The document provides information on developing and implementing survivorship care programs that meet Commission on Cancer (CoC) accreditation standards. It discusses how PCRMC in Rolla, Missouri established their survivorship care processes over time to meet these standards, including developing a navigation process, integrating distress screening, and creating survivorship care plans. The document offers advice on using regulations, existing staff, and starting the process at the beginning of a patient's cancer journey to establish survivorship programs efficiently.

1. Carol Walter, MSN, RN

2. AKA……

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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)

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Our Process:
How it started……
Long ago in a galaxy far, far away……

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PCRMC – Rolla, MO

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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

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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…

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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

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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

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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.

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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.”

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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)

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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

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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

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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

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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

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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.

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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

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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

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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

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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

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“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

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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.“

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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

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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

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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

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CoC Guidelines and Meaningful Use
Requirements:
**Use regulations and mandates to move your
process forward**
Advice from the Trenches…

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How to Get There in Less than 2 Years…
1. Evaluate existing staffing strengths
2. Understand program staff requirements

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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….

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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

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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

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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)

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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

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41. © American College of Surgeons 2016—Content cannot be reproduced or
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42. © American College of Surgeons 2016—Content cannot be reproduced or
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43. © American College of Surgeons 2016—Content cannot be reproduced or
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Our Survivorship
Care Plan

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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

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Delbert Day Cancer Institute

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

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