10/19/2017

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The Cancer Survivorship Initiative

Lisa D’Andrea RN, BSN, OCN, CNBN, CPN

Wilson Cancer Resource Center, Beaumont Troy

Assistant Nurse Manager, Oncology Nurse Navigator

and Breast Cancer Survivorship Clinic Facilitator

The Beaumont Survivorship Mission

The Cancer Survivorship Program will partner with patients, families and their healthcare providers to promote optimized health and

healing of mind, body and spirit.

We will support and empower patients through integrative practices and education before,

during and beyond treatment.

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Survivorship Statistics

Breast Cancer Stage 5 Year Relative Survival Rate

0 (in situ) 100%

l 100%

II 93%

III 72%

IV 22%

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- National Cancer Institute’s SEER Database 2014 (Survivorship, epidemiology, and end results)

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How Many People Survive 5 Years Or More after Being Diagnosed with Cancer of Any Site?

- Based on data from SEER 18 2007-2013. - Gray figures represent those who have died from cancer of any site. - Green figures represent those who have survived 5 years or more

Percent Surviving 5 Years 67.0%

Survivorship Statistics

Predicted Survivorship Forecast

• 15.5 Million 2016

• 26.1 Million 2040

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- National Cancer Institute , July 8, 2016

Benefits of Survivorship Practices

• Meets the standards and mandates of practicing institutions

• Qualifies institutions for accreditation eligibility

• Provides the patient with optimal outcomes

• Facilitates patient-provider relationships throughout the continuum of care

• It is the right thing to do for the patient

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Institutional Best Practices Patient Care Best Practices

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The Standards

Commission on Cancer

• Standard 3.3 Survivorship Care Plan: The cancer committee develops and implements a process to disseminate a comprehensive care summary and follow-up plan to patients with cancer who are completing cancer treatment.

- Commission on Cancer

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The Standards

NAPBC

• Standard 2.20 - A comprehensive breast cancer survivorship care process, including a survivorship care plan with accompanying treatment summary, is in place within six-months of completing active treatment and no longer than one-year from date of diagnosis. The survivorship care process is evaluated annually by the Breast Program Leader (BPL).

- National Accreditation Program for Breast Centers

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- Oncology Nursing Society

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“Every cancer patient looks forward to

the day when the doctor says that treatment is finally complete.

At that point, the end of cancer treatment signals the beginning of a new

journey: Survivorship”.

- National Comprehensive Cancer Network

The Patient’s Perception What does survivorship mean to your patient?

For those who have completed treatment, think for a moment… How do you think they feel?

Excited? Relieved? Grateful? Thankful?

Not always…

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The Burdens of Survivorship Physical

Pain, Fatigue, Lymphedema, Neuropathy, Vaginal Dryness, Chemo-Brain

Emotional

Anxiety, Fear, Anger, Guilt, Grief, Spirituality

Situational Returning to Work, Loss of Friendships/Relationships, Financial Disparities, Inability to Achieve Pleasure with

Intimacy

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Late Effects of Treatment • Blood Clots • Cardiac Toxicities • Infertility • Lymphedema • Neuropathies • Pulmonary Fibrosis • Premature Menopause • Secondary Malignancies

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Survivorship Models

• Oncology Nurse Navigator facilitated

• Oncology Nurse Practitioner facilitated

• Non-clinic / ONN one-on-one visits

• Others

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Breast Cancer Survivorship Clinic Overview

• Group education session – Survivors gather in the Wilson Cancer Resource Center

– Introduction of survivorship resources

– Brief educational session • Social worker

• Dietitian

• Sharing and Caring representative

• Group tour of Integrative Medicine department

• Private consultations – Nurse Navigator

– Physical Therapist

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Survivorship Clinic Facilitators

Oncology Nurse Navigator

Assess, support, educate, review NCCN guidelines, complete and review the survivorship treatment summary and care plan,

provide referrals, and reinforce physician follow-up

Physical Therapist

PT/OT assessment, review FACT-G document, provide recommendations for therapy, perform lymphedema

measurements, return to work readiness, suitability for exercise screening, exercise and wellness program

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Survivorship Clinic Facilitators

Dietitian

Dietary education, nutritional counseling, resources, recipes

Sharing and Caring Representative

Breast cancer education, resources, and support

Integrative Medicine Representative

Therapeutic massage, guided imagery, other services as needed

Social Worker

Financial resources, support groups, counseling

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Following the Clinic…

• The patient receives assistance with referrals and appointments

• The patient is referred to their appropriate treatment team physician for follow-up needs

• The patient receives a thank you letter and a copy of their treatment summary care plan

• The patient’s oncology treatment team, PCP and OB-GYN receive a letter and copy of the treatment summary care plan

• The patient is encouraged to visit the ONN as frequent as needed for ongoing support

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Fabulous Feedback!

