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Implementing the Patient-Centered Navigation Process

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Implementing the Patient-Centered Navigation Process

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Learn from the example of a small regional medical center, how to use limited resources to introduce an oncology patient navigation & survivorship program that meets CoC standards and improves the patient experience

Learn from the example of a small regional medical center, how to use limited resources to introduce an oncology patient navigation & survivorship program that meets CoC standards and improves the patient experience

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Implementing the Patient-Centered Navigation Process

  1. 1. Carol Walter, MSN, RN
  2. 2. AKA……
  3. 3. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Objectives The participant will be able to: 1. Understand and use the guidelines of meaningful use, CoC and other certifications to push their processes forward. 2. Assess who they have around them and the resources available to assist in the process of navigation and survivorship. 3. Use survivorship tools at the beginning of a patient’s journey that will help the participant create a survivorship care plan (SCP). 4. Strengthen patient-centered navigation to promote survivorship. (What’s best for the patient)
  4. 4. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Our Process: How it started…… Long ago in a galaxy far, far away……
  5. 5. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. PCRMC – Rolla, MO
  6. 6. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. PCRMC – started in 1955 (young by hospital standards) 255 bed hospital 3 medical oncologists 1 radiation oncologist Rolla, MO 17,000+ Cancer – 440 (have analytical and non-analytical) new diagnosis per year Treat 380 average per year (diagnosed and/or treated here) Largest health care system in a 90 mile radius St. Louis Columbia (University of Missouri) Springfield, MO (3rd largest city in MO) PCRMC Summary & History
  7. 7. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. 2002 - Lost in Transition 2010 - PCRMC first CoC-accredited 2013 – (Jan) - I was hired • Navigation required for 2015 • Varian/Aria/Equicare purchased 2013 – (Jan – July) • Learning, training • Start oncology patient portal • Distress Assessments with breast cancer patients only 2013 – July • Added MSW to our program • Distress Assessments added for all patients **November, 2013** – My first memo to our program outlining CoC guidelines and what we needed to do in our organization How We Got Started…
  8. 8. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. How We Got Started… • 2015 – May - Radiation Oncology starts sharing patient portal with patients • 2015 – June – Social worker adds survivorship care plans • 2015 – October - First Dr. (Radiation Oncologist) provides Survivorship Care Plan to a patient
  9. 9. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Overview: How to Introduce or Improve Services within Your System 1. Use regulations & mandates to move your process along 2. Use existing opportunities & timing to move your process 3. Use existing staff to assist in the process 4. Start survivorship at the beginning of the patient’s journey 5. Focus on patient-centered care
  10. 10. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Patient Navigation Process (S3.1) A patient navigation process, driven by a triennial Community Needs Assessment, is established to address health care disparities and barriers to cancer care. Resources to address identified barriers may be provided either on-site or by referral.
  11. 11. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Navigation is a Process From AONN conference 10-1-15 from Dr. Aaron Bleznak – current CoC surveyor and member of Program Review Subcommittee “3.1, 3.2, 3.3 is not about navigators, but about the process and outcomes.”
  12. 12. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Navigation - Process, not a person Navigation process - patient access to the care they need Cancer Committee - must a have a policy on the navigation process Report annually to the Cancer Committee: • Health disparities • Navigation process • Potential for changes • Populations being served • Barriers that still need to be overcome Navigation Process (S3.1)
  13. 13. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Community Needs Assessment (CNA) Resources for the information needed: • Hospitals required to have a CNA • County Health Departments • Cancer Registry ‒ Talk with your Registrar ‒ Access to immense information • CDC • National Cancer Institute • State of Missouri • ACS
  14. 14. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Community Needs Assessment (CNA) • Must be done every 3 years. (once every survey cycle) • Must address cancer in the community. • Cancer committee must: • Define the scope of the CNA • Be involved in the design of the assessment • Include CANCER-related questions
  15. 15. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Community Needs Assessment (cont’d) • Cancer Committee (CC) must be involved and review the results yearly – not just every 3 years • CC must assess if navigation meets the barriers or do new goals need to be established • Each year the process must address a different, additional barrier • Your program may repeat a barrier IF your CC determines it is the most important area of concern • Must document discussion in CC minutes if you chose to do the same barrier
  16. 16. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Psychosocial Distress Screening (S3.2) Each calendar year, the cancer committee develops and implements a process to integrate and monitor on-site psychosocial distress screening and referral for the provision of psychosocial care
  17. 17. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Requirements The CC will: • Develop and implement a process to provide and monitor distress screening either on-site or by referral • Determine pivotal medical visit(s) during which a patient will be screened for distress • Review evaluation of findings and document in CC meeting minutes.
  18. 18. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Documentation Annual psychosocial services summary documenting: • Methods used to monitor and evaluate distress screening activities • CC minutes documenting discussion of process and tools implemented to provide, monitor, and evaluate distress screening
  19. 19. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Improving The Process How can we improve process, documentation and evaluation? • Example: Algorithm to address distress scores: • 1 – 3 – steps to do?? • 4 - 6 – plan – re-evaluate • 7 – 10 – plan (any one with 7-10 automatically populates to Social Worker) https://www.cancercare.on.ca/toolbox/symptools/pati ent_symptom_management_guides
  20. 20. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Resources for Distress Assessment • NCCN • Equicare • ACS Our program has incorporated and adapted these resources to make our own distress assessment Documentation can be entered into: • Aria • Varian and • Equicare
  21. 21. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.
  22. 22. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.
