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Cancer Program Standards 2012

Continuum of Care Services:

Focus on Survivorship Care Plans

Connie Bura

Administrative Director,

Commission on Cancer

Chicago, IL

Pamela Milberg,

Director of Survivorship Programs

National Coalition for Cancer Survivorship

Silver Spring, MD

Regina Franco, MSN, NP

Spartanburg Gibbs Cancer Center of the

Spartanburg Regional Healthcare System

Spartanburg, SC

Focus on Survivorship Care Plans

Purpose

• To provide participants from CoC-accredited cancer programs, or

those seeking accreditation, with information about the definition

and requirements, process, documentation, and compliance

expectations for Standard 3.3 Survivorship Care Plan.

• To define survivor care plans and the evidence to support their

development and distribution to patients completing treatment

• To overview the Journey Forward Survivorship Care Plan Builder

along with a case study demonstrating its implementation

Focus on Survivorship Care Plans

Learning Objectives

• Understand the rationale, requirements, and compliance

expectations for the CoC Standard 3.3 Survivorship Care Plan

• Illustrate the key components of a comprehensive care summary

and follow-up plan

• Describe the Journey Forward Survivorship Care Plan Builder,

and demonstrate how one facility utilizes the tool to assist

oncology professionals in creating custom care plans for cancer

patients and their physicians

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Survivorship Care Plan –

Phase in 2015

Standard 3.3 - The cancer committee develops and

implements a process to disseminate a

comprehensive care summary and follow-up plan to

patients with cancer who are completing cancer

treatment. The process is monitored, evaluated, and

presented at least annually to the cancer committee

and documented in minutes.

Survivorship Care Plan • Process Requirements

Plan is provided by principal provider(s) who coordinated

treatment with input from other care providers

Summary of treatment received is given to patient upon

completion of treatment

Plan contains record of care received to include

o Disease characteristics

o Treatment received

o Clear steps for care after active treatment based on recognized

evidence-based standards of care

Minimum standards for care plan components

o IOM fact sheet - From Cancer Patient to Cancer Survivor: Lost in

Transition, 2006 • Institute of Medicine • www.iom.edu

Survivorship Care Plan

• Documentation

The program completes the Survey Application

Record (SAR)

o Sample of comprehensive care summary and follow-

up plan (summary of treatment received and follow-

up care plan)

o Provide description of process to provide

comprehensive care summary and follow-up plan

o Enter date of cancer committee meeting when

monitoring and evaluation of plan took place

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Survivorship Care Plan

• On-Site Survey

Surveyor will discuss methods implemented to

create and disseminate a summary of treatment

and survivorship cancer plan with cancer

committee

• Rating

Cancer committee developed process to

disseminate plan

Each year, process is monitored, evaluated,

and results presented to cancer committee

Survivorship Care Plan • Resources

Care planning templates available from

o American Society of Clinical Oncology (ASCO)

o Journey Forward Survivorship Care Plan Builder

o LIVESTRONG

Institute of Medicine (IOM)

oPublication: From Cancer Patient to Cancer

Survivor: Lost in Transition

oFact Sheets

CoC Best Practices Repository

o www.facs.org/cancer

Survivorship Care Planning

The Case for Coordinated Care

Pamela Milberg

Director of Survivorship Programs

National Coalition for Cancer Survivorship

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National Coalition for Cancer Survivorship

• Founded in 1986 by a diverse group of

leaders in cancer care, research, support,

and advocacy

• Defined the terms survivor (anyone with a

diagnosis of cancer and for the remainder of

life) and survivorship (living with, through,

and beyond cancer)

• 2001 Institute of Medicine (IOM) Report,

Crossing the Quality Chasm

• 2006 IOM Report, From Cancer Patient to

Cancer Survivor: Lost in Transition

• 2007 Journey Forward Collaboration, NCCS,

UCLA Cancer Center Survivorship Program,

Wellpoint, & Genentech to build a tool for

medical professionals to implement care

planning

NCCS Mission

To advocate for quality

cancer care for all people

touched by cancer.

Institute of Medicine: From Cancer Patient

to Cancer Survivor: Lost in Transition

• Report Findings (2005)

Survivorship care is a neglected phase of the cancer care

trajectory

Few guidelines on follow-up care

Cancer care is often not coordinated

• Recommendation:

“Cancer Survivorship Care Plan”

Building bridges between oncology and primary care

providers

Developing guidelines for improving quality

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What kinds of Survivorship Care Plans exist?

