Complying with 2012 ACoS COC Standards

The American College of Surgeons (ACoS) Commission on Cancer (COC) issued their working draft of the 2012 Cancer Program Standards. Click here to view the updated proposed standards. Chapter 3 addresses Continuum of Care Services and that's where you'll find two standards that concern provision of survivorship services. Standard 3.1 concerns Patient Navigation, Standard 3.2 Psychosocial Distress Screening, and Standard 3.3 Survivorship Care Planning. This post will address one option for complying with the latter 2 standards.

The NCCN's Distress Management Guidelines offers a tool to monitor distress in cancer patients. It's a simple 0-10 scale for patients to grade their level of distress, similar to pain assessment. Whereas pain assessment has been called the 5th vital sign, distress assessment is being termed the 6th vital sign. Linking the two in terms of conducting regular assessments of each using a 0-10 scale may make a new assessment easier to integrate into routine clinic processes. The NCCN also provides a checklist for patients to complete that explains what specific physical or psychosocial issues they're having at the clinic visit. Providers can then respond to identified issues by making appropriate referrals to the social worker, pastoral care, counselor, dietitian, etc. A score of 4 or more, or evidence of significant distress should prompt providers to respond through referrals or addressing the source of distress. If clinics choose to use the NCCN tool, they will need to obtain permission to use the tool. We were asked to also add a disclaimer and the text for the disclaimer was provided by the NCCN. This approach has a couple of potential disadvantages. One, new version of the guideline will require revision and permission from the NCCN once again. Two, if you're going to use a tool such as this, you must have a reliable mechanism in place to make and document appropriate referrals. We chose to consider a modified tool based on the NCCN guidelines, but one which provides information to patients about available services, rather than having patients respond "yes" or "no" to a list of possible issues. You can view a draft of that tool here. Feel free to adapt it for your clinic's use. The ACoS COC standard requires cancer centers to screen for distress at least 1 time per patient at a pivotal medical visit. We have chosen the initial consult with the medical oncologist, prior to initiation of treatment; a second assessment at the treatment midpoint; and a third assessment following completion of treatment as patients enter the survivorship phase.

The standard for providing patients and primary care physicians with Survivorship Care Plans is a little more difficult to implement. We chose a brief two page document for the primary care physician. You can view a draft of it here. While it's important for the patient to receive this document as well, as a part of a complete medical record, a more useful care plan for patients is the LIVESTRONG care plan at http://livestrongcareplan.org/. We don't have a dedicated survivorship nurse to complete the care plan, so we're talking about having our case managers complete the top portion that documents past medical history, details of the diagnosis, and any cancer-related surgeries. When the patient completes radiation, the radiation nurse completes that portion, and the chemotherapy nurses complete their portion. The remaining sections can be completed by the clinic nurse at the first visit following completion of treatment. We're calling that the survivorship visit.

Standard 3.2 must be in place as of January 1, 2012, while Standard 3.3 will be phased in over the next 3 years. This is just one suggestion for how these standards might be implemented. Please share your experience and give readers other options for becoming compliant with these changes.