Elizabeth McGrath, DNP, APRNDarcy Kreis MS, RN

Norris Cotton Cancer Center Dartmouth Hitchcock Medical Center

Lebanon, NH

Adaptation of Survivorship Care Plans in the Age of the EMR

Challenges & Practical Solutions

• Describe the essential components a Survivorship Care Plan (SCP)

• List strategies to overcome barriers to implementation of SCPs

• Identify mechanisms to incorporate an SCP into the EMR

Objectives

• NCI designated cancer center in rural New Hampshire• Main campus located in Lebanon NH• 14 oncology outreach sites throughout NH/VT• Over 60 specialty programs• Affiliated with Geisel Medical School at Dartmouth College• 3 Year Hematology/Oncology fellowship program• 16 Hem/Onc APRN’s Lebanon campus

Norris Cotton Cancer Center

• APRN’s work in collaboration with physician, see patients independently and in conjunction with the team

• Team includes RN clinical coordinators, patient navigators, research RN’s, pharmacists, nutritionist, PT/OT, psychiatry, chaplaincy, social work, palliative care, supportive services, and administrative support

• Inpatient and outpatient• APRN’s are responsible for care of patients across the cancer continuum

which includes Survivorship Care Plans (SCP’s)• QI project was done to standardize the process of developing SCP’s and the

delivery of the SCP to patients & PCP’s

APRN Role

Institute of Medicine (2007) recommendations from:Cancer Patient to Cancer Survivor: Lost is Transition

• Raise awareness of cancer survivorship• Provide a care plan for survivors• Develop clinical practice guidelines for caring for cancer survivors• Overcome healthcare system challenges • Address cancer survivorship as a public health concern• Address survivors’ employment concerns• Improve access to adequate and affordable health insurance• Invest in research

Background

Survivor care plan (SCP) serves as an individualized plan of care

Institute of Medicine (2007) recommended Survivorship Care Plan (SCP) include:

• Treatment summary• Detailed plan of follow-up care• Late effects

American College of Surgeons Commission on Cancer (CoC) has mandated that all patients receive a SCP after completion of therapy as a condition of accreditation

after 2015

Background

Historically patients lack knowledge regarding:

• Follow-up care• Surveillance recommendations• Who is responsible for care• Recurrence anxiety • Long term side effects and complications

Background

Cancer patients are faced with unique challenges

• Psychological• Social/Financial• Physical• Spiritual

Background

Ferrell et al. 1995

Models of SCP Care• Physician Led• APRN Led

• Higher overall satisfaction• Better education – verbally and written with review of SCP• Skill Set, time and clinical expertise make APRN’s ideal for role• Only model of care that improved QOL measures and process/cost

efficiencySpears, J. et al 2017

Background

SCP Templates

• American Society of Clinical Oncology- (Chemotherapy Treatment Plan & Summary

• LIVESTRONG (LIVESTRONG Care Plan)• National Coalition for Cancer Survivorship (Journey Forward)

Background

NCCC has been providing SCP’s since 2007• Iterative process

Pilot study with PCP’s to test original template• Made improvements based on findings

Study to evaluate effectiveness with patients and PCP’s• Confirmed SCP are valuable to both patients and PCP’s

Background

Dulko, et al. 2013

2014 developed Survivorship Steering Committee• 2- 0.2 FTE funded positions

• MD & APRN as co-chairs• Interdisciplinary

Subcommittee focus areas: • Survivorship Care Plans• Psych-oncology including Distress screening• Prehab/rehab• Neurocognitive screening • Chemotherapy-induced peripheral neuropathy • Communications

Background

• A standardized process does not exist• Does not exist in EMR• Inability to incorporate existing templates into EMR

• LIVESTRONG• ASCO guidelines• Journey Forward

Barriers to SCP’s

• Quality improvement task force put in place • Interdisciplinary membership

• Physician• APRN’s• Informatics Specialist• Quality Improvement Project Manager

• DMAIC process followed

Addressing Barriers

Value of Quality Improvement Initiative

• Inherent administrative buy-in

• Standardized process development with outcomes measured and process refined

• Creates performance expectations

Addressing Barriers

Quality Improvement

SCP subcommittee meeting monthly since 10/14

Goals • Standardize SCP format across all disease sites• Develop work flow for completion and delivery of SCPs• Mechanism to identify appropriate patients• Implement comprehensive symptom assessment tool during SCP visit• Adopt best practice for symptom management

SCP Subcommittee

• All patients treated with curative intent chemo/radiation

• SCP completed within 30-90 days after completion of therapy

• Created and delivered by APRN’s

• Integrate the SCP into the EMR

Process Improvement Objectives

Barriers to SCP’s include time and cost

Expectation that EMR can expedite SCP development and delivery

Templates are key• UNC able to decrease time to build SCP from 20 minutes to 5

minutes Zabora et al, 2014 Myer et al, 2015

•

EMR Integration

Patients treated at

NCCC with

curative intent

Pre- EMR Measurements

Initially a random chart review of 50 charts revealed only 4 (8%) had a completed SCP

Measurements

• Lack of standard process to identify eligible patients

• Lack of standardized tool to document SCP

• Recent adoption of EMR- no placement for SCP

• APRN knowledge deficit regarding value of SCP visit

• Time involved in creating SCP

• No scheduling process for SCP visit

Root Causes

• Create an SCP template following ASCO guidelines

• Disease groups to build specific templates

• Integrate SCP into EMR• Begin at time of diagnosis

Steps Taken

• Role of Informatics Specialist/Resources• IT knowledge• IT resources for EMR build

