Initial Assessment, Survivorship Care Plans

Initial Assessment, Survivorship Care Plans The first step of the collaborative is to perform an assessment of your Cancer Center. The goal is to identify what resources and supports are in place that can assist with the implementation of survivorship care plans. This assessment is comprehensive so many Cancer Centers will not have all of these supports in place. The questions are organized by category. The questions do not need to be completed in order and there will be times you may skip to the next question. In each section you will proceed down the page unless the symbol gives you different directions. Check our yes/no boxes by clicking on them. Questions about the assessment can be directed to Debbie Webster at websterd1@michigan.gov. Current Support: Determine if your organization has established support for survivorship care plans. I. Survivorship Care Plan Champion: A. Do you have a physician champion? II. 1. If no, is there a physician that could be recruited to be a physician champion? 2. If no physician champion, is there an administrative champion for this project? 3. If none of the above, is there a nurse who will champion this project? Cancer Committee: A. Is the cancer committee aware of the care plan standard 3.3? Name: skip to Section II. Name: skip to Section II. Name: skip to Section II. Name: skip to Section III. 1

1. Are they committed to implementing this standard? Explain: III. 2. Briefly describe the cancer committee s current plan for care plan implementation? Survivorship Care Plan Multidisciplinary team: A. Do you have a team designated to work on the implementation of Survivorship Care plans? 1. What is the composition of your multidisciplinary team? a. Do you believe that all essential providers are represented? b. What additional providers are still needed for your team? 2. Please identify who will be needed in your system on a multidisciplinary team for implementation of care plans. B. Separate from the care plan team, is additional support needed to assist with implementation of standard 3.3 for Survivorship Care Plans? IV. 1. Is there a plan to gain their support for survivorship care plans? Financial support: A. Is there financial support (i.e. budget) to implement survivorship care plans? B. Will staff be hired to implement care plans or will current staff assume the responsibility? skip to Question 1. skip to Question 2. Members and Roles: skip to Question B. Name and Position: skip to Question B. Name and Position: continue to Question 1. skip to Section IV. Staff will be hired to implement care plans. Current staffing will assume responsibility. Unknown Current Programs: Identify survivorship programs that could assist with implementing survivorship care plans. 2

V. Survivorship Clinic: A. Do you have an established survivorship clinic to provide services after treatment ends? 1. What is the purpose of this clinic? (i.e. One time visit to transition to PCP, ongoing survivorship, etc.) 2. What cancers are served by the survivorship clinic? 3. Approximately what percentage of cancer patients are served by the survivorship clinic? 4. Does the Survivorship Clinic provide care plans? Skip to Question B. Briefly Describe: Breast GI cancers Specify Other: Colorectal Lung Prostate Other Percentage: skip to Section VI. skip to Question 5. 5. If your survivorship Clinic does NOT provide care plans, is it possible they could do so in the future? B. If no clinics are in place, do you have other survivorship programming/ structures that may be useful in implementing survivorship care plans? Reason : skip to Section VI. Current Treatment Summaries & Care Plans: Determine what process is currently in place for Treatment Summaries and Care Plans VI. Current survivorship care plan implementation: A. Do you provide treatment summaries or survivorship care plans to any of your patients? Note: This question assumes that Survivorship Care Plans include a treatment summary skip to Section VII. Specify: Treatment Summaries only Survivorship Care Plans Some of both depending on patient population 3

1. What survivorship care plans have you already developed? Breast GI Cancers Specify Other: Colorectal Lung Prostate Other We do not do care plans Click here to enter text. 2. For what patient populations are treatment summaries being provided? 3. Are treatment summaries / care plans provided to all patients in this population? a. How is it decided what patient receives a treatment summary / survivorship care plan? Breast GI Ca Colorectal Lung Prostate Other We do not provide treatment summaries cers skip to Question 4. Disease Process Complexity of care Other Specify Other: Click here to enter text. Describe other: Click here to enter text. b. In what area(s)/clinic(s) do you implement survivorship care plans? 4. Approximately what % of your population are you providing care plans for? a. Approximately what % of your population are you providing treatment summaries only? 5. Is the treatment summary / survivorship care plan being provided to the patients and the patient s primary care providers? 6. Will the model currently used to provide care plans/ treatments summaries in these area(s)/clinic(s) work within new cancer types or is a new model of implementation needed? 7. Are there specific barriers to spreading survivorship care plan implementation to new cancer types (i.e. nurse navigator limited to one cancer type, administrative support)? To the patient only To the provider only To both the patient and the provider To neither the patient or the provider, model will work with new cancer types., new model of implementation needed. 4

