Cancer Survivorship Care: Implementing the CoC Standard

Sherry Soeder, CNP

Sherry Soeder, CNP

What elements need to be part of survivorship plans, and how can providers implement the standard for this care set by the Commission on Cancer (CoC)? These questions are at the heart of efforts by healthcare teams to provide follow-up care to the nation’s ever-growing numbers of cancer survivors. For insight into how these challenges impact clinical practice, Oncology Nursing News sat down with Sherry Soeder, CNP, a nurse practitioner in radiation oncology at the Cleveland Clinic Cancer Center. Soeder outlined practical suggestions to facilitate coordinated survivorship care. These include better collaboration between oncology and primary care teams, achieving leadership buy-in, and deploying digital strategies to assist in the creation of a customized care plan for each survivor.

Oncology Nursing News: What are some of the barriers to providing survivorship care?Soeder: Survivorship care is a priority on the cancer care continuum. It has been for a number of years now, stemming from the Institute of Medicine's (IOM) 2005 report: From Cancer Patient to Cancer Survivor, Lost in Transition. The IOM offered 10 recommendations at that time, and one called for the creation of treatment summaries and follow-up plans for our patients. That recommendation is now a CoC standard, and we're currently in the phase-in period of full implementation by January 2019.

Among the barriers are multiple definitions for survivors and survivorship, a shortage of primary and oncology providers—and nurses as well—and we don't have a lot of outcomes data. Specifically, there’s a need for more collaboration among provider teams, development of IT-based strategies, and leadership buy-in.

What role does collaboration play in survivorship?

In the ideal situation, a patient who is newly diagnosed will come to us, will have established care with a primary provider, but then the patient and the family and the oncology team and the primary care team all become partners in all of this. So the oncology team provides the cancer care, and at the end of it, we assemble these documents—the treatment summary, the follow-up plan. We present these to the patients at the survivorship visit. We also give these documents to the primary care team, and then everyone is on the same page, everyone knows the expectations, everyone follows the plan.

The reality of the situation is that we have more and more survivors, which is a good thing, but we also have provider shortages, fragmented care, and role confusion as to who manages which needs.

Part of how to address this involves education. The literature all very consistently advocates for education all around, for physicians, physician assistants, nurses and NPs, social workers. This means coming together—the oncology team and the primary team in joint education—teaching and learning from each other.

We're talking about physical care for cancer survivors, psychosocial adjustments, health and wellness counseling; we're talking about communication, and we're talking about collaboration and sharing this care. When we do all of that together, we're getting everything done. We're not leaving anything out, and we're not duplicating our efforts.

How does leadership buy-in affect implementation of the survivorship care standard?

The buy-in starts from the top. It filters its way through the organization. Some of it has to do with attitude—we don't have a choice, this is a mandate. But we do have a choice in how we perceive and approach it. As a group, we can either do the letter of the requirements, just the minimum to meet the standards for accreditation. Or, we can embrace the spirit of the mandate, showing that we really believe in what we're doing and providing the best care.

The IOM report said this is just good clinical practice. We need to recognize this from the top down; this is a long-term process and requires a change in the culture. There's not an endpoint here. We're going to have groups that are resistant to change, and there will be obstacles and failures. We need to have champions in our group. This means nurses, physicians, everyone involved, embrace the philosophy, they practice it, they get the information out to others, and they promote the benefits of the model.

We also need to have a flexible attitude. We need to understand that even the way survivorship care is structured in 2016 may look very different in 2017 and beyond. We're also in the phase-in period now. We're seeing more and more cancer survivors, we're doing more of these treatment summaries and more of the survivorship visits. We're going to have an ever-increasing amount of follow-up care that we need to be a part of, and that should be shared with the primary care team. So we need to do this well.

How does information technology contribute to survivorship planning?

I think it's one of the areas where we can make some of the fastest progress. Electronic medical record (EMR) use to document clinical care and for billing purposes is pretty widespread in the United States right now, though certainly not universal.

Let's take the example of a newly diagnosed patient with breast cancer who has an EMR. We take the ASCO template and link it to that record, and that patient's operative note and pathology can be auto-populated right into that treatment summary, and as that patient proceeds through treatment with chemotherapy, radiation, and further surgeries, etc., that information drops into the template. The treatment summary may someday be able to just write itself.

And when we look at the survivorship care plan, the follow-up plan going forward, it's always personalized, but the information about complications and this particular patient’s tolerance to treatment can be input as well. For instance, if that patient developed a deep vein thrombosis, in the follow-up plan we're making sure that patient is directed to the thrombosis clinic for follow-up ultrasounds, and we'll get that patient off anticoagulants at the appropriate time.

IT can help us going forward in getting patients on the proper schedule for follow-up imaging and bloodwork, for notifying patients of appointments, notifying us when results are in. It has huge potential to be a real work saver.