💞 Safe And Secure Call Girls Prayagraj 🧿 9332606886 🧿 High Class Call Girl Se...
Survivorship Care and Care Plans: Transforming Challenges into Opportunities
1. Survivorship Care and Care Plans:
Transforming Challenges into Opportunities
Carrie Tompkins Stricker, PhD, CRNP, AOCN®
Chief Clinical Officer & Co-Founder
Carevive Systems, Inc.
Oncology Nurse Practitioner
Abramson Cancer Center
University of Pennsylvania
3. Objectives
• To describe the goals, content, and value
of survivorship care plans (SCPs) and
mandates for their delivery
• To discuss a step-wise approach to
implementing SCPs in your center
• Discuss examples of successful
implementation and outcome evaluation
• Describe existing evidence & gaps
4. New Models of Survivorship Care are
Needed
• Accountable Care Act (U.S.)
– Call for new care delivery models, population health
– Emphasis on cost as it relates to quality
• Institutions need solutions for “tsunami of
demand” due to aging & improved survival
• Current models inadequately address supportive
care needs of cancer survivors
– 70% of survivors in LAF survey said oncologist did offer
support for secondary/supportive care needs
– PCPs report knowledge gaps, & survivors express less
confidence in PCP’s survivorship care abilities
Cox. J.V., 2011; Wolff SN, Hichols C, Ulman D, et al. 2005; Mao, Bowman, Stricker et al., 2009; Kantsiper, M et al.
2009; Nissen, M.J., et al. 2007.
5. Implications of Survivors Unmet
Needs
• PATIENT: Negative health outcomes
– Two times greater risk of death in depressed
cancer survivors
– Unmet needs previously described
• SYSTEM: Cancer center loss of market
share
– Dissatisfied survivors may seek care elsewhere
– Greater population health costs
– Downstream revenue loss
Mois et al, 2013, Mayer et al., 2011; The Advisory Board Co. Oncology Roundtable, 2014
6. Opportunity
• Improve outcomes and QOL for cancer
survivors
• Improve the ability of oncologists to
provide care to cancer patients with
greatest need
• System ROI:
– Increase new patient volume and associated
revenue
7. Challenge
• Oncologists often want to maintain control
& do not coordinate care well
• Survivors are in limbo- who does what?
• PCP’s are not prepared
7
McCabe, JCO: 2013Grunfeld , JCO; 2006, 2011Cheung, JCO; 2009, 2010;
Del Giudice, JCO; 2009Nekhlyudov, JCO; 2009
8. Primary care providers lack knowledge
about cancer survivorship
• Primary care provider (PCP) knowledge of chemotherapy
effects
Cancer Drug % of PCPs that correctly ID’ed late effects (n = 1,072)
Cyclophosphamide 15% correctly identified premature menopause; 17% correctly
identified secondary malignancy as late effect
Oxaliplatin 22% correctly identified peripheral neuropathy
Paclitaxel 22% correctly identified peripheral neuropathy
Doxorubicin 55% correctly identified cardiac dysfunction
Only 6% of PCPs were able to correctly identify all late effects
Nekhlyudov L, Aziz N, Lerro CC, Virgo K. Presented June 2, 2012. ASCO Annual Meeting. Abstract 6008] UPDATE
9. From Challenge …
To Opportunity
• Oncologists may want to maintain control
& do not coordinate care well
– Engage oncologists in the dialogue and planning
– Develop shared care and care transition models
• PCP’s are not prepared
– Provide education, resources, & tools (SCPs)
• Survivors are in limbo- who does what?
– Survivorship care plans!!!
9
McCabe, JCO: 2013
Grunfeld , JCO; 2006, 2011
Cheung, JCO; 2009, 2010
Del Giudice, JCO; 2009
Nekhlyudov, JCO; 2009
10. IOM Recommendation #2:
Survivorship care plans
“Patients completing primary treatment should be
provided with a comprehensive:
1. Cancer treatment summary
2. Follow-up (survivorship) care plan
… that is clearly and effectively explained
Hewitt, Greenfield, & Stovall (2006). From Cancer Patient to Cancer Survivor: Lost in
Transition. The National Academies Press: Washington, D.C. (p. 151).