After the IOM report, three things happened:

1. ASCO began developing paper-based care plan

templates; these continue to be developed

2. One-off, localized programs were developed

3. A unique collaboration created Journey Forward

UCLA Comprehensive Cancer Center

National Coalition for Cancer Survivorship

WellPoint

Genentech

Oncology Nursing Society recently joined

What is Journey Forward?

• Vision

The Survivorship Care Collaborative will transform

long-term health care for cancer survivors

• Mission

To improve the health and well-being of cancer survivors by

facilitating and enhancing communication and care

coordination among stakeholders

• Goals

To promote physician and patient understanding of late- and

long-term effects of cancer treatment and survivorship

To improve continuity and coordination of care for cancer

survivors

What is Survivorship Care Plan Builder 3.0?

• Free Survivorship Care Plan Builder software that aid in the collection of information about treatment, surveillance guidelines, and late- and long-term effects to monitor

Four current templates

New templates under construction

• Resource directory for oncology professionals,

primary care providers and survivors

• Survivorship library with select, searchable articles

• Patient Medical History Builder resource for survivors

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Key Features of SCPB 3.0

• Easy-to-use forms that expedite the

preparation of treatment summaries and

follow-up care plans

• Helpful, time-saving utilities such as a built-in

regimen library, BSA and BMI calculators, and

various checklists

• Ability to expand Care Plans with information

on symptoms to watch for, effects of treatment,

support resources, and more

“The Journey Forward Survivorship Care Plan

taught me that I wasn’t alone. It helped answer

my questions and was very specific about what I

should expect after surviving the cancer that

ravaged my body. It seemed like it was

designed specifically for me. Journey Forward is

the bridge from cancer fighter to cancer

survivor.”

-M., Non-Hodgkins Lymphoma Cancer Survivor

Start Screen

To begin, the oncology professional either selects a template or chooses a

recently edited care plan

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General Information

The user can add as

many additional,

custom contacts as they wish

All contact

fields have

auto-complete so users can select

from a list of

previously

entered contacts

Background Information

The form contains a

number of drop-

down lists to minimize the amount

of data entry that the

user needs to do

Treatment Plan

The lymphoma

regimen selection list

includes:

•CEPP

•RCDOP

•RCHOP

•RCHOP14 •RDHAP

•REPOCH

•RESHAP

•RICE

Users can add

additional regimens to

the lymphoma regimen

library at their

discretion

BSA and BMI

are calculated

automatically

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Treatment Summary

The table of

chemotherapy agents

is displayed automatically, based on

the regimen selected

Follow-Up Care

The Coordinating

Provider selection lists

are based on the Care Team contact list

entered on the General

Information page

The Patient’s Care Plan

• After the oncology professional completes the template,

they hit Print to build the care plan that will be provided

to the patient and/or their other physicians.

• The oncology professional can attach documents from

the Survivorship Library to the care plan at this point,

directed at either the PCP or the patient.

• The care plan can be printed as a hard copy or PDF, or

exported to Excel or Word.

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Print Options

The print options list

the documents in the

Survivorship Library

that may be relevant

to this care plan

The oncology

professional simply

checks the box to

include a document

in the print-out or

PDF

Survivorship Library: Document Editor Users of the tool can select documents from the Survivorship Library to add

to the care plan

Sample Care Plan

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JourneyForward.org Website

Slides Courtesy of Journey Forward

Gibbs Cancer Center

Case Example

Application of Journey Forward

Survivorship Care Plans

Regina Franco MSN, NP

Survivorship Coordinator

Spartanburg Gibbs Cancer Center

Gibbs Cancer Center • 538 beds, Tertiary Medical Center

• Multi-hospital system

• 1674 new analytic cancers diagnosed (2009)

• More than 500 physicians

• Community Clinical Oncology Program (CCOP) since 1983

• Magnet Hospital Certification

• Comprehensive Community Cancer Center Accreditation by CoC

• CoC Outstanding Achievement Award Recipient - 2006 & 2009

• QOPI Certified

• MD Anderson Affiliation 2005-

• Advanced Technology - IMRT, TomoTherapy, Stereotactic Radiosurgery, Robotic Surgery

