Georgia CORE Best and Promising Practices

On November 27, 2012, we had the opportunity to speak on Survivorship Care Planning at Georgia CORE's one day seminar, held in Atlanta at the Georgia Tech Global Learning Center. The purpose of the meeting was to bring together oncology providers from around the state to discuss how best to work collaboratively to meet the ACoS 2012 Program Standards and create quality cancer programs. The standard that addresses survivorship care planning is being phased in over a three year period. By 2015, we should be providing our patients completing their first course of therapy with a Treatment Summary and Care Plan. These documents summarize the patient's cancer experience in a concise format, and offer guidelines for healthy living, optimal follow-up, and screening recommendations.
At South Georgia Medical Center, we have been doing this for about a year, and the response from our patients has been very positive. We use a template we developed locally for the Treatment Summary and pair it with a LIVESTRONG Patient Care Plan. For patients with a well-tolerated and uncomplicated diagnosis and therapies, it takes about 30-40 minutes to complete the Treatment Summary, plus an additional 10 minutes for the Care Plan. While this can be time consuming, the resulting documents are useful to the patient, the oncology team, and the primary care provider. We use a consultation model in our survivorship clinic. The Nurse Practitioner meets with the patient for an hour to review the Treatment Summary and Care Plan and discuss survivorship issues identified by the patient as concerning or causing significant distress. The patient then meets with the Dietitian and Social Worker to complete the survivorship evaluation and plan. Patients are offered a follow-up visit in 1-3 months, depending on the need. This model provides the survivor with knowledge about the next phase of care, resources to manage challenges, and three points of contact for additional follow-up as needed. Our experience is just one way to meet this standard, but we find it works well without adding a lot of additional resources. If you have experience with another approach, I hope you'll share it with us on this blog!