11. Purpose of Care Plans
Survivor
PCPOncologist
• Enhance communication
• Coordinate care
• Increase surveillance
• Identify and manage long term/late effects
• Encourage health monitoring and promotion
13. Survivorship Care Plans (SCPs):
Mandates
• Commission on Cancer (CoC)
– 10% of all cancer survivors by January 2015
– 25% by January 2016; 50% by Jan 2017
– 100% by 2019
– Focus on high volume malignancies first
• Breast, colorectal, lung, lymphoma, prostate
• National Accreditation Program for Breast
Cancer (NABPC)
– 50% of all breast survivors in 2015
– 100% in 2016
– Delivery by 6 months following treatment
14. Commission on Cancer (CoC)
Proposed Standard 3.3 (by 2015)
• The cancer care committee develops and implements a
process to disseminate a comprehensive care summary &
follow-up plan to patients with cancer completing cancer
treatment
• A survivorship care plan
– Is prepared by the principal provider(s) who coordinated the
oncology treatment
– Is given to the patient on completion of treatment
– Contains a record of care received, important disease
characteristics, and a written follow-up plan
Commission on Cancer, 2011. Cancer Program Standards: Ensuring Patient – Centered Care
15. Readiness survey of CoC member
institutions (early 2014)
• Only 37 percent "completely confident” in
ability to implement SCP by 2015
• Only 21% had developed a SCP process
…. ASCO and the CoC respond…
Mayer DK (2014). Clin J Oncol Nurs 18(6):615-6.
16. SCP Since IOM Report: Barriers
• Inconsistent uptake
• Time to develop
• Lack of reimbursement;
• Lack of role clarity regarding who will be completing and
maintaining the information (oncologists, oncology nurse
practitioner/nurse);
• Lack of partnership between oncology and primary care
providers to facilitate communication and coordination of care;
• Paucity of data about SCPs and improved patient outcomes.
• A lack of compatibility of existing templates with EHR and
difficulty in capturing critical information into the SCP.
18. ASCO Clinical Expert Statement on
Survivorship Care Planning
• Addresses barriers to SCP Delivery
– Esp. time to complete
• Key assumptions re: SCPs
– SCP should
• Be simple, clear, understandable
• Identify who is responsible for outlined actions
• Be given to those NED & completing active Tx
• Be shared with patient & PCP and stored in EMR
– Does not replace
• Discussions between patient & oncology provider
• The medical record
Mayer et al. (2014). J Oncol Pract [Epub ahead of print doi:10.1200/JOP.2014.001321.]
19. Treatment Summary:
ASCO data elements now with less detail
http://www.cancer.net/sites/cancer.net/files/cancer_survivorship.pdf
Principles for inclusion of data elements
Should influence follow-up care
Such data varies between cancer types, requiring
templates to be disease-specific
Enable contact with treating oncology providers as
required for ongoing or future care
Note: Many previously required details did not meet
these criteria (e.g., dose) and were removed
20. …BUT more emphasis on a
personalized follow-up plan
• Oncology team member contacts
• Need for ongoing adjuvant therapy
• Intervention to manage ongoing problems from cancer/Tx
• Surveillance plan, incl. who responsible*
– Schedule of follow up visits
– Cancer surveillance tests for recurrence
– Cancer screening for early detection of new primaries
– Surveillance for late effects
• Possible symptoms of cancer recurrence to report
• Late- and/or long-term effects (incl. symptoms to report)
• A list of items (e.g. emotional or mental health, parenting,
work/employment, financial issues, and insurance)
• Health behaviors and promotion
*who, how often, and where
21. Survivorship Care Plans in context
• “It’s not about the paper, It’s about the
process” (Melissa Hudson)
• …. a survivor care plan is only as good
as the services that it documents.
– these services and resources are what is
so incredibly valuable to cancer survivors1
1Silver, J. Physical Medicine and Rehabilitation 3, 503-506
22. Stakeholder Perspectives
• Generally positive endorsement of SCPs
– Survivors
• have informational needs that SCPs address
• voice widespread support/desire for SCPs
– Primary care providers (PCPs)
• express lack of comfort in treating survivors
• view SCPs as fostering collaborative care
– Oncology providers
• voice support & value as a communication tool
• express pragmatic concerns about implementation
– Format, time, personnel, resources
Salz et al., 2012.
23. How to accomplish all this?
• Six steps!
a. To develop a programmatic approach to
survivorship care
b. To create treatment summaries and
survivorship care plans
a) Adapted from Cancer Survivorship Training - www.cancersurvivorshiptraining.com; courtesy of Jennifer
Klemp, PhD
b) Adapted from: Advisory Board Company: Oncology Roundtable, 2014
25. Six steps
• To create treatment summaries and survivorship
care plans
Adapted from: Advisory Board Company: Oncology Roundtable, 2014
26. Step 1: Start Small
• Select target population(s) for pilot
– Start with a population where you have
champions & resources; grow from there
• Providers/staff
– Look internally to available resources
– Who’s available? Who’s interested?
