The transition from treatment to follow-up care: A critical time for patient navigation.

2017 ◽  
Vol 35 (5_suppl) ◽  
pp. 83-83
Author(s):  
Sam Gaster ◽  
Rita Sanem ◽  
Diane Jones-Larson ◽  
Jordan Fiegen ◽  
Jamie Arens
Keyword(s):  
Cancer Care ◽  
Patient Navigation ◽  
Critical Time ◽  
Care Plan ◽  
Survivorship Care Plan ◽  
Successful Implementation ◽  
Long Term Effects ◽  
Patient Navigators ◽  
Follow Up Care

83 Background: There are many points of transition in cancer care, and each presents a unique set of challenges for patients and providers (Nekhlyudov, Levit, Hurria, & Ganz, 2014). This includes the transition from treatment to follow-up care, or the transition to survivorship. For patients, challenges include the need for continued support, education, and communication with the cancer care team. For providers, challenges include the management of late- and long-term effects, modification of health behaviors, and coordination with other providers (IOM, 2005). These challenges can be overcome with patient navigation services. However, survivors’ access to these services is not universal. This evaluation describes the implementation and assessment of these services at six regional cancer centers in the Midwest. Methods: Key stakeholders designed a protocol for survivors to receive patient navigation after their transition to follow-up care. These navigation services are provided by nurse and social work navigators, and involve placing outbound calls to survivors. These contacts occur approximately two weeks after survivors receive a survivorship care plan (SCP) and a needs assessment. Results: From August through September 2016, 33 (91.67%) survivors were contacted by patient navigators. Three survivors could not be reached. Twenty-one percent (n = 7) of survivors contacted had not previously received navigation services. However, all survivors contacted received navigation services that would not otherwise been provided. Contacted survivors expressed high satisfaction with the services, and the most common needs addressed were anxiety and fatigue. Conclusions: Results support the value of patient navigation services for cancer survivors. This evaluation describes the successful implementation of a protocol for the continued navigation of survivors after their transition to follow-up care. Results encourage further development and evaluation of this protocol, including its impact on symptom management, health promotion, and care coordination via referrals and the provision of education and resources.

Patient Navigation and Cancer Care Delivery

2018 ◽  
Author(s):  
Harold P. Freeman ◽  
Melissa A. Simon
Keyword(s):  
Health Care ◽  
Cancer Care ◽  
Patient Navigation ◽  
Care Delivery ◽  
Clinical Care ◽  
Quality Care ◽  
Successful Implementation ◽  
Care Continuum ◽  
Patient Navigators ◽  
Health Care Delivery Systems

Although the US health care system offers the very best care to many, the poor and uninsured typically face challenges in accessing timely health care, even when faced with a life-threatening disease such as cancer. Spurred by unmet patient needs and the growing complexity of health care delivery systems, patient navigation seeks to diminish social, economic, cultural, and medical system barriers to timely quality care. This case study discusses the emergence of patient navigation as a strategy for improving cancer outcomes, especially among vulnerable populations. It explores challenges and opportunities related to advancing successful implementation of patient navigation across the cancer care continuum. It seeks to harness and apply the power and energy of patient navigators with the goal of guiding individuals across the health care continuum—from the communities where they live all the way through screening, diagnosis, and treatment at clinical care sites.

Developing a cultural and socioecological patient-centered survivorship care plan template for African American survivors.

2012 ◽  
Vol 30 (34_suppl) ◽  
pp. 40-40
Author(s):  
Kimlin T. Ashing-Giwa ◽  
Carlyn Tapp ◽  
Shirley Brown ◽  
June Smith ◽  
Eudora Mitchell ◽  
...  
Keyword(s):  
African American ◽  
Cancer Survivors ◽  
Medical Care ◽  
Care Plan ◽  
Survivorship Care Plan ◽  
Survivorship Care ◽  
Patient Centered ◽  
Community Based ◽  
Follow Up Care

