Background: Commission on Care (CoC) Standard 3.3 states cancer centers need to focus initial efforts for survivorship care plan (SCP) delivery to patients treated with “curative intent and have completed active therapy (other than long term hormonal therapy).” The criteria on who is
a survivor, includes individuals with cancer from all disease sites. However, patients with metastatic disease, though survivors by some definitions, are not targeted for delivery of comprehensive care summaries and follow-up plans under CoC Standard 3.3.
Methods: The cancer committee at the John D. Dingell VAMC started working on the initial template for SCP in April 2013. The template was available in CPRS for the required survivorship care plan note by October 2013. Two nurse navigators were hired in 2014 to assist with beginning
this process. Review of eligible patients with the oncologist was done on a weekly basis. The nurse navigator then would prepare the note and meet with the patient to summarize the plan with a copy for their reference.
Our cancer committee met again in early 2015 and standard guidelines reviewed with minor adjustments made with the SCP template. Also, training was provided to designated staff of urology, surgery, and radiation oncology services regarding completion of SCP for their oncology patients. Required data elements included in the new survivorship care plans are details regarding treatment summary; contact information; diagnosis; stage of disease; surgery; chemotherapy; radiation therapy; and side effect management. Other information with the SCP includes ongoing adjuvant therapy; clinic visit schedule; cancer surveillance tests for recurrence; cancer screening tests and other periodic testing/exams related to specific diagnosis. Also, stressed with survivors is the importance of reporting any new, unusual and/or persistent symptoms need be brought to the attention of their provider.
Conclusions: The CoC states that the SCP can be completed by physicians; registered nurses; advanced practice nurses; nurse practitioners; physician assistants; and credentialed nurse navigators. As the number of cancer survivors continues to increase, the ongoing evaluation of long-term late effects of cancer treatment is important. The SCP is used to promote wellness and improve quality of life in cancer survivors.
