PCSM-02SURVIVORSHIP CARE PLANNING IN THE NEURO-ONCOLOGY CLINIC

Abstract

A 2006 Institute of Medicine report recommended that cancer survivorship care planning be implemented into comprehensive care of the patient with cancer. Survivorship care planning is a planned approach to addressing 1) prevention of late effects, 2) surveillance for cancer progression or late effects, 3) intervention for symptoms arising from the cancer or its treatment, and 4) coordination of care amongst healthcare providers. In response to the recommendations, we developed a cancer survivor component of care that was added to the current clinical program and delivered by advanced practice nurses. Survivorship care planning was implemented at completion of the concomitant phase of treatment, upon completion of the adjuvant phase of treatment, and at any time treatment changed. A survivorship care plan template was developed as part of the electronic medical record (EMR) and used to guide survivor discussions. The care plan addressed the four key aspects above with recommendations for interventions related to each aspect. Inclusion of the care plan in the EMR allowed all neuro-oncology team members to provide input into and be able to view the plan collectively; the plan was also shared electronically with the primary provider. Ongoing symptoms were identified using patient self-report data to supplement the examination, and addressed on an individual basis with additional referral to a web-based self-management program. Research about program efficacy is ongoing. Challenges were encountered in identifying reimbursement options and program adaptation to a wide variety of tumor types. A multidisciplinary approach was found to be most helpful in implementing survivorship care planning into comprehensive care for the person with a brain tumor.