Care Coordination for the Oncology Survivorship Patient: A New Focus

Posted by Cam McClellan Teems

October 21, 2019 at 4:28 PM


The Commission on Cancer's DRAFT Revised Standards (May 16, 2019) and its new Standard 4.8, include a clear impact on the previous Standard 3.3  It appears the the CoC is shifting the main emphasis from the actual provision of the Survivorship Plan document to a broader provision of coordination and care for those events/items in the Plan.  After all, what benefit is a document telling a patient about recommended screening-for-recurrence events or possible late effects - if the patient is ultimately left to their own devices in order to maintain a surveillance schedule and manage their anxiety of recurrence. A Plan and help with that Plan's contents is the proverbial brass ring here.

Patients who have completed active treatment, often feel set adrift when their treatment-specific appointments come to a close.  This is what they told the Institute of Medicine when they were surveyed and then came the push for a focus on survivorship from the IOM and within the American College of Surgeon's Commission on Cancer. Likely, this shift to a 4.8 world will be a welcome change from a labor-intensive percentage requirement of document sharing, to a re focus on the patient's themselves.  Now, we can focus on coordinating the patient's Plan-recommended events and ongoing monitoring for onset of late effects.  What this new survivorship world will require is the ability to manage the patients in survivorship through ongoing patient touchpoints for screening event compliance, managing ongoing distress, late effect education, monitoring adherence to long-term oral chemotherapies and so on.  There is so much to do for this population of patients that a piece of paper could never have accomplished anyway.  

The Cordata to-do list for planning your implementation of Standard 4.8:

  • Appoint a Survivorship Coordinator.  See the Cancer Committee requirements for this role.
  • Develop a survivorship program team.  This is a representative team of those providing survivorship services or simply your Center's survivorship stakeholders.
  • Decide on your three (3) Survivorship Services to offer to patients: treatment summaries; survivorship care plans; screening programs for cancer recurrence; screening for new cancers; seminars for survivors; rehabilitation services; nutritional services; psychological support & psychiatric services; support groups and services; formalized referrals to experts in cardiology, pulmonary services, sexual dysfunction and fertility counseling; financial support services; and physical activity programs.  Many of these you likely already offer.  Now, you just need to be able to measure the benefits of providing them as organized offerings of your Survivorship Program and if there were barriers - what they were.
  • Make sure you can monitor and coordinate your survivorship patient population in an organized group - through a care coordination application like Cordata or an oncology information system or your EHR.  Regardless of the system, the populations should be clearly separate from your active patient populations, easily communicated with through texting or email, correctly identifiable by original tumor type, and thoroughly reportable.
  • Run some test reports on your Survivorship Services offered so that you can see what services are being provided and embraced by the patients, as opposed to those that are simply being offered to no avail.  At a minimum, the report should include an estimate of the number of cancer patients who participated in the three identified services and identification of the resources needed to improve the programs, if any barriers to adoption were encountered.


More to come on this topic in future Blog posts.


Topics: survivorship, care coordination

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