• Support from Director of Quality and Patient Safety• Embedded in department

• Autonomy• Clinical Background

Informatics

Pre-work, SCP template were found in letters

Steps to Developing a Survivorship Care Plan Template

Pre-work, SCP template were found in letters

Steps to Developing a Survivorship Care Plan Template

SCP template were found in letters but were transitioned to flowsheets, now found under problem list.Steps to Developing a Survivorship Care Plan Template

SCP in EMR

ComplCompleted SCP

• Edited 16 flowsheets with individual disease specialty • Submit changes to IT builder on IT team• Builder makes changes in test environment called TST• Changes are tested by a second builder• Submit changes to eDH approval workgroup for review and approval• Changes moved to eDH with next weekly update

Steps to Developing a Survivorship Care Plan Template

3 months after initial roll out repeat chart audit demonstrated:

• Better utilization of IT support in audit• 200 charts reviewed (fit criteria)• Increased to 11%• Continued work on EMR integration

• Work arounds• Letters

Measurements

Adaptation of Survivorship Care Plans in the Age of EMR'sAnna Schaal MS, APRN; Darcy Kreis MS, RN; Claire Pace MS, APRN, Jennifer Snide MS; Elizabeth McGrath DNP, APRN

Norris Cotton Cancer Center, Lebanon, New Hampshire2016

1. Hewitt, M., Greenfield, S & Stovall, E. (2005) From cancer patient to cancer survivor: Lost in transition. Committee on cancer survivorship. Improving care andquality of life , Institute of Medicine & National Research Council. The National Academies Press. Washington, D.C.

2. McCabe, M.S, Bhata, S., Oeffinger, K.C., Reaman, G.H., Tyne,C., Wollins,D.S. (2013). American Society of Clinical Oncology Statement:Achieving high-quality cancer survivoship care. Journal of Clinical Oncology, 31 (5).

DMAIC Model of Process Improvement

§ Study is needed to continue to assess the usefulness of the SCP

§ EMR data extraction using doc flowsheet functionality

§ Improve SCP dot phrase to include common symptom management

Define

Background

Methods

Measure

Future Directions

References

Cancer survivors and their health care providers are faced with unique challenges following the completion of cancer therapy

§ increased risk of both cancer and its treatment related morbidities

§ premature mortality§ confusion regarding suggested surveillance and routine

screening§ coordinating care with multiple health care providers

It has been recommended by the Institute of Medicine and ASCO that patients be presented with a Survivorship Care Plan (SCP) at the completion of cancer care

Analyze

Who should receive a SCP? All patients treated at NCCC with chemotherapy or radiation therapy with curative intent. What is the SCP? It is a summary of their specific cancer diagnosis and treatment as well as a guide for patient’s use in managing their symptoms. When is the SCP visit to take place? 30-90 days after completion of therapy.Who will create and deliver the SCP visit? Nurse Practitioners at the NCCC.

Goal: 70% of eligible patients receive SCP by 2016

Random chart review of 50 patient charts (2015)

Completed SCP’s = 4 or 8%

Random chart review reveals patients rarely receive SCP’sRoot causes include:§ Lack of standard process to identify eligible patients§ Lack of standard tool, chart placement. Difficulty

with EMR§ Knowledge deficit regarding value of SCP visit§ Time involved in creating SCP and scheduling SCP

visit

Improve

Control

§ Implemented standard EMR functionality to document Survivorship Care Plans in a central location within the medical record

§ Quarterly evaluation of number of SCP’s done for qualified survivors

§ Ongoing assessment of workflow

Improve

§ Standardizedcollection of disease specific patient level information that flows automatically to the Survivorship Care Plan

§ Created templates incorporating ASCO guidelines related to disease specific follow up by oncology and primary care providers, including a plan for disease surveillance and education regarding health behaviors to promote wellness

After 6 months – 11% increased to 16%

• EMR integration completed with APRN training• 200 chart reviews• ALL NP’s participated in chart reviews• Data collected for root causes of incomplete SCP’s

Repeat Measurement

Complex patients on Maintenance/hormonal therapy • need to re-define “curative therapy”

Timing for bone marrow transplant patients

Local oncology follow up

Providers who do not have NP collaboration, i.e. radiation

Root Causes

• Process to identify patients across all disease management groups• Standardized scheduling process

• Increase delivery of SCP to 70% of all eligible patients by the end of 2017

• Establish maintenance and updates of electronic templates

• Expand Survivorship care planning to include metastatic long term survivors

Next Steps

Institute of Medicine. Cancer care for the whole patient: meeting psychosocial health needs. Washington, D.C: National AcademiesPress: 2007.

Spears, J.A., Craft, M.C, & White, S. (2017). Outcome of cancer survivorship care provided by advance practice RNs compared to other models of care: A systemic review. Oncology Nursing Forum 44(1); 34-41.

Mayer, D., Taylor, K.,Gerstrel, A., Coghill,A. & Birken, S.A. (2015). Implementing survivorship care plans within an electronic medical record. TheOncologyJournal.com. Dec; 980-989.

Zabora, J.R., Bolte, S., Brethwaite, D., Weller,s. & Friedman,C. (2015). The challenges of the integration of cancer survivorship care plans with electronic medical records. Seminars In Oncology Nursing 31(1); 73-78.

Kantor, D. & Suzan, Z. Issues of Cancer Survivorship. Philadelphia, PA: Wolters Kluwer: 2016.

Ferrell, B. R., Hassey-Dow K., Grant, M. (1995). Measurement of the QOL in cancer survivors. Quality of Life Research, 4; 523-531.

Dulko, D., Pace, C.M., Dittus, K.L., Sprague, B.L., Pollack, L.A., Hawkins, N.A., & Geller, B.M. (2013). Barriers and facilitators to implementing survivor care plans. Oncology Nursing Forum. Nov; 40(6); 575-580.

References

Thank You