• Convene a multidisciplinary team
– Engage stakeholders, incl. MDs
27. Case Example: Start Small
• Breast cancer pilot demonstration project
at UNC
28. Previous UNC SCP Efforts
Presented By Deborah Mayer at 2015 ASCO Annual Meeting
29. Step 2: Choose or Build a
Template
Step 3: Identify data sources
30. Step 2: Choose or build a template
• Understanding and weighing options
– Freeware
– Homegrown template(s)
– Commercial software
31. Step 2: Choose or build a template
• Understanding and weighing options
– Freeware (Oncolife, LIVESTRONG, Journey
Forward)
• Least automation; Greatest staff time
• Variable degree of content maintenance
– Homegrown/EMR template(s)
• Up-front staff/system investment
• Ongoing maintenance
– Commercial software
• Up front cost, with potential long term savings
– Automation, tailoring, content maintenance
– Downstream referrals, population management
35. SCP Options: Case Examples
• Freeware
– Journey Forward demonstration project* at
UNC over 1 year
• n = 75 approached, 34 SCPs delivered
• 90 minutes to complete surgery + chemo SCP
• Homegrown
– UNC
• Templates in EPIC developed over years
• High resource consumption to develop & maintain
content, challenges with implementation
• Commercial
– Hartford Healthcare; 2014 transition from
Equicare to Carevive
*Mayer et al, 2014
36. SCP Options: Case Examples
• Freeware
– Journey Forward demonstration project* at
UNC over 1 year
• n = 75 approached, 34 SCPs delivered
• 90 minutes to complete surgery + chemo SCP
• Homegrown
– UNC
• Templates in EPIC developed over years
• High resource consumption to develop & maintain
content, challenges with implementation
• Commercial
– Hartford Healthcare; 2014 transition from
Equicare to Carevive
*Mayer et al, 2014
37. EPIC Treatment Summary and
Survivorship Care Plan
Template
Highlights:
• EPIC 2014 (enhanced workflow
with EPIC 2015)
• @___@ fields will auto-fill
• MUST use the problems list
• Data can be manually entered
or smart text
• Functionality lost for version
2010 users is limited to
discrete data points
• Meaningful use:
• Printed and/or
• Included in MyChart
• Templates in prodution:
• General (customizable)
• Breast
• GI
• GU
• Lung
• Adult Survivors of
Childhood Cancers
38.
39.
40. SCP Options: Case Examples
• Freeware
– Journey Forward demonstration project* at
UNC over 1 year
• n = 75 approached, 34 SCPs delivered
• 90 minutes to complete surgery + chemo SCP
• Homegrown
– UNC
• Templates in EPIC developed over years
• High resource consumption to develop & maintain
content, challenges with implementation
• Commercial
– Hartford Healthcare; 2014 transition from
Equicare to Carevive
43. Step 3: Identify data sources
• Survivor identification and tracking
• Treatment summary data sources
• Care plan content
44. Challenges of SCP delivery:
Data/Content
• Populating treatment summary is difficult
and time consuming
– Data in many places, not discrete
45. Step 3: Identify data sources
• Treatment summary data sources
– Registry
– EHR
• Survivor identification and tracking
– Registry
– EHR
– Clinician dependent
• Care plan content
– Guidelines, evidence
– Resources, education
46. SCP Data sources: Case examples
• Treatment summary data sources
– EHR: Billings Clinic, Cerner
– Registry: Virtua/Hartford with Carevive
• Survivor identification and tracking
– St. Luke’s MSTI
– Virtua cancer center
• Care plan content
– Guidelines, peer-reviewed evidence
– Provider consensus?
– Resources and education
49. Challenges of SCP delivery:
Data/Content
• Keeping content up-to-date and evidence
based is resource-intense and difficult
• Staff and IT resource utilization
– One center estimates investment of 1 year of
programming time1
– FT survivorship coordinator plus disease-specific
teams required to create & maintain templates2
1Zabora et al. (2015).; 2Rosales et al., 2013
54. Step 4: Assign Staff
Responsibilities
• Which personnel for which steps?
– Data analysts/registrars?
– Nurses, nurse navigators
– Billing providers (APP’s, MDs)
• Considerations
– Availability, buy-in and sustainability
– Matching skill sets to responsibilities
• Operating at top of license/skill set
– Mix of skill sets
58. Step 5: Select a Delivery Method
and Model
• Models of care
• Approaches to delivery
59. Evolving Survivorship Care Models
Multidisciplinary
– physician, nurse practitioner, psychologist, social worker
Disease-specific
– Breast, prostate
Consultative service
– One-time comprehensive visit
– Treatment Summary and Care Plan
Integrated Care Model
– Usually a NP or APP works within the team, or navigator
– Ongoing care
Shared Care Model
– Collaboration with primary care
60. Step 5: Select a Delivery Method
and Model
• Delivery approaches
– Integrated or free-standing/consultative?