  23. 23. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. A process to develop and implement a comprehensive care summary and follow-up plan for patients. The process must be monitored and evaluated at least yearly. CoC says this process is to focus on the sub-set of patients with curative intent (not necessary to do stage 4 at this time – however we do most of the time.) 3.3 – Survivorship Care Plan Stage 1, 2, 3
  24. 24. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. “Within the SCP processes are policies identifying the appropriate healthcare provider(s) from the patient’s oncology care team who will be responsible for approving and discussing the SCP.” *Physicians *Registered Nurses *Advanced Practice Nurses *Physician Assistants *Credentialed clinical navigators (???? – definition) (does not include lay navigators) Survivorship Care Plan
  25. 25. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.
  26. 26. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.
  27. 27. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Survivorship Care Plan Standard of Care: “Upon discharge from cancer treatment, every patient and their primary health care provider should receive a written follow-up care plan incorporating available evidence-based standards of care.“
  28. 28. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. CoC also says the process can be phased-in: • 2015 – 10% of patients must have a comprehensive care plan and survivorship visit • 2016 – 25% • 2017 – 50% • 2018 – 75% • 2019 – 100% Survivorship Care Plan
  29. 29. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. This should include at a minimum: • Likely course of recovery from treatment toxicities, as well as need for ongoing health maintenance/adjuvant therapy • Diagnostic tests and results • Tumor Stage and characteristics of their cancer • Date of diagnosis • Treatments provided – surgery, chemotherapy, radiotherapy, transplant, hormonal therapy, gene therapies, clinical trials, treatment responses, toxicities experience • Agents, doses, regimes of treatments • Support Services provided – psychosocial, nutrition, etc • Contact info of all providers and institutions • Coordinator of care sources – Livestrong, ASCO, IOM What Goes into a SCP
  30. 30. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. What Goes into a SCP (cont’d) Standard of care Follow-up plan: • Recovery plan and health maintenance • Recommended cancer screenings and other testing with schedule of when they should be performed and who should provide them • Possible late and long-term effects of treatment and symptoms • Possible insurance, employment, and financial consequences and referrals as needed for counseling, legal aid, financial assistance • Information on effective chemo-prevention strategies for secondary prevention (tamoxifen, ASA) • Referral to specific follow-up care providers, support groups and PCP • List of cancer-related resources and information • Healthy behaviors • Genetic Counseling • Chemo prevention • Referrals to resources and rehabilitation services • Stop-smoking and other health services
  31. 31. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. CoC Guidelines and Meaningful Use Requirements: **Use regulations and mandates to move your process forward** Advice from the Trenches…
  32. 32. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. How to Get There in Less than 2 Years… 1. Evaluate existing staffing strengths 2. Understand program staff requirements
  33. 33. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Begin at the beginning! • Start your survivorship care plan when you have a new patient • Find technology that supports you ‒ For us that is Equicare –  We add patients in Equicare  We get them signed up for the portal  Their care plan is started… Advice from the Trenches….
  34. 34. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Our current process… Navigation - Nurse (*generally starts at diagnosis) • Distress assessment (DA) • Packet of information • Referrals as needed • Support and visits as needed • Entry into system (that leads to survivorship) Navigation - Social Worker (*generally starts at first visit) • DA if not already done • Referrals and support as needed Navigation & Survivorship - Beginning to End
  35. 35. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. First visit – Radiation oncology • RN entry into the EMR system (if not already in) • Gives the patient the print out ‒ Portal invitation ‒ List of Care-givers First Visit - Medical Oncology • CMA entry into the EMR system (if not already in) • Gives them the print out ‒ Portal invitation ‒ List of Care-givers TIPS: • Use who you have and who will be most likely to do this for the patient • For Meaningful Use - document who has a computer, who will log & who refuses Patient Portal  Survivorship Care Plan
  36. 36. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.
  37. 37. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Our SCP • Welcome letter - Congrats! You are a Survivor • Patient Portal instructions (again) • Treatment Summary • Education • Follow-up plan • PCRMC Care team names and contact info • Local support group info • Rehab assessment and referral • Distress Assessment (final)
  38. 38. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Our EMR feeds everything from MO/RO (Aria/Varian) into Equicare (the portal, survivorship EMR). If you start this process at the point of patient admission to services, you will have a complete document at the end of treatment. Survivorship Process - Technical
  39. 39. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.
  40. 40. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.
  41. 41. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.
  42. 42. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.
  43. 43. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.
  44. 44. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Our Survivorship Care Plan
  45. 45. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. What does the patient want? When do they want it? Who else can get it? Being flexible: • Is the patient too sick at the first meeting? • Is there too much info? (Overwhelmed) • Tech savvy? Computer or internet at home? What works? What doesn’t? Ever-changing… Patient-Centered Care
  46. 46. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons. Delbert Day Cancer Institute
  47. 47. Resources • NCCN - http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#supportive • Livestrong - http://livestrongcareplan.org/ • ACS – www.cancer.org • Equicare Health - http://equicarehealth.com/ • GW Cancer Institute: https://smhs.gwu.edu/gwci/survivorship/ncsrc/national-cancer- survivorship-center-toolkit • Cancer Care Ontario - https://www.cancercare.on.ca/toolbox/symptools/patient_symptom_management_guides • ASCO - http://www.asco.org/sites/www.asco.org/files/survivorcompendium2014_web.pdf • IOM - http://www.nationalacademies.org/hmd/Reports/2005/From-Cancer-Patient-to- Cancer-Survivor-Lost-in-Transition.aspx • NCCS – National Coalition for Cancer Survivorship www.canceradvocacy.org www.canceradvocacy.org/toobox. • Academy of Oncology Nurse & Patient Navigators – www.AONNonline.org • STAR Program – Survivorship Training and Rehab – http://starprogramoncologyrehab.com • Nurses Guide to Cancer Survivorship Care plans – www.curemagazine.com
  48. 48. © American College of Surgeons 2016—Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.