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Gibbs Survivorship Clinic Visit

What Happens in This Clinic? • Comprehensive History and Physical After

Therapy to Screen for Potential Late Effects

• Education on disease Prevention and Screening

• Survivorship Care Plan including a Cancer Staging

Summary, Treatment Summary and Roadmap of

Follow-up Care & give pathology report

• Dialogue Regarding Concerns – Needs

• Referrals

• Connection to Cancer Center & Community

Resources

A Survivorship Visit

Patient completes treatment and goes to SGCC Survivorship

Clinic 1-3 months after completion of therapy

Patient info is pulled from EHR

SCP is completed by Survivorship Care

Nurse

SCP is reviewed by Survivorship Clinic

Coordinator and given to patient with copy of

pathology report

SCP also given to primary care physician,

radiation and/or medical oncologist.

Survivorship Clinic Pathway

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Initial Pilot Studies Using JFCPB

• SURVIVORSHIP PILOT STUDY SRHS1-2009 2 different methods for documentation of breast

cancer patients’ treatment (N=24)

Method 1: JFCPB Method

Method 2: MD Dictated treatment summary

• Summary: RR= 72%

• Favorable ratings from patients for both treatment summaries

• Limitations not an existing survivorship care plan template for

comparison

patients did not cross over to experience the other arm

Initial Pilot Studies Using JFCPB

• SURVIVORSHIP PILOT STUDY SRHS2-2009 Goal was to utilize the JFCPB & website with several

staff members of varied nursing backgrounds to identify minimum requirements needed to document treatment history in this software

N=9

A secondary objective was to receive more feedback from breast cancer survivors regarding the form, software program

• Survivorship plans were well-received

• Medical oncologists are familiar with the appearance and information in this report

Survivorship Care Plan Experience

• 27 JF Care Plans – in pilot studies

• 100 JF Care Plans – in survivorship clinic

over past 12 months

• Evals collected from patients and also

from PCPs

• JF Care Plans easy to use, simple to

read & used for patient and PCP (in

addition to a survivorship progress note)

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Historical & Current Staff

Comments Re: JFCPB Pros

• Information located as a portable electronic file

• Much information provided to the patient on this website re: survivorship

• Precise easy to follow for patient

• NP or experienced oncology RN can complete – Physician doesn’t have to do

Cons

• **Need to have a space where path report can be attached. All patients need a copy of their path report for their files

• Time consuming – 30 – 60 minutes per patient for abstraction

• No ability to use this for metastatic disease patients

• Drop down menus have limitations

• Treatment descriptions are cumbersome

Journey Forward Care Plan Builder

Slides Courtesy of Journey Forward

Electronic files of

survivorship care

plan/treatment summary &

path reports were valued by

majority of survivors

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Patient Toolkit

• Description of survivorship care planning

• Patient version of ASCO surveillance guidelines

• Medical History Builder (CD ROM)

• Tools to facilitate patient-provider communication

regarding survivorship care plans

• Resource directory

Slides Courtesy of Journey Forward

Survivorship Care Planning Pearls

• Sending an Update Medical Info form to patient home for them to complete and bring in to appt is beneficial

• The same JFCP is sent to the PCP

• Directions are given to the patient how to go on-line and download information care plan reader from JF website and that there is additional info there for patients

• Pathology reports are also given with the care plans

• Patients are offered to have information electronically on a security encrypted flash drive. 85% patients want – no extra charge for this.

Survivor Comments

• I found the information very helpful and the questions I asked were answered. I feel better knowing about my options and support groups available….

• Appreciate Survivorship Plan – the connection gives a feeling of assurance that all has been and is being done to understand my needs…..

• This is a great program – needed to both hear it and have it on paper…

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JourneyForward.org Website

Slides Courtesy of Journey Forward

Questions?

Please visit the CoC’s CAnswer Forum

to post questions on this Webinar:

http://cancerbulletin.facs.org/forums/

Additional resources on the new Standards can be

found at the Accreditation Best Practice Repository:

http://www.facs.org/cancer/coc/bestpractices.html

Webpage addresses and log in instructions can be found

in the attachment posted along with the presentation

handouts.