Survivorship care at MSTI meets new standards, allows for patient engagement and satisfaction, and improves care coordination; costs are covered by reimbursement.

No abstract

94 Background: The Commission on Cancer (CoC) standard 3.3 requires that all patients who complete cancer treatment receive a survivorship care plan (SCP). To aid in care coordination, the standard also requires that the SCP be provided to the patient’s primary care provider (PCP). St. Luke’s Mountain States Institute (MSTI) has been providing patients and PCPs with SCPs for more than 5 years. Other local accredited cancer centers also provide SCPs for their patients. Methods: In partnership with the local chapter of the American Cancer Society, MSTI created an online survey aimed at assessing the utilization of the SCP in primary care clinics and the PCP’s comfort level carrying out the recommended surveillance. The survey link was distributed through email to approximately 300 PCPs across a large geographical area in varying sized practices. Results: Sixty three responses were received in 3 weeks with 46 responses from physicians and 17 responses from advanced practice providers. All of the respondents said they care for cancer survivors in their practice but 54% have never received a SCP. Twenty nine reported having received a SCP and answered 8 questions related to how they use the SCP in practice. The majority refer to the SCP to monitor for recurrence and 52% use it as a tool for coordination of care. Forty eight percent use the SCP to manage co-morbid conditions. Ninety-five percent of all respondents indicated they feel comfortable carrying out a surveillance plan provided by the oncologist for patients 2 years out from treatment. Sixty-four percent indicated they would like additional education about caring for cancer survivors. A common theme in comments included the desire for improved communication between the oncologists and PCPs. Conclusions: This standard was created in part to improve care coordination between oncologists and PCPs. More than have of the PCPs in the MSTI service area have not seen a SCP for their patients. Most indicated they are comfortable providing surveillance if they have a clear follow-up care plan from the oncologist. More than half want additional information about caring for cancer survivors. Future exploration could include assessment of barriers to communication and utilizing the SCP in practice.

32 Background: New 2015 Commission on Cancer (CoC) standards require that all patients who complete treatment receive an individualized survivorship care plan (SCP). To meet this new standard St. Luke’s Mountain States Institute (MSTI), with support from the NCCCP, implemented a process that is multidisciplinary, efficient and sustainable. Methods: At MSTI, the patient’s SCP is a modified ASCO template with a comprehensive care plan and is prepared in the EMR by a Registered Health Information Technician (RHIT). This document is reviewed during a one hour visit with a nurse practitioner and a social worker. The patient participates in the discussion and sets wellness goals for healthy survivorship. The provider’s dictation is mailed to the PCP with the SCP. From Aug. 2011 – June 2012, 53 breast cancer patients were seen in 1 hour joint nurse practitioner/social work survivorship visits. A chart audit was conducted for these patients and follow-up phone calls were done with 36 patients at one month post-visit to evaluate patient understanding and satisfaction. Financial analysis was also completed to determine return on investment (ROI). Results: From chart review, the most common patient concerns were nutrition and weight loss (36%), anxiety (23%), fatigue (21%), depression (17%), caregiver stress (19%) and sexuality (17%). Phone calls showed high patient satisfaction and understanding. Patients rated the following statements on a Likert scale from 5=strongly agree to 1= strongly disagree: I understand my treatment summary and care plan 92% strongly agree or agree, I feel the survivorship visit met my survivorship needs, 97% strongly agree or agree, and 76% of participants were still working on wellness goals at one month. Patient accounts were reviewed showing approximately 50% ROI. Conclusions: It is possible to implement sustainable and comprehensive survivorship care that meets the new CoC standards. The model at MSTI provides increased patient engagement, patient satisfaction, and improved patient provider communication in addition to ROI. Opportunities remain to measure long term health outcomes and downstream revenues associated with this survivorship model. Project funded with Federal funds from the NCI, Contract No HHSN261200800001E.