Peter Bach talked about the CMS Oncology Demonstration Project, and said that in this next year they will be asking oncologists to submit information on three things. One is explaining the primary purpose of the visit. Good luck on that. You can always make up something, so I guess it is not that hard. Second, whether they are following evidence-based practice guidelines. Good luck on that one too. And number three, clarifying the patient disease status according to specifications.

Phyllis Torda talked about the NCQA quality initiatives and noted that the survivorship care plan could be incorporated into several of their initiatives such as efforts to identify high risk patients and ASCO’s Quality Oncology Practice Initiative. A question asked for all the panelists was, “Who is going to be responsible for implementing the plan?”

Finally, Doug Ulman discussed empowering the patient with information and education, providing electronic records, and coordinating the care infrastructure.

During this session, the role that nurses may be able to play in the delivery of the care plans was emphasized. And that was pretty much it for this session.


Moderator: Steven Wolff, Virginia Commonwealth University

Reported by: Regina Benjamin, Bayou La Batre Rural Health Clinic

Kevin Oeffinger began our session by giving us a nice overview of the rationale for the shared care model. Pat Legant then talked about clear communication, how important it was, and the fluidity of specialty versus primary care roles, and how responsibility goes back and forth from one provider to the other, and waxes and wanes over time. Importantly, the patient has to be part of that care team. Ann Partridge discussed the fragmented nature of the healthcare system. She pointed out that we need a clear, direct definition of who is going to do what, and in what setting. Dr Partridge also discussed some of the psychosocial concerns of cancer survivors. Then I talked about how important it is, as is highlighted in the IOM report, that awareness be raised of the needs of the cancer survivors.

Speaking as a primary care physician, it is often the case that cancer patients lose touch with me as their provider. I will diagnose a patient with cancer, for example, and send them to a surgeon, and the surgeon will take care of them. Then the surgeon calls the oncologist, and I am left out of the loop and lose the patient over time. It may be a year or two before I get that patient back unless the family calls and says, “You know what those surgeons want to do?” Primary care physicians need not get left out of that

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