Getting Survivorship Care Planning Off the Page and Into Practice

Jennifer Klemp, PhD, MPH

Jennifer Klemp, PhD, MPH

With an ever-growing number of cancer survivors has come an increased demand for survivorship care. This is a good problem to have, posing both opportunities—but also challenges—for oncology practitioners, including nurses and nurse navigators.

To learn more about the changing landscape of survivorship care, Oncology Nursing News spoke with a leading expert in the field, Jennifer Klemp, PhD, MPH, director of cancer survivorship and an associate professor at the University of Kansas Cancer Center.

In this interview, Klemp offers insights on some of the critical issues that clinicians face, among them: how to deliver optimal survivorship care, what ingredients go into the plan, how to measure progress, and how is this care reimbursed?

Why is measuring survivorship outcomes so important?

Cancer survivorship continues to evolve and there is a lot that we still don't know, including what metrics we should be using [to measure outcomes], how do we really deliver evidence-based care, and how do we pay for it?

A lot of the work that I've been doing focuses on metrics. What does the program look like? How are we making sure patients receive good survivorship care plans? And a care plan is only a recipe, so how do you make the recipe and how are you going to measure that? We measure things like how many breast cancer survivors end up getting their colonoscopy? And we've seen an estimated 27% rate go up to a 78% rate. But as we measure that, now what's our next step? We need to show this is viable as we expand outside of the breast cancer setting.

Everything nowadays has to have a metric. So I always tell practitioners, "You need to have your clinical hat on, but you also need to have a business hat on." Because if we want to really make healthcare work, we have to ask ourselves what are those outcomes? And if the outcomes aren't what we expect, why is that? Is it that we need to change our process, or is it that we're looking at the wrong outcome?

From that, you always have to consider the financial aspect as well. "Are we able to get reimbursed for [these services]?" And if you think about survivorship care plans in general, these are pieces of paper that can take a really long time to compile and prepare—over an hour. So here, we've been able to integrate that entire process into our electronic health record which, in and of itself, is an outcome—that we've taken something complicated and made it easier for our provider team.

What are some of the most important practitioner considerations in survivorship right now?

The biggest question in survivorship is, "Should we give a care plan to every patient?" I believe we should. Whether they’re a patient with a noninvasive cancer, a patient who's going to be cured, or now we have a whole new world of metastatic disease where patients live not just a short period of time, but for years.

Another point is, we need to move survivorship to the time of diagnosis. If we wait until after patients are done with treatment, we've missed an opportunity for education to mitigate any symptoms or late effects. I think that piece in general is going to be a challenge, because we're really introducing survivor-related issues for patients and their caregivers from the time they walk in our door.

Finally, how do we pay for it? How do we pay for the staff needed to deliver this type of care? And how do we report outcomes to make sure that insurers understand that it's evidence-based, and this is part of standard care that every patient should receive?

How do financial issues affect the survivorship providers?

The finance piece is a huge barrier for many patients. Patients have copays and as we know, deductibles are very high. So when you think about how to integrate survivorship care into practice, I don't want patients to have to pay extra copays for something that should be a standard part of their healthcare. At our institution, we integrate survivorship care planning into regular follow-up visits. They're extended visits, but then patients don't have to come yet another time.

And the other piece that I think has been very helpful in terms of cost is to risk stratify patients. What I mean by that is not everyone needs to go to the fertility specialist or the cardio-oncologist, but we do need to send the right populations for additional services or screening. I think if we can build in a risk-stratification model, then we're going to be much more mindful of the cost as well. It's not a one-size-fits-all model, so we have to be very structured on how we stratify those patients.

What do you hope survivorship looks like in 10 years?

Being a caregiver myself for a mother 20 years ago who went through breast cancer treatment as well as a bone marrow transplant, I've seen things change significantly from that time. But the experience is also a motivator to make things better—heart health, bone health, and all the aspects that keep a patient happy and healthy and hopefully extend quality and quantity of life.

My hope for the next 10 years is that all these pieces, which right now feel maybe a little “extra” or “boutique-y,” really become part of a comprehensive, personalized plan for a patient—from soup to nuts—and it's not something optional—it becomes part of their care.

And then, hopefully, we start preventing additional cancers by screening these patients more effectively and managing them appropriately.