Meeting Abstract

JL528. Survivorship Care Planning in a Large, Multi-Clinic Cancer Program

Jamie Cairo, DNP, Aurora Cancer Care, and Dorry Mitchell, Aurora Health Care; Milwaukee, Wisconsin

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Abstracts From 
JADPRO Live at APSHO 2017
Marriott Marquis, Houston, Texas • November 2–5, 2017

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Background: Aurora Health Care (AHC) is comprised of 15 hospitals and 22 oncology clinics. Aurora Cancer Care, a Commission on Cancer (CoC) accredited program, diagnoses nearly 8,000 new patients with cancer a year, more than any other health system in Wisconsin. The CoC’s Survivorship Standard 3.3 requires accredited cancer programs to provide curative intent cancer patients with survivorship counseling and a care plan. AHC was challenged to develop a model of survivorship care that can work at multiple sites across the system.

Methods: Workflow planning and education began at all oncology clinics in 2014. A system wide delivery plan was developed and launched in the first quarter of 2015. In 2016 the program set a goal of targeting 25% of eligible patients. Thirteen disease-specific survivorship care plans were built into the EMR with some auto population functionality. The care plans allow for multiple disciplines to enter data during or after the patient’s treatment. The model of survivorship care delivery is an “embedded consultation” with an advanced practice provider or cancer nurse navigator completing the care plan and meeting with the patient at the end of first-line treatment. A clarity report was launched Q3 of 2016.

Results: Projected volumes were estimated based on registry data from the previous year with a goal of disseminating 1,000 care plans in 2016 to meet the 25% CoC standard. Over 1,200 care plans were generated and/or were given to patients and their primary care providers. Breast, bone marrow transplant, prostate and colorectal cancer were the most used care plan templates.

Conclusion: Data review from 2016 demonstrates success with the current workflow and model of delivery. Aurora is on track to continue to meet the CoC’s yearly benchmarks. There has been a high level of engagement with the APPs and CNNs who have taken ownership of survivorship care planning, which has contributed to the success of the program thus far. The most significant barriers identified are the difficulty in identifying and tracking curative intent cancer patients to make sure that they are scheduled for a survivorship visit and developing a consistent reporting strategy using data from the EMR.

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