40 Background: Cancer and its treatments bring added health and life challenges. Cancer survivors require ongoing surveillance and medical care. To facilitate best practice in follow-up care, the Institute of Medicine, the American Society of Clinical Oncology and advocacy organizations advise that cancer survivors be provided with treatment summaries and Survivorship Care Plan (SCP). African-American breast cancer survivors (AABCS) have poorer outcomes characterized by greater morbidity and mortality, hence warranting their careful surveillance and follow-up medical care. SCP investigations are urgently needed to improve follow-up care and cancer outcomes in AABCS. Methods: The study embraced a community-based participatory research framework, building upon a series of research projects conducted by the African American Cancer Coalition, a partnership of scientific researchers and community-based advocates. Three informative focus groups were conducted with AABCS (N=25) and advocates (N=3) to obtain input on cultural and socio-ecological SCP contents to increase patient responsiveness. Results: AABCS believed that increased mortality may be due to comorbidities and inadequate surveillance and follow-up care. Participants recommended that the SCP attend to and document all comorbidities and medications; allow for participation of primary care providers; referrals for providers especially surgeons who are familiar with treating AABCS to the reduce keloid, and health advisories on nutrition, exercise and stress management. Quality-of-life related components and community referrals should be included because they are important for overall health. AABCS noted the importance of spirituality in life, and the disproportionately high levels of socioecological stress in the community. Conclusions: Participants infused cultural and socioecologic relevance towards the development of a patient centered SCP template to increase acceptability and utilization among AABCS. Participants underscored that developing the SCP responsive to AABCS and facilitating adherence to SCP recommendations, are areas warranting increased intervention and research.

Integrating the primary care physician into cancer follow-up.

2016 ◽  
Vol 34 (3_suppl) ◽  
pp. 102-102 ◽  
Author(s):  
Andrew L. Salner ◽  
Deborah Walker ◽  
Amanda Seltzer ◽  
SarahLena Panzer ◽  
Carrie Stricker ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Primary Care ◽  
Primary Care Physician ◽  
Care Physician ◽  
Care Plan ◽  
Survivorship Care Plan ◽  
Survivorship Care ◽  
Care Plans ◽  
Follow Up Care

102 Background: After a diagnosis of breast cancer, it can be difficult for patients to understand the role their primary care physician (PCP) should play in their follow up care. Methods: 65 women (mean age 60 years, SD = 10) with breast cancer (stage 0-III) were seen by a nurse practitioner for a 60-90 minute consultative survivorship visit and received a treatment summary and personalized survivorship care plan (SCP) utilizing Carevive Care Planning Systems software. The Carevive system incorporates patient-reported and clinical data to create tailored care plans with personalized recommendations for follow up care and supportive referrals, including direction to follow up with primary care for specific care and health maintenance activities. Approximately 6 weeks following their survivorship care visit, patients completed a survey assessing their use of and satisfaction with the SCP. Patients were advised that the SCP would be mailed to their referring oncologist and primary care physician. Results: Out of 65 sent, 35 surveys have been completed to date. Survivors were diagnosed approximately 10 months prior, and all were within 6 months following completion of treatment. All patients (100%) reported that they read, or planned to read, their survivorship care plan packet carefully. While all care plans included a recommendation to follow up with their PCP, only (71%) of survivors remembered receiving this recommendation. Of those who did, most (74%) had either seen or scheduled an appointment with their PCP. Patients who reported higher anxiety at the time of the survivorship visit were more likely to report that the follow up care plan helped them take action about seeing their PCP (p = .03). Conclusions: Coordination between primary and oncology care providers has previously been shown to improve the quality of care for cancer survivors. SCPs that emphasize the importance of and activities to be undertaken in primary care may help to improve this coordination. Continuation of this research will help to better understand how to integrate the primary care physician into cancer follow up care. Updated data will be shared at time of presentation.

Impact of survivorship care plan (SCP) document on cancer survivors’ understanding of their cancer care and follow up.

