A Team Approach to the Development of an Educational Survivorship Program Led by an Advanced Practice Nurse in a Community Cancer Center

August 2012 Vol 3, No 4
Carol Blecher, RN, MS, AOCN, APNC, CBPN-C
Trinitas Comprehensive Cancer Center, Elizabeth, New Jersey
Barry S. Levinson, MD
Trinitas Comprehensive Cancer Center, Elizabeth, New Jersey
Nancy DiLiegro, PhD, FACHE
Trinitas Comprehensive Cancer Center, Elizabeth, New Jersey
Sonal Bahl, CBPN-C
Trinitas Comprehensive Cancer Center, Elizabeth, New Jersey
Cheryl Wachtel, RD
Trinitas Comprehensive Cancer Center, Elizabeth, New Jersey

Background: According to data released by the National Cancer Institute and Centers for Disease Control and Prevention, there were 11.7 million cancer survivors in the United States in 2007, and these numbers continue to grow. Studies have shown that cancer survivors are faced with multiple challenges including psychosocial, physical, sexual/reproductive, relationship, work, and financial issues. In order to meet the complex needs of these individuals, a multidisciplinary educational team approach is vital. Care must be coordinated within the team involving primary care physicians (PCPs), oncologists, social workers, dietitians, physical therapists, complementary therapists, and nursing staff. Quality of life (QOL) must be evaluated and care plans developed with a focus on the patient’s current needs as well as the standards set by the American College of Surgeons, National Accreditation Program for Breast Centers, American Society of Clinical Oncology, and Oncology Nursing Society.

Objective: As is the case for many community hospitals, we are in a situation where we must do more with less, which requires working smarter. In order to develop a survivorship program that is valuable, the program must be utilized and deemed worthwhile by all participants. Education for all participants is an important component of getting buy-in from all team members.

Methods: We identified our core team which consists of the cancer center medical director, hospital administration, advanced practice nurse (APN), social worker, and nutritionist. Our “Stay Well Survivorship Program” consists of formal visits initially involving the APN, social worker, and nutritionist. These visits include a physical assessment, QOL evaluation, survivorship care plan review, and nutritional counseling. Potential for referrals include genetic counseling, complementary therapy services, rehabilitation/fitness services, and financial counseling. Entry points and the referral system were identified. The role of the staff in the education and referral process was delineated. Patient education for this program is introduced at the initial treatment-planning visit with the presentation of a survivorship information packet, as well as through continuous educational/support programs for patients and their families. Education is ongoing for all hospital and cancer center nursing and medical staff regarding the issues surrounding survivorship as well as a review of the information provided in the Survivorship Care Plan (Journey Forward). Letters introducing the PCPs to the program as well as office outreach programs are planned to obtain commitment from this group. Evaluation of the program is ongoing through the use of customer satisfaction surveys.

Results/Conclusions: This program was initiated in 2010, with some referrals; but recently, with changes in the organizational structure of the Cancer Center, we have become more focused on the program, continuing its development from a wellness promotion perspective. Using current evidence, we are promoting a program of quality survivorship care for our patients, as well as a value-added service for PCPs.

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