More Than One Way to Provide Survivorship Care

July 2016 Vol 7, No 6

At the 2016 Oncology Nursing Society Annual Congress, nurses from different practice settings described the various ways in which they have developed and implemented survivorship care plans, which are expected to be needed for more than 18 million individuals within 10 years.

Outsourcing to the Community

“Ours is a small private care setting, so resources for providing survivorship care are limited. We have to refer out, while hospital-based practices may have these resources within arm’s length,” said Amita Patel, MSN, NP-C, OCN, of Regional Cancer Care Associates LLC in central New Jersey. “We reached out to various health professionals in our community to provide counseling in their respective areas of expertise.”

Coauthor Shannon Woerner, MSN, ANP-BC, OCN, added, “We probably treated hundreds of patients before we had a mechanism in place to capture patients in the adjuvant setting.”

The aim of these oncology nurses was to increase awareness about survivorship and to develop outside resources that could enhance a comprehensive survivorship program. They now ensure that all patients receiving adjuvant treatment have survivorship visits after completing therapy; this follows the ASCO Survivorship Care Plan. They reached out to potential resources in the community by letter, and got a good response.

The resource list currently includes dietitians, psychologists, and health maintenance and smoking cessation specialists. These potential referral sources are compiled and centralized into a computer folder for easy access during patient visits. Their list currently holds about 10 nutritionists, 15 mental health providers, and 7 pulmonologists (for smoking cessation).

“As the practice is getting bigger, we are branching out, and we are trying to reach into new geographic locations to make connections,” Ms Woerner said.

With greater attention to survivorship, their survivorship visits more than doubled between 2014 and 2015. Primary care physicians receive copies of the patients’ survivorship care plans, helping to transition them back to their main provider.

The nurses also determined that the percentage of “satisfied” patients jumped by more than 10 points with a better survivorship plan in place.

They are now looking for community resources for fertility and genetic counseling.

Managing a Survivorship Program “From Afar”

A survivorship care plan was described “from a nurse coordinator perspective” by Amy Monroe, BSN, RN, CNOR, of Froedtert Hospital and the Medical College of Wisconsin, Milwaukee. The program was started almost 3 years ago within the gynecologic oncology department for patients with stage 1a endometrial cancer and has since expanded. According to Ms Monroe, the process works—but is not ideal.

This department was one of the first to develop an innovative model for providing survivorship care plans to patients. Early buy-in from providers was due to an advanced practice provider promoting the use of the survivorship care plans, but the plan was actually developed and is being implemented by Ms Monroe, a nurse coordinator.

“There were no additional full-time employee resources available for this process, so the program needed to absorb the work with the current team,” she explained. She is not embedded within the clinic but has an office elsewhere in the hospital where she also serves as a new patient coordinator.

“I come down to the clinic when the patient is being seen by the provider,” she said.

The point of her poster, she said, was to show that “you can tap a person who is not actually in the clinic to be your survivorship coordinator.”

New patients are captured by the nurse coordinator at the weekly tumor conference, and established patients are forwarded to Ms Monroe via the electronic health record (EHR). She keeps track of all patients in the EHR, fills out the survivorship care plans, and meets with each patient to explain the plan.

She sees more than 50 patients a year after they complete chemotherapy, but preferably not on the first post-op visit. “I found that when I saw them that early, there was too much going on,” she said.

This role has its challenges, she acknowledged. The current process is not sustainable for meeting the survivorship needs of all eligible patients. She often wastes time waiting for patients and could benefit from having a scheduling template. She would prefer to meet patients first on another visit. And it is difficult to “figure out the denominator” for the required number of care plans per year to satisfy the Commission on Cancer, she said.

While the process is at least reaching survivors with critical information, she added, “consideration should be given to the development of a survivorship clinic.”

Hospital-Based Nurse Navigator Helps Community Oncologists

Claire98px“The oncology nurse navigator is uniquely positioned to take the lead in care coordination of cancer survivors,” according to Claire Sutherby, BSN, RN, CMSRN, of Deaconess Hospital in Newburgh, IN.

Deaconess’ Cancer Committee adopted the ASCO Survivorship Care Plan templates and added a survivorship nurse navigator to its multidisciplinary treatment team, which also includes medical, radiation, gynecologic and urologic oncologists, a genetic counselor, a pharmacist, and support therapy clinicians, she said.

The survivorship nurse navigator reviews and monitors individualized survivorship care plans with patients after they complete their primary treatment. The navigator also advises patients when to seek treatment for side effects or concerns, discusses surveillance guidelines, navigates the patient through support therapies, and provides education on cancer prevention and screening.

Ms Sutherby sees patients with malignancies other than breast, lung, and head and neck cancers, which have their own navigators. She is hospital-based, but coordinates care for patients of 5 oncologists who practice in multiple locations in the community without survivorship care systems.

“I use the ASCO template and add the recommended screening, information on side effects and so forth depending on their type of cancer,” she said.

Ms Sutherby, who receives a list of patients from the cancer registry, enters them into her Outlook calendar, determines their anticipated date of treatment completion, and schedules the survivorship visits. She currently has about 300 patients eligible for survivorship care planning.

“The development of the cancer survivorship program within the interprofessional care team will not only meet the objectives of the Institute of Medicine and Commission on Cancer but also improve the navigation of care for cancer survivors through the continuum of care,” she pointed out.


Patel A, Woerner S, Flocco T. Nurse practitioners develop a comprehensive survivorship program in the private practice setting. 2016 Oncology Nursing Society Annual Congress. Poster 9.

Monroe A. Survivorship care plan delivery process from a nurse coordinator perspective. 2016 Oncology Nursing Society Annual Congress. Poster 11.

Sutherby C, Wilson D. The survivorship journey: development and implementation of a survivorship care plan program. 2016 Oncology Nursing Society Annual Congress. Poster 58.

Related Articles
Category VIII: Survivorship and End of Life
November 2020 Vol 11, No 11
Transitioning Patients After Breast Cancer Treatment: Implementing Survivorship Care Plans
October 2015 Vol 6, No 5
With the increasing number of cancer survivors and their complex needs, new models of care are needed to aid patients in their transition to survivorship care. An individualized treatment summary and survivorship care plan can help patients and healthcare providers smoothly transition to survivorship care in a community-based setting.
Will a 6-Week Zen Connection Program Impact Integrative Holistic Care for Breast Cancer Survivors?
Sharon Inzetta, RN, MS, CBCN, CN-BN
November 2019 Vol 10, No 11
Last modified: March 10, 2021

Subscribe to the Journal of Oncology Navigation & Survivorship®

To sign up for our print publication or e-newsletter, please enter your contact information below.

  • First Name *
    Last Name *
    Profession or Role
    Primary Specialty or Disease State
  • Please enter your mailing address.

    Address Line 2
    Zip Code