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

Background: The path to a survivorship program includes key elements to ensure a successful and sustainable program. At Anne Arundel Medical Center (AAMC) we implemented these fundamentals in the development of our breast survivorship program. This abstract outlines fundamental steps in the process.

Methods: First, a needs assessment was conducted using data from our tumor registry. We conducted a literature review including the Institute of Medicine’s report “Lost in Transition: From Cancer Patient to Cancer Survivor” and research from the NCI’s Office of Cancer Survivorship. Consistent with the nation, we found a growing volume of cancer survivors living longer and needing assistance. Training and networking were critical in the program development as well. AAMC staff attended George Washington’s Executive Training on Navigation and Survivorship. This 2-day seminar helped define a framework and featured organizations with operational survivorship clinics. Next, a project team was created and included a nurse practitioner, nurse navigator, administrative director, and medical oncologist. The project team defined the goals of the survivorship program, focusing on our commitment to support survivors as they progress through the continuum of care in the areas of health monitoring, disease prevention, and overall wellness. Another crucial step was to research possible funding sources, both internal and through grants. AAMC applied for a grant through the Susan G. Komen Foundation and was awarded a 1-year grant to assist with the implementation of our survivorship clinic. The breast survivorship clinic visit consists of a consultation with the nurse practitioner and oncology social worker. Patients receive a “Survivor Path” that serves as a care treatment summary, including diagnosis details, comorbidities, treatments, and providers. It is vital that this Survivor Path is provided to primary care providers and other professionals from the care team in order to provide seamless care. In addition to creating the program, we were tasked with marketing the program. Promotional materials were made available to patients in waiting rooms of oncology providers. “Lunch and Learn” sessions were coordinated to establish a dialogue with primary care offices. A presentation of the survivorship program was conducted for all disciplines at a “tumor board” conference to ensure an understanding across departments within the health system.

Conclusion: Finally, 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.