– Individual or group?
– One-time or longitudinal?
62. Delivery Models & Outcomes: Case
Examples
• Integrated, dual provider model (NP, SW)
– St. Luke’s MSTI
• Group visits
– Duke University
• Nurse-led, longitudinal
– Minnesota Oncology
• Disease-specific, integrated care model
– Kansas University
64. Survivorship Sustainability
Investment of Resources
Estimated salary cost for 90 min SW time,
75 min NP time, and 1 hour of RHIT time
per survivorship clinic patient+ 20%
indirect cost =
$141.73
65. Survivorship Sustainability
Billed to Pt and Insurance
• Average Professional/Facility Fee
• $272.67
• Level 3 or 4 professional fee with
extended time for education and level 3 or
4 facility charge
Reimbursement
$150.69 or 55% of billed amount =
6% Return on Investment
66. Turning challenges into
opportunities…
• Evidence-based, disease-specific content
continually updated by expert faculty
• Personalized and localized content
– to optimize patient satisfaction/engagement
– to improve provider efficiency
• Registry data & EMR integration
– to improve efficiency
• Reimbursement opportunities maximized
– Visit complexity, coordination of care,
performance-based payments, downstream
revenue
67. Research on Care Plans
Survivor
PCPOncologist
Enhance communication
Coordinate care
Increase surveillance
Identify and manage long term/late effects
Encourage health monitoring and promotion
69. Survivorship Care Plans: Outcomes
• Small pilot studies of EOT visits including
SCPs
– Improved adherence to breast/cardiac surveillance1
– High patient satisfaction2,4,5
– Reduced patient concerns/unmet needs3,5
– Improved preparedness for care (survivors)3
EOT = End of treatment
1.Oeffinger, K.C., et al., 2010; 2. SA Crowley et al., 2010; 3. CH Jagielski et al., 2010;
4. Salner et al (2012) . 5. Jefford et al. (2011);
70. Results
• Breast survivors used SCP in mean of 6.9
ways
– finding resources, referrals, engaging in health
behaviors
• Reported SCPs as useful, informative,
reassuring
• Outcomes
– Improved
• perceived coordination of care
• knowledge of cancer effects and follow up care
72. But…..
• Average time to prepare and deliver SCP
– 2 ½ - 3 hours per patient
….. And…….
73. Survivorship Care Plans: RCTs
• Grunfeld et al 2012
– n = 408 BrCA survivors
– no improvement in cancer-related distress
• Hershman et al 2013 2
– n = 126 BrCA survivors
– No improvement in distress, concerns
– Decreased cancer worry
• Brothers et al 2012
– 121 GYN cancer survivors, randomized to SCP vs usual care
– Both groups rated their care highly, with no difference between
arms
• Dutch ROGY Trial of an automated SCP in GYN-Onc
– Mixed results re: patient satisfaction with information and care
1. Grunfeld et al., 2011. 2. Hershman et al., 2012. 3. Brothers et al. 2012; 4. Kim A.H. et al., 2012; Nicolaije et al.,
2015.
74. SCP trials to date: Limitations
• Sample selection
– Who benefits?
• Intervention design
– SCP content, timing
– Process of delivery
• Outcome measurement
– Linkage of outcomes assessed to intervention
content
– Relevance of outcomes selected
Stricker, Jacobs, & Palmer (2012)
75. SCP Research:
Other Challenges
• Sample issues
– Cross contamination in RCTs
• Intervention design
– Concordance of content with standards
– Limited guidance on best processes
• Outcome measurement
– Selection of outcome variables
– Limited availability of relevant metrics
Stricker, Jacobs, & Palmer (2012)
76. SCP research:
Solutions and needs
• Innovation in intervention
– IT-facilitated solutions
– Personalized SCPs
– Longitudinal approaches
• Methodologic approaches
– Metrics for examining concordance
• Link content to outcomes
– Outcome metric development
• Repositories and knowledge sharing
77. Overall Conclusions
• Systematic yet personalized approaches are
needed to improve quality care in survivorship
– Survivorship care plans are a tool to support overall
programmatic approaches
– Infrastructure and technology solutions needed to
maximize reach and impact
• Use a stepwise approach to development &
implementation
• Additional research needed to document best
models, outcomes, and value
– Contribute to these efforts through careful programmatic
evaluation
78. carevive.com
THANK YOU
▸To see all the 10 Ways in action, click below:
Request a Demo
▸More information on the Oncology Care Model
• The Oncology Care Model: Ten Strategies for Hospitals
• Patient Navigation: 4 Ways to Gear Up for the Oncology Care
Model
• The Oncology Care Model (OCM) Model Explained