2018 ◽  
Vol 36 (7_suppl) ◽  
pp. 53-53
Author(s):  
Farhan Shahzad Imran ◽  
Heather Gorea ◽  
Brittany Heatherington ◽  
Susan Hodes ◽  
Nancy Mary Pictor ◽  
...  
Keyword(s):  
Side Effects ◽  
Phase I ◽  
Cancer Survivors ◽  
Phase Ii ◽  
Cancer Care ◽  
Cancer Surveillance ◽  
Care Plan ◽  
Survivorship Care Plan ◽  
Survivorship Care

53 Background: Follow up care for cancer survivors is often sidelined due to the lack of well-defined guidelines. A “Survivorship care plan (SCP)” document has been proposed to summarize key aspects of cancer care and the future follow up plan. Survey results of cancer survivors who had not received an SCP were compared with those who did receive an SCP. Methods: Surveys were mailed to patients who had completed cancer therapy with curative intent over two phases; phase I included patients who did not receive an SCP and phase II included patients who had received an SCP. The survey was designed to test understanding of diagnosis (stage), care team, symptoms of relapse, surveillance plan, and side effects of treatment. Microsoft Excel was used to calculate descriptive statistics on the quantitative data and frequency counts for the qualitative data. Results: During Phase I, 162 cancer survivors completed the survey and reported diagnosis of colon (2%), lung (6%) or breast (90%) cancer. During Phase II, 107 cancer survivors completed the survey and reported diagnosis of colon (2%), lung (8%), breast (44%) or other (44%) cancer. For both phases, only 2% patients could not correctly identify their cancer diagnosis. Only 12% Phase I and 18% Phase II patients were unable to identify the stage of their cancer at diagnosis. Phase I patients were better able to recall discussing their follow up plan with their provider (95%) and which tests should be performed as part of their cancer surveillance (86%) when compared to Phase II patients (90% and 78%, respectively). Phase II patients were better able to identify factors associated with their cancer where 57% accurately listed symptoms suggesting cancer recurrence and 52% correctly listed potential long-term side effects of cancer treatment. Only 20% and 17% Phase I patients correctly listed examples of each, respectively. Conclusions: Although it is intuitive that an SCP would improve patient understanding, we found a less than expected impact. Patients scored similarly or less favorable in most aspects with the distribution of the SCP, but were better able to identify signs and symptoms of disease recurrence and potential side effects of treatment.

scholarly journals Strategies for Successful Survivorship Care Plan Implementation: Results From a Qualitative Study

2018 ◽  
Vol 14 (8) ◽  
pp. e462-e483 ◽  
Author(s):  
Sarah A. Birken ◽  
Alecia S. Clary ◽  
Shampa Bernstein ◽  
Jamiyla Bolton ◽  
Miriam Tardif-Douglin ◽  
...  
Keyword(s):  
Care Plan ◽  
Survivorship Care Plan ◽  
Future Research ◽  
Survivorship Care ◽  
Care Providers ◽  
Improvement Program ◽  
Care Plans ◽  
Follow Up Care ◽  
Oncology Practice

Introduction: Care for US cancer survivors is often fragmented, contributing to poor health outcomes. Care and outcomes may improve when survivors and follow-up care providers receive survivorship care plans (SCPs), written documents containing information regarding cancer diagnosis, treatment, surveillance plans, and health promotion. However, implementing SCPs is challenging. As such, we sought to identify strategies for successfully implementing SCPs. Methods: We measured SCP implementation using performance data from cancer programs participating in the American Society of Clinical Oncology Quality Oncology Practice Initiative, an oncologist-led quality assessment and improvement program. We used semistructured interviews with cancer program employees (eg, physicians) to identify strategies for successfully implementing SCPs by comparing approaches in cancer programs that, according to Quality Oncology Practice Initiative performance indicators, developed and delivered SCPs to a relatively small proportion of eligible survivors and their follow-up care providers (ie, low performers; n = 6 participants in five programs) with approaches among programs with better performance (ie, moderate performers; n = 15 participants in nine programs). Results: Ten of 14 cancer programs developed SCPs for ≥ 50% of eligible survivors; two of 14 delivered SCPs to any survivors; and eight of 14 delivered SCPs to ≥ 25% of follow-up care providers. We found that moderate performers proactively addressed SCP requirements, leveraged requirements to improve survivorship care, set internal targets, automated implementation, had active leaders and champions, and tasked appropriate employees with SCP implementation. Conclusion: SCP implementation remains challenging. We identified strategies for successfully implementing SCPs. Future research should examine how cancer programs have achieved these strategies; findings could contribute to an understanding of the changes needed to implement comprehensive survivorship care.