Editor's Notes

  • I started in the middle…
    our cancer center was CoC certified
    They found out that navigation needed to be in place by 2015, so I was hired in Jan, 2013 to get a navigation and survivorship process.
    So as a new person, with no power and no previous experience with CoC or any idea of what to do…..
    Myself and the newly hired SW came in and created this process…..
    And you can too.

    Phelps County built a Community Hospital in Rolla in the 1950’s. In 1982 – a new Medical Oncologist came to town and started oncology services here. He grew his practice and built The Bond Clinic – about 4 miles from the hospital. (In 19--?) PCRMC brought Radiation Oncology to Rolla – within the walls of the hospital. In 2011, PCRMC bought The Bond Clinic – where Medical Oncology and chemo services remain. In 2014, a generous donation was made to start and build the Delbert Day Cancer Institute (DDCI) – that will combine Medical Oncology, Radiation Oncology and all support services under one roof. Building started in April, 2015 and we hope it will be completed in October of 2016, moving all Oncology services in one beautiful, new building connecting to the hospital. A Nurse Navigator (myself), a MSW and a registered dietician were hired in early 2013 to add support services to the current cancer services. All were already PCRMC employees, but changed roles to serve cancer patients full-time. All 3 currently travel back and forth from PCRMC to the Bond Clinic to provide those services to all patients. So to say we started disjointed, is an understatement.
     
