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Implementing Cancer Survivorship Care Planning: Workshop Summary
complicated, and with no electronic records and limited communication, achieving integrated coordinated care can be very difficult.
How can one address this challenge? There are many solutions on the horizon. Integrated electronic medical records will be helpful if somebody is cared for within one system but, as previously mentioned, many patients are in and out of different care settings, often with incompatible information systems. Patient navigators can help patients with communication and coordination of care to ensure completion of the recommended treatment. Posttreatment consultation planning and counseling may also help, but issues that are salient at the end of treatment may not be fully addressed at the outset. None of these strategies is widely available for patients receiving active treatment today. Transition care planning is needed to address issues of coordination of care and quality of care throughout the care trajectory.
Why is survivorship care planning needed, and why is it so vital now? The Survivorship Care Plan is a vehicle that summarizes and communicates what transpired during cancer treatment. It is, in some respects, similar to a hospital discharge summary. Imagine someone being discharged from the hospital without a discharge summary. Whether it is a short or long hospital stay, it would be very cumbersome and time-consuming for the primary care provider responsible for postdischarge care to review the hospital chart to learn what went on during the stay and to divine the care plan for his or her patient. Providers are not reimbursed for preparing the hospital discharge summary, yet completing them is legally required. This obligation to document is inculcated into students throughout medical training. In an analogous fashion, it makes common sense for treating physicians, at the conclusion of treatment, to summarize and document the episode of cancer care.
The Survivorship Care Plan also needs to be prospective and record the known and potential late effects of cancer treatments with their expected time course. This may be very challenging because, as mentioned, there is a paucity of follow-up data for some treatments. More importantly, though, oncologists need to communicate to the survivor and to the other health care providers not only what has been done, but also what needs to be done in the future. This prospective plan is especially important in light of the mobility of the patient population, as well as the difficulty in retrieving older records. If patients were routinely given a formal document at the end of treatment that explained what went on, both in technical and lay terms, it would help them wherever they went and wherever they sought later care. This record could be updated fairly easily if there were such a foundation document.
As envisioned, the Survivorship Care Plan would also function to promote a healthy lifestyle to prevent recurrence and reduce the risk of other comorbid conditions. A summary document with a recommended follow-