September 2011 VOL 2, NO 5

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Tracking Processes

A Path to Improving the Continuum of Care: Developing a Survivorship Clinic

A. Vance, RN 

Background: Anne Arundel Medical Center’s (AAMC) tumor registry data indicated a growing population of cancer survivors. A survivor needs assessment and literature review was conducted. We found that survivors are being followed inconsistently by cancer specialists compared with primary care providers. Survivors are often unfamiliar with the details of their treatment history and are unable to share accurately pertinent medical information with their healthcare providers. Primary care providers are often unfamiliar with cancer treatments or with recommendations regarding screening for long-term complications of cancer and treatment regimens.

Purpose: To create a sustainable Breast Cancer Survivorship Clinic.

Methods: A survivorship program includes key elements to ensure a successful and sustainable program. A literature review and patient needs assessment was conducted. Key staff attended the George Washington Cancer Institute’s Executive Training on Navigation and Survivorship. This 2-day seminar helped define a framework and featured organizations with operational survivorship clinics. A project team was created and included a nurse practitioner, nurse navigator, administrative director, medical oncologist, and primary care physician. The project team defined the goals of the survivorship program, focusing on our commitment to support survivors as they progress through the years, especially the long-term effects of treatment on their physical and psychosocial well-being. A crucial step was to research possible funding sources, both internal and through grants. AAMC applied for a grant through the Susan G. Komen Foundation. AAMC was awarded a 1-year grant to assist with the implementation of our survivorship clinic with matching funds from the hospital. The breast survivorship clinic visit consists of a consultation with the nurse practitioner and the oncology social worker. Patients and physicians including primary care receive “Survivor Path,” an end-of-treatment care summary and individualized recommendations. Recommendations for follow-up care and survivor education materials are customized to the needs of each patient based on his or her disease and its treatment. Promotional materials were made available to patients in waiting rooms of oncology and primary care providers. Physician continuing medical education and lunch-and-learn sessions were coordinated to establish a dialogue and educate both primary care and specialty practices. The survivorship program was presented at all tumor boards to ensure uniform knowledge across the health system.

Results: The Breast Cancer Survivorship Clinic has been created and will begin scheduling patients on September 19, 2011. We have collaborated with medical, radiation, and surgical oncologists and primary care providers in our market. The treatment summary and care plan format has been developed, and we will be promoting the clinic to our survivors by scheduling visits 4 to 6 weeks after completion of active treatment. It is necessary to provide ongoing assessment and evaluation to improve and expand the program. The ultimate success of the program will rely upon ongoing executive sponsorship, objective evaluation, sustainable funding and, most importantly, tangible patient benefits.

Conclusions/Implications: The creation of the Breast Cancer Survivorship Clinic has been a work of collaboration, teamwork, and patient-centered care. The clinic is projected to see between 25 and 50 patients in the first 6 months and provide care plans to the survivors and their primary care providers. Outcomes to be monitored will be compliance with follow-up appointments; participation in the nutrition, exercise, and support care programs; and patient and provider satisfaction scores at first visit, 6 months, and 1 year.

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