    Our processes have come along just as disjointed as well.
    When I was hired, I was given the tasks of all navigation services, starting the oncology patient portal, adding the oncology survivorship and adding the EMR for these services (Equicare) to the new Oncology EMR – Varian. Within the first year I was hired to the navigation position, we went live with Aria in Medical Oncology and it was joined with Varian in radiation oncology.
     
    I was a known person, but starting a new position with no supervisory control over any of the people that needed to become users of the new system and help the process function. I started by doing all the distress assessments (DA) of breast cancer patients. It soon became very apparent we needed to assess all patients. Our MSW began adding DA for the remaining patients.
     
    About a year later, I started doing all the survivorship care plans to all patients finishing treatments. But because I was one person and still haven’t figured out how to be in 2 places, 4 miles apart at the same time, I was missing people as they finished treatments. So I would then call them and do the DA over the phone and then mail their survivorship care plan. About a year later, my supervisor decided the SW also needed to add survivorship care plans to her duties. So she started doing all the non-breast cancer survivorship care plans. But she felt inadequate because there is a lot of medical information to discuss with the patient, which she did not feel qualified for.
  • 90 miles from any larger center
  • Phelps County built a Community Hospital in Rolla in the 1950’s. In 1982 – a new Medical Oncologist came to town and started oncology services here. He grew his practice and built The Bond Clinic – about 4 miles from the hospital. (In 19--?) PCRMC brought Radiation Oncology to Rolla – within the walls of the hospital. In 2011, PCRMC bought The Bond Clinic – where Medical Oncology and chemo services remain. In 2014, a generous donation was made to start and build the Delbert Day Cancer Institute (DDCI) – that will combine Medical Oncology, Radiation Oncology and all support services under one roof. Building started in April, 2015 and we hope it will be completed in October of 2016, moving all Oncology services in one beautiful, new building connecting to the hospital. A Nurse Navigator (myself), a MSW and a registered dietician were hired in early 2013 to add support services to the current cancer services. All were already PCRMC employees, but changed roles to serve cancer patients full-time. All 3 currently travel back and forth from PCRMC to the Bond Clinic to provide those services to all patients. So to say we started disjointed, is an understatement.
     
    Our processes have come along just as disjointed as well.

  • When I was hired, I was given the tasks of all navigation services, starting the oncology patient portal, adding the oncology survivorship and adding the EMR for these services (Equicare) to the new Oncology EMR – Varian. Within the first year I was hired to the navigation position, we went live with Aria in Medical Oncology and it was joined with Varian in radiation oncology.
     
    I was a known person, but starting a new position with no supervisory control over any of the people that needed to become users of the new system and help the process function. I started by doing all the distress assessments (DA) of breast cancer patients. It soon became very apparent we needed to assess all patients. Our MSW began adding DA for the remaining patients.
     
    About a year later, I started doing all the survivorship care plans to all patients finishing treatments. But because I was one person and still haven’t figured out how to be in 2 places, 4 miles apart at the same time, I was missing people as they finished treatments. So I would then call them and do the DA over the phone and then mail their survivorship care plan. About a year later, my supervisor decided the SW also needed to add survivorship care plans to her duties. So she started doing all the non-breast cancer survivorship care plans. But she felt inadequate because there is a lot of medical information to discuss with the patient, which she did not feel qualified for.
    Memo:
    To discuss: Brenda, Jason, Rhonda, Sarah, Carol, Lorie, Susan
     After doing this for about a year, I realized that we had many holes in our current system. But I had to work with the current players in the current system to bring light to these issues and help current employees understand where we needed to be with navigation and survivorship services to be CoC compliant, as well as offering patient-centered navigation and survivorship services – not just what fit in best with the services we had. After attending an AONN conference I came back with the information I needed to improve our survivorship program.
    I took it to my supervisor and showed her in the guidelines where we had holes and deficits.
     
