history information. The nurse reviews the family history, asking for additional information as needed, and completes a Red Flags Checklist to determine if the patient should be considered for changes in screening and/or a referral to genetic clinic.

The nurse submits a task in the EHR for the provider to review the patient’s family history and nurse recommendation. The provider can use a Genetics Referral Checklist to determine if the patient should be referred to cancer genetic clinic. The patient is scheduled for a follow-up appointment after the Nurse Wellness Visit and genetic appointment to review any recommendations for changes in management.

This example was based on Maine Dartmouth Family Medicine Residency’s model for cancer risk assessment in family practice. For more information, contact Dr. Greg Feero at