• “Looking around at all of you here – I know that I am truly cared about.”

• “I feel better today just knowing that there are so many resources available for me now that I am finished with treatment.”

• “Beaumont is top notch! What an incredible program.”

• “This was great. I wish that my mother would have had this same opportunity when she was sick.”

• “Thank you for spending this time with me. I really am going to be alright.”

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The Key Elements of the SCP

• Demographic Information • Diagnosis • Pathology / Grade / Stage • Genetics • Personal and Family History • Surgical Intervention • Chemotherapy / Endocrine Therapy • Radiation Therapy • Post Treatment Concerns • Recommendations for Follow Up • Preventative Measures • Cancer Surveillance • Legal “clause”

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Legal clause: “This is a Clinical Summary and Care Plan, to be used as a guide. It is NOT a legal medical record. Should you require your medical records, please contact your physicians office(s) and/or hospital medical records.”

The Key Elements of the SCP

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- American Society of Clinical Oncology - CANCER.NET

Survivorship Care Plan Templates

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Survivorship Care Plan Templates

- Memorial Sloan Kettering - MSKCC.ORG

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American Society of Clinical Oncology

Care plan templates, guidelines for breast and colorectal cancer follow-up

Journey Forward

Tool for developing care plans based on ASCO recommendations Disease-specific treatment follow-up guidelines

National Comprehensive Cancer Network

Registration is required, but access to these guidelines is free.

LiveStrong Careplan Powered by Penn Medicine’s OncoLink

Patients can develop their own care plan to be reviewed by their healthcare team

Memorial Sloan Kettering Cancer Center

Treatment summary and care plan

- MSKCC.ORG

Survivorship Care Plan Resources

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Delivery of the Survivorship Care Plan

Upon completion of treatment, the oncology nurse navigator: • completes the document • reviews the document with the patient, and makes any

necessary changes • distributes a copy of the completed document to all of the

patient’s oncology treatment providers, the PCP and the patient • documents in the patient’s chart that the patient has received

the document (*or declined)

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Documentation Samples I met with this patient one on one during her Breast Cancer Survivorship Clinic visit. I provided her with resources, encouragement and emotional support. We discussed the importance of achieving her personal survivorship goals, and resources that are available to her. I reviewed the NCCN guidelines for breast cancer survivorship. She verbalized understanding of the recommendations for continued visits with her treatment team (breast surgeon, medical oncologist and radiation oncologist) at intervals that provide optimal surveillance. I reviewed her treatment summary and care plan, and answered all questions to her satisfaction. She, along with her primary care provider and her treatment team will receive a copy of this document. She expressed the following post-treatment concerns: ***. I provided her with non pharmacological interventions, and referred her to her respective treatment team providers. We reviewed the importance of incorporating exercise and a healthy diet into her lifestyle. She verbalizes that she is able to complete her ADLs without difficulty, and participates in the following enjoyable activities ***. She was encouraged to meet with me at any time with further questions/concerns/support needs.

Documentation Samples

Upon completion of *** cancer treatment, a survivorship care plan has been completed for this patient with the most current information available to date. I contacted this patient in an effort to deliver *** cancer survivorship care plan. This patient has declined all opportunities (clinic/one on one ONN visit/telephone consultation) at this time. This document has been routed to the patient's PCP and oncology treating physicians. *** was encouraged to contact me at any time for a thorough review of this document, ongoing support and resources.

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How we achieved it…

In an effort to provide our oncology patients with the most optimal survivorship outcomes, it is imperative that we collaborate with one another to build strong

working relationships.