    PCMRC Survivorship timeline:
    January , 2013 – I moved into the role of Nurse Navigator for Breast Services
     
    April – July, 2013 – Learning and training on our EMR Patient portal program
     
    November, 2013 – First memo outlining CoC guidelines and what we need to do in our organization.
     
    November, 2013 – NN begins giving survivorship care plans to patients at the end of their treatment.
     
    May, 2015 – Radiation Oncology begins doing portal information
     
    June, 2015 – SW starts doing survivorship care plans
     
    October, 2015 – First survivorship care plan meeting with a patient by a physician.
     
    *********************************************
    Mission of navigation and survivorship (match mission of hospital)
     
    Goals (SMART)
     
    Navigation: set up a process and evaluation, outcomes
    Community Assessment – define our community to serve, resources, disparities, State/national statistics,
    Metrics to use
    Evaluation
     
    Start patient care plan establishing goals and expectations

     
    Survivorship: set up process and evaluation
    Comprehensive care summary (Patient care plan) to patient and PCP
     
    What is included in a patient care plan?
     
    IOM 2006: Cancer Survivorship Planning:
    *Post-treatment and late effects
    *Psychosocial and supportive needs
    *Healthy lifestyle behaviors (SBE, smoking cessation)
    *Employment and health insurance issues
    *Disease management and recurrence monitoring
    *Coordination of care plan with the health care team
     
    Survivorship 3 phases –
    Transitional 1-2 years
    Extended 2 – 5 years
    Permanent
     
    Refer to: Lost in transition 2005 IOM
    Establish PCP home
    Address other health care needs
    Economic needs
    Psychosocial needs
    Family unit needs
    Risk of recurrence
    Quality of life (how to measure - scale)
    Spiritual needs (hope)
     
     
     
     

  • *Note* – 2 years later……
    When I was hired, I was given the tasks of all navigation services, starting the oncology patient portal, adding the oncology survivorship and adding the EMR for these services (Equicare) to the new Oncology EMR – Varian. Within the first year I was hired to the navigation position, we went live with Aria in Medical Oncology and it was joined with Varian in radiation oncology.
     
    I was a known person, but starting a new position with no supervisory control over any of the people that needed to become users of the new system and help the process function. I started by doing all the distress assessments (DA) of breast cancer patients. It soon became very apparent we needed to assess all patients. Our MSW began adding DA for the remaining patients.
     
    About a year later, I started doing all the survivorship care plans to all patients finishing treatments. But because I was one person and still haven’t figured out how to be in 2 places, 4 miles apart at the same time, I was missing people as they finished treatments. So I would then call them and do the DA over the phone and then mail their survivorship care plan. About a year later, my supervisor decided the SW also needed to add survivorship care plans to her duties. So she started doing all the non-breast cancer survivorship care plans. But she felt inadequate because there is a lot of medical information to discuss with the patient, which she did not feel qualified for.

    Until then I had been adding all the patients to the EMR (Equicare), giving them portal information and giving them their survivorship care plans.
  • Mission of navigation and survivorship (match mission of hospital)
     
    Goals (SMART)
     
    Navigation: set up a process and evaluation, outcomes
    Community Assessment – define our community to serve, resources, disparities, State/national statistics,
    Metrics to use
    Evaluation
     
    Start patient care plan establishing goals and expectations

     
    Survivorship: set up process and evaluation
    Comprehensive care summary (Patient care plan) to patient and PCP
     
    What is included in a patient care plan?
     
    IOM 2006: Cancer Survivorship Planning:
    *Post-treatment and late effects
    *Psychosocial and supportive needs
    *Healthy lifestyle behaviors (SBE, smoking cessation)
    *Employment and health insurance issues
    *Disease management and recurrence monitoring
    *Coordination of care plan with the health care team
     
    Survivorship 3 phases –
    Transitional 1-2 years
    Extended 2 – 5 years
    Permanent
     
    Refer to: Lost in transition 2005 IOM
    Establish PCP home
    Address other health care needs
    Economic needs
    Psychosocial needs
    Family unit needs
    Risk of recurrence
    Quality of life (how to measure - scale)
    Spiritual needs (hope)
     
     
     
     
  • When I attended this conference – this is the message I brought home.

     
     
  • Let’s look to CoC guidelines for the process.