8. Do you provide education to patients on the purpose and use of survivorship care plans? a. Which staff provides this education, or if none, who could? 9. In questions a.-d. below, identify the staff that are involved in the care plan process with their qualifications. (RN, OCN, NP, other?) a. Who retrieves data from medical records? b. Who writes care plans? c. Who meets with the patient? d. Who sends care plan to Primary Care Provider? 10. How was it decided to implement this process? (i.e. We never set up a process, the Breast Nurse Navigator just volunteered; the process came out of our survivorship workgroup etc.) Staff Training: Determine what staff already knows about Standard 3.3 (Survivorship Care Plan Process) and what needs to be accomplished. VII. Increase Survivorship Care Plans Awareness and Educate Clinical Staff A. Do clinical staff know the requirements of Standard 3.3? B. Do they understand the reason for and goal of the program? C. Have you provided education to clinical staff about care plans to date? skip to Section VIII. 5

1. If no, do you have plans to provide training to clinical staff? a. Are there regular physician trainings where survivorship care plans could be discussed? b. Are there regular nurse trainings? Explain: c. Are there other clinical staff trainings? Access to Patient Records: Determine the format that patient information is stored in for populating care plans. VIII. Medical Records A. When compiling treatment summaries / survivorship care plans is all information necessary available in the patient chart? Skip to Question B. I don t know. We haven t completed treatment summaries /care plans Skip to Question B. 1. How do you obtain missing information? B. Do you use Paper Charts? Skip to Question C. 1. Where are these charts kept? a. Can you easily access these charts? Skip to Question C. b. Are there ways to make this process simpler? How? C. Do you use Electronic Medical Records? 1. Do you use an EMR to record all data or is it recorded on paper and inputted at a later date? Skip to Section IX., all patient data is record in EMR., data is recorded on paper and inputted to EMR at a later date. 6

a. Does this vary between surgical oncology, medical oncology and radiation oncology? b. How does this vary between employed providers and private practice providers? 2. Are there ways your EMR can assist in populating the survivorship care plan? 3. Do you have the ability to manipulate the data fields in your EMR to obtain information necessary for the survivorship care plan? 4. Can you search for specific patient information needed for the survivorship care plan in the EMR (i.e. treatments received, side effects of treatment and ongoing care, surgeries, provider information)? 5. Can reports be easily compiled and printed on portions of the EMR or does the entire EMR need to be printed by itself? How? Reports can be easily printed How? Entire EMR must be printed Other Explain Other: Current cancer population: Knowledge of your cancer patient population will assist you in developing a list of resources for inclusion in care plans. IX. Cancer Patient Population: A. Gender: approx. % males approx. % females B. Age Range: C. Diagnosis Rates (approximate): % Breast % Colorectal % GI cancers % Lung % Prostate % Other D. Language(s) Spoken: English Spanish Specify: Specify other: Click here to enter text. Arabic Other 7

Survivorship Resource Information: Knowing what resources are needed and available to include in survivorship care plans will help organize information for staff. Readily Available Resources: A. Which of the following resources (within or outside your health system) are readily available to assist you in planning survivorship care for the client? 1. Financial: 2. Mental Health: 3. Physical Health/Activity: 4. Sexual Health: 5. Nutrition: 6. Are additional resources needed? 7. Are resources identified and procedures in place for commonly used referrals? Specify: Input from Other Stakeholders: Including end users and others who may use the information within the survivorship care plan can help determine process steps and what information is necessary to include. Primary Care Physicians: A. Have you gathered input regarding survivorship care plans from primary care physicians (i.e. what information they find most important and valuable)? 8

Cancer Registry: A. Cancer Registry: 1. How current is your registry with imputing cancer data and treatment? 2. How complete is your registry record for patients? Is medical oncology data consistently reported to the registry? 3. Do you have C/NET Solutions registry software? FYI... this software can populate a Journey Forward care plan. Data Collection: Understanding how you will track and record survivorship care plans is an important piece of building a successful program. A. Do you have a way to track the progress of a patient s survivorship care plan? 1. What mechanism is used to determine a care plan is complete or needs more information? 2. How is it documented that the patient has received the care plan? 3. How is it documented that the primary care physician has received the care plan? B. Does your EMR allow for storage of the care plan in a retrievable manner, so that you can count the number of care plans produced? C. Does your EMR allow for you to document that care plans were provided to primary care providers? We don t have an EMR. We don t have an EMR. This project was supported in part by funding from the Centers for Disease Control and Prevention (CDC) Cooperative Agreement 5U55DP003040. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC. 9