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Beaumont Health System, Oncology

Survivorship Program Model

Page 1 of 1

Beaumont Hospital, Troy

Management Engineering (REW)

Cancer

Survivorship

Program

The Patient is the

Center of All

We Do

Oncology

Rehabilitation

Nutrition

Program

Psychosocial

Support

Program

Nutrition and

Cooking

Classes

(TR & GP)

Seminars /

Lectures

One-on-one

Consults

with Dietitian

Support

Groups

Acute Care

Therapy

Services

Community

Education

Outpatient

Therapy

Online

Resources

and Classes

Field Trips

i.e. Market

(RO)

Peer-to-

Peer

Support

Referrals:

Psycho-

social prof-

essionals

Long Term

Follow up

Follow up w/

Referring

Physician &

PCP Testing and

Late Effects

Follow Up

Link with

ONNs,

Genetics and

Resource

Center(s)

Referrals

as needed (Naturopaths,

Weight Control

Center, etc.)

PT and/or OT

Consultation/

Screening

Fatigue

Assessment

& Referrals

Research

Breast

Cancer

Patient

Surveillance

Version: 32Updated: March 30, 2017

Reviewed: March 30, 2017

Clinical

Summary &

Survivorship

Care Plan

Patient referral to program

Cancer

Survivorship

Clinics

Pediatric

Long Term

Follow up

Clinic

Spiritual

Care

Including:

Primary Care Neurology

Parenthood & Fertility Psychology

Endocrinology Orthopaedics

Cardiology Pulmonary

Gynecology Audiology

Sexual Health Nephrology/Renal

Others as needed

Sharing

and

Caring

Silver

Linings

Program

Coordination

Palliative

Care

Multi-

Disciplinary

Clinics

Community

Groups &

ACS

Financial

Assistance

Referrals

Smoking

Cessation

Referrals

IT

Cancer

Resource

Centers

Social

Work

Pediatric

Rehab

Home Care

Services /

Hospice

Clinical

Trials

Genetics

Navigation

Process

Integrative

Medicine

Clinical Massage Therapy Scar Therapy

Acupuncture Lymphatic Massage

Naturopathy Indian Head Massage

Guided Imagery Hydrotherapy

Reflexology Cranial Sacral Therapy

Reiki Energy Balancing M.D. Consults

MISSION: The Cancer Survivorship Program partners with patients, families and their healthcare

providers to promote optimized health and healing of mind, body and spirit. We support and

empower patients through integrative practices and education before, during and beyond treatment.

Educational

Programs

Work-

abilityPalliative

Care

Healing

Arts

Oncology

Residency

Program

Speech

Pathology

Survivorship

Exercise &

Wellness

Program

Pediatric

Rehab

Rehab

Services

(PT/OT/

SP)

Orthotics

&

Equipment

Groups/

Recreatio

n

SW/

Behavioral

Therapy

School

Support

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Breast Cancer Survivorship Clinic: Troy

Flow for 3 Patients/Clinic

Contacts: Dr. Brown, Angela DeLaere, Tom Lanni,

Lisa Muma, Jeanne Parzuchowski, Dr. Stromberg,

Ryan Wood, Reyna Colombo, Laurel Martinez, Lisa

D’Andrea, Gail Elliott-Patricolo, Kathy Warzybok

Patient referred

by physician or

self

Description: The process of

seeing a patient in the survivorship

long term follow up clinic following

their oncology treatment

Page 1 of 1

Beaumont Hospital, Troy

Management Engineering

Version: 9 – APPROVEDLast Edited: March 10, 2016

Legend: EndStart

Process

Process

StepDecision

Clinic Participants

Suite 350 Clerical Staff

Process

Change To Be

Made

Process

Change

Completed

Patient registered

and scheduled for

clinic via WCRC

Nurse Navigator (NN)

prepares for clinic by pulling

together forms, creating

clinical summary & care

plan and preparing for day

of clinic. Discuss care plan

with referring physician as

appropriate

Patient arrives in WCRC;

Clerical staff greets

patient, collects forms,

checks if FACT-G

completed and provides

any paperwork

Physical Therapist provides screening for

needs and recommendations (including back

to work) (will follow up with physician for

therapy prescription if needed)

and reviews FACT-G (paper) and

documents score in clinic note.

PT/OT prescription form completed – brought

to PT/OT clerical to fax and track.