    Mission of navigation and survivorship (match mission of hospital)
     
    Goals (SMART)
     
    Navigation: set up a process and evaluation, outcomes
    Community Assessment – define our community to serve, resources, disparities, State/national statistics,
    Metrics to use
    Evaluation
     
    Start patient care plan establishing goals and expectations

     
    Survivorship: set up process and evaluation
    Comprehensive care summary (Patient care plan) to patient and PCP
     
    What is included in a patient care plan?
     
    IOM 2006: Cancer Survivorship Planning:
    *Post-treatment and late effects
    *Psychosocial and supportive needs
    *Healthy lifestyle behaviors (SBE, smoking cessation)
    *Employment and health insurance issues
    *Disease management and recurrence monitoring
    *Coordination of care plan with the health care team
     
    Survivorship 3 phases –
    Transitional 1-2 years
    Extended 2 – 5 years
    Permanent
     
    Refer to: Lost in transition 2005 IOM
    Establish PCP home
    Address other health care needs
    Economic needs
    Psychosocial needs
    Family unit needs
    Risk of recurrence
    Quality of life (how to measure - scale)
    Spiritual needs (hope)
     
     
     
     
  • You can use all or a few of these to establish the needs in your community. You MUST address cancer in the community assessment for the cancer committee.
  • (resources are also listed on the last slide.)
  • Our distress assessment. Done at the beginning and end of treatment.
  • Our EMR – SCP examples….
  • The Survivorship process starts at the patient’s beginning.
    We now evaluate each patient for distress assessment and physical assessment for rehab services at the first meeting or in the first week.
    We then re-evaluate at the end of treatment. We use the STARR program for cancer rehab, but by starting at the beginning with an evaluation, we have better information for use and insurance coverage at the end of treatment.
    We also give a list of support groups at the beginning and the end.
     
    **Early evaluations make it easier at the end to assess the effects of cancer on a patient, get them early referrals and helps assess how much support they may need at the end of treatment**

  • There is no definition of a “credentialed clinical navigator”. There are several agencies that offer credentials for navigators. Use the CoC clarifications (September 2, 2014).
  • Portal sign up, and explain side functions
  • Tumor board information
  • We are still working on this. We hope to have it developed soon that it goes to the PCP electronically but we also want to do PCP education so they will understand what they are receiving.
  • Must document to show your percentage. Right now, ours is _____________%
    CoC clarification September 9, 2014.
  • What goes in a survivorship care plan…..
  • One of our Doctors wants to expand it so it is more like the patient’s medical record. But it really isn’t. It is for the patient, not a provider. It is FOR the patient and they should be able to read it.
  • Our first provider that wanted to do a survivorship care plan was after a conference that he attended. Hit up providers right after they attend a conference. They are now hearing about these requirements. And as they see they cannot add the time in their schedule, they will ask for an APRN. We hired an NP in both med onc and rad onc.
  • I became overwhelmed with trying to get a SCP to every patient. Then our SW had emergency surgery. Then our Dr. decided this was the right thing to do, his nurse took them over. What I realized was that she likes control of that office. Find someone who like total control. Get them involved.
    Other scenario: Asking through the chain of command and finally getting a “no”. Then someone volunteered. Find your people. Get them on board by what is THEIR STRENGTH!
    Goals: Does your center have to have goals for each employee. This is a great goal.
    Signing patients up for the portal, presenting their survivorship care plan, etc.
  • “current” We are ever changing and evolving our processes to make them better, include more staff, reach more patients and meet our goals.
  • Meaningful use – our documentation has a place to “click” whether the patient “accepts” or “rejects” the portal – this flows over to our meaningful use dash board, so we can see % using the portal.
  • Meaningful use info – red dot is the goal, green line is the actual, based on electronic documentation.
  • Education – includes side effects, late effects and what to look for
  • Education information.
  • Medical information – diagnoses, treatments, medications, surgeries,
  • Navigation information
  • Follow-up plan
  • Questionnaires that can be given or sent electronically.
  • SCP
  • Our “current” process - We are ever changing and evolving our processes to make them better, include more staff, reach more patients and meet our goals.
  • This has already changed….. Expected opening Jan, 2017.
  • Free resources

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