Enhancing the cancer survivors' experience with tailored supportive services.

2015 ◽  
Vol 33 (29_suppl) ◽  
pp. 236-236
Author(s):  
Guadalupe R. Palos ◽  
Paula A. Lewis-Patterson ◽  
Patricia Chapman ◽  
Katherine Ramsey Gilmore ◽  
Maria Alma Rodriguez
Keyword(s):  
Late Effects ◽  
Physical Symptoms ◽  
Care Plan ◽  
Survivorship Care Plan ◽  
Survivorship Care ◽  
Care Providers ◽  
Care Plans ◽  
Follow Up Care ◽  
Education Needs

236 Background: Maintaining health and well-being is a primary goal throughout the cancer experience. The dynamic nature of a survivor’s trajectory makes it difficult to tailor education and supportive care services to their actual needs. We sought to determine information and education needs preferred by survivors who had returned to their communities after completing their treatment. Methods: We partnered with survivors' advocacy groups to conduct a needs assessment with adult survivors attending a community survivorship conference. Once eligibility was confirmed, verbal consent was obtained, and instructions were given on survey completion. A modified version of the NCI Follow-Up Care Use among Survivors survey was used. Analyses focused on clinical/sociodemographic characteristics, preferences for follow-up care, information/education needs, and sources for receiving health information. Simple descriptives were used to report the results. Results: We distributed 284 questionnaires and 169 were returned, yielding a 59.5% response rate. Respondents were mostly female (79.9%), married (58.6%), college educated (81.7%) and had ver 10 post-treatment years (47.3%). 51.3% were diagnosed with breast cancer and 81.8% reported being in good to excellent health. 57.3% had follow-up cancer care, 30.8% did not recall having a discussion with their provider about late-effects, and 57.6% reported not receiving a summary care plan. 83.7% preferred to have the same provider follow them and 95.2% reported their oncologist would be their ideal doctor. Survivors preferred more information on ways to improve memory/concentration (83.9%), energy/exercise (83.3%), and maximizing the benefits of their survivorship care plan (74.6%). Preferred information sources were health care providers (78.0%) and the internet (39.3%). Conclusions: These survivors reported a high level of unmet information needs related to self-management of physical symptoms. Patient-provider communication about late-effects and benefits of survivorship care plans continues to be inadequate. Physicians and other providers are in ideal positions to initiate conversations about supportive survivorship care early in the patient experience.

Survey of cancer survivors' understanding of their cancer care and follow-up plan.

2016 ◽  
Vol 34 (3_suppl) ◽  
pp. 51-51
Author(s):  
Farhan Shahzad Imran ◽  
Caroline Andrews ◽  
Kathy Doerner ◽  
Brittany Heatherington ◽  
Susan Hodes ◽  
...  
Keyword(s):  
Side Effects ◽  
Cancer Survivors ◽  
Cancer Care ◽  
Cancer Recurrence ◽  
Cancer Surveillance ◽  
Care Plan ◽  
Survivorship Care Plan ◽  
Curative Intent