Patient follows up with

physicians as appropriate

WCRC Nurse Navigator or Clerical

connects with patient by mailing or

emailing pre-clinic documents to

patient for completion prior to clinic

(to bring with them) and calls for

follow up as needed

NN and all clinicians

document clinic in Troy

Survivorship MDC Note

(ONC TR BREAST

SUR CLIN) in Epic

Clerical/NN

communicates patient

list and information to

clinic participants

Monday before

Thursday clinic

Patient schedules and

completes follow up testing

and any other support

services desired (nutrition,

counseling, resource center

information, integrative

medicine, rehab)

NN to forward clinical

summary and care

plan to referring

physician(s) as

needed

Nurse Navigator

Nurse Navigator provides:

(1) individualized clinical summary &

survivorship care plan for late effects from

medications, radiation and/or surgery

(2) education and information packet

(3) communication regarding follow up testing

and services as needed following NCCN

guidelines for surveillance – communicate

back to appropriate physician for follow up

Pre-clinic documents:

- Welcome letter

- Quality of life assessment:

FACT-G

Clinic preparation

documents:

- Clinical summary

and Care plan

Clinic documents:

- Education/Information - WCRC referral form

- PRA/SRA - Weight loss info

- Fertility info - Genetics info

- Consent form - Business cards

- Integrative Medicine Guided Imagery CD

- ACS referral form (if needed)

- NCCN guidelines (Breast Cancer Follow up Plan)

- Brochures: ACS, Integrative Medicine, Silver

Linings, Naturopathic Medicine, Exercise & Wellness,

Life After Treatment, Choices for Good Health,

Sharing & Caring, Spiritual Care

Clerical staff checks

out patient and

provides satisfaction

survey

Forms

Rehabilitation (PT) and

Nurse Navigator huddle

to discuss cases and

approach (Suite 350

small conference room)

Clerical/NN calls

patients to remind

about clinic and

paperwork

Dietitian provides

group education re:

nutrition

Integrative Medicine

staff provides

education session

Social Worker

provides group

education re:

psychosocial

support

Group Education

Session (WCRC)

[11:30am-12:30pm]

Clerical staff checks

patient in and escorts to

exam rooms; Asks

patient to complete

FACT-G if not done

already Integrative Medicine

staff provides tour of

department then

escorts patients to

Suite 350

Patients meet with

Nurse Navigator and

Physical Therapist

individually

(3 SURVIVORS)

Sharing & Caring

staff provides

education session Nurse Navigator and

Physical Therapist

regroup during and/or

at end of clinic

Clerical staff

scans in all forms

from clinic

(including FACT-

G)

WCRC Clerical provides

FACT-G forms back to

PT/OT during/after clinic

Individual Sessions (Suite 350)

[12:30pm-1:30pm]

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Barriers to Implementation

• Lack of resources

• Lack of funding

• Time constraints

• Lack of supportive structure

• Lack of standard processes

• Disengaged leaders or staff

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Empowerment

I would like to encourage all of you to empower yourselves! Identify your personal goals and address the barriers that are disrupting the

quality of your life as a survivor!

Through our survivorship programs, classes, support services and physician visits, help is available!

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A well developed survivorship program will meet the standards of your institution, and help your patients to

achieve the most optimal quality of life.

Questions

If you or anyone that you know could benefit

from oncology resources and support…

Please visit me in the

Wilson Cancer Resource Center.

248-964-3432

Thank you!

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• American College of Surgeons. Accessed 17 April 2017. • Cancer.Net. Accessed 17 April 2017 • "Comparison of CoC and NAPBC Survivorship Standards." Oncology Nursing Society.

https://www.ons.org/sites/default/files/Comparison_CoC_NAPBC_SurvivorshipStandards.pdf. Accessed 22 April 2017.

• "NAPBC Standards Manual 2014 Edition." American College of Surgeons. https://www.facs.org/~/media/files/quality%20programs/napbc/2014%20napbc%20standards%20manual.ashx. Accessed 8 May 2017.

• National Comprehensive Cancer Network. Accessed 3 February 2017.

• "Online Resources for Survivorship Planning." Memorial Sloan Kettering Cancer Center. https://www.mskcc.org/referring-

physicians/survivorship/survivorship-care-plan. Accessed 1 May 2017.

• "Survival Statistics." National Cancer Institute. https://seer.cancer.gov/statfacts/html/all.html. Accessed 23 April 2017.

• Wilson, Ian (Senior Corporate Counsel), Legal Affairs. Beaumont, Troy.

• Wood, Ryan (Manager) Management Engineering and Kaizen Improvement. Beaumont, Troy.

References