51 Background: The follow up care for cancer survivors is often sidelined due to the lack of well-defined guidelines. A “Survivorship care plan (SCP)” has been proposed to summarize key aspects of the cancer care and the future follow-up plan. Cancer survivors who had not received SCP were surveyed to gauge their understanding of their cancer care. Methods: Patients who had completed cancer therapy with curative intent during a 2 year period (2013-2014) were mailed the survey questionnaire. This questionnaire was designed to test understanding of their diagnosis (stage), care team, symptoms of relapse, surveillance plan, and short and long term side effects of their treatment. The Cancer Center’s medical record database was systematically searched to identify subjects. Microsoft Excel was used to calculate descriptive statistics on the quantitative data and frequency counts for the qualitative data. Results: 161 cancer survivors completed the survey of the total 342 mailed. The majority of these patients had breast (92%) cancer. Other cancer survivors had a diagnosis of lung (6%) and colon (2%) cancer. Only 2% patients did not know their cancer diagnosis. 12% patients did not know the stage of their cancer. 98% patients were able to report their surgeons’ name, however 85% and 89% could not recall their medical and radiation oncologist, respectively. 95% patients recalled discussing their follow-up plan with their provider but only 86% patients knew which test(s) should be performed as part of their cancer surveillance. Only 68% patients accurately listed a few symptoms suggesting cancer recurrence, while 62% survivors correctly listed a few potential long term side-effects of cancer treatment. Conclusions: There are several deficiencies in survivors’ understanding of their cancer care. Further research is needed to assess and compare if these deficits can be improved by a SCP document.

scholarly journals Correction to: Survivorship Care Plan Implementation in US Cancer Programs: a National Survey of Cancer Care Providers

2018 ◽  
Vol 34 (3) ◽  
pp. 623-623 ◽  
Author(s):  
Sarah A. Birken ◽  
Sarah Raskin ◽  
Yuqing Zhang ◽  
Gema Lane ◽  
Alexandra Zizzi ◽  
...  
Keyword(s):  
National Survey ◽  
Cancer Care ◽  
Care Plan ◽  
Survivorship Care Plan ◽  
Survivorship Care ◽  
Care Providers ◽  
Plan Implementation

scholarly journals The Role of Patient Navigators in Ambulatory Care: Overview of Systematic Reviews

2021 ◽  
Author(s):  
Hannah Budde ◽  
Gemma Williams ◽  
Juliane Winkelmann ◽  
Laura Pfirter ◽  
Claudia Bettina Maier
Keyword(s):  
Health Services ◽  
Health System ◽  
Ambulatory Care ◽  
Systematic Reviews ◽  
Patient Navigation ◽  
Transitional Care ◽  
Emergency Department Visits ◽  
Patient Navigators

Abstract Background: Patient navigators have been introduced across various countries to enable timely access to healthcare services and ensure completion of diagnosis and follow-up of care. There is an increasing amount of evidence on the positive effect of patient navigation for patients. The aim of this study was to analyse the evidence on patient navigation interventions in ambulatory care and to evaluate their effects on individuals and health system outcomes.Methods: An overview of reviews was conducted, based on a prespecified protocol. All patients in ambulatory care or transitional care setting were included in this review as long as it was related to the role of patient navigators. The study analysed all roles of patient navigators covering a wide range of health professionals such as physicians, nurses, pharmacists, social workers as well as lay health workers or community-based workers with no or very limited training. Studies including patient-related measures and health system-related outcomes were eligible for inclusion. A rigorous data collection was performed in multiple data bases. After reaching an inter-rater agreement, title and abstract screening was independently performed. Of an initial 8362 search results a total of 673 articles were eligible for full-text screening. An extraction form was used to analyse the nine included review.Results: Nine systematic reviews were included covering various patient navigation roles in cancer care, disease screening and transitional care. Seven systematic reviews primarily tailored services to ethnic minorities or other disadvantaged groups. Patient navigators performed tasks such as providing education and counselling, translations, home visits, outreach, scheduling of appointments and follow-up. Six reviews identified positive outcomes in expanding access to care, in particular for vulnerable patient groups. Two reviews on patient navigation in transitional care reported improved patient outcomes and hospital readmission rates and mixed evidence on quality of life and emergency department visits.Conclusions: Patient navigators have shown to expand access to screenings and health services for vulnerable patients or population groups who tend to underuse health services.

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