The Survivorship Care Plan: More Than Just a Handoff

February 2018 Vol 9, No 2

The survivorship care plan (SCP) is used to assist cancer survivors with the transition from active treatment to the survivorship phase, and according to Staci Oertle, RN, MSN, APN, AOCNP, Nurse Practitioner, at MD Anderson Cancer Center at Cooper, Camden, NJ, all nurses play a significant role in the delivery of this vital aspect of survivorship care.

Education and guidance are needed during the survivorship phase because the life of a survivor does not return to the way it was prior to diagnosis and treatment. The SCP should be introduced to most patients at the time of diagnosis to help them navigate this challenging and complex time in the cancer continuum and begin their transition to a “new normal,” she said at the Academy of Oncology Nurse & Patient Navigators (AONN+) 8th Annual Navigation & Survivorship Conference.

The now famous 2006 Institute of Medicine report, From Cancer Patient to Cancer Survivor: Lost in Transition, drew attention to the many problems survivors face once their treatment ends. It was noted in the report that primary care physicians (PCPs) and other providers were not aware of the long-term side effects of cancer treatment, and that they often did not receive guidance from oncologists. Additionally, survivors were not being informed about how to manage the transition and often went back to their PCPs rather than continuing follow-up with their oncologists. One of the recommendations that resulted from the report was individualized SCPs for cancer survivors.

Why Is an SCP Important?

The SCP relays information to the patient and the care team about the patient’s cancer, its treatment, and the next steps of care. It improves the coordination of care by indicating who will be in charge of each of its aspects and opens the door to discussions. Studies show that providers who receive these plans are 9 times more likely to discuss survivorship care with their patients. “It’s so important to make sure that everyone involved in the patient’s care receives a copy,” she said.

A good SCP contains 2 basic aspects: a treatment summary and a follow-up plan of care. The treatment summary includes the patient’s background and personal information, lists the team involved in the patient’s care, and includes a record of the cancer diagnosis and a summary of treatments received. The follow-up plan details the expected late effects of the cancer and its treatment, as well as recommendations for care and follow-up, such as surveillance for recurrence, screening for new cancers, health promotion, and referrals to outside resources not limited to cancer care but encompassing such issues as employment and insurance.

According to Ms Oertle, there is a lack of research about the impact of SCPs on patient outcomes; therefore, it is crucial to make these plans meaningful and useful to each individual patient. She recommends conducting a needs assessment to identify existing resources and address deficiencies. “It’s difficult to have 1 person cranking out these SCPs,” she said. “Many members of the team can ‘own’ a piece of the care plan, and you need that team approach to capture revenue and provide quality survivorship care.”

Focus on the Patient, Not the Requirements

According to Patricia Leighton, MSN Ed, OCN, ONN-CG, from Greenville Health System Cancer Institute, Center for Integrative Oncology & Survivorship, Greenville, SC, buy-in from the entire care team about the value of the SCP visit can be a challenge, but effective delivery of an SCP requires a supportive oncology-trained staff dedicated to the delivery of quality survivorship care. “It’s not just about the hand-off of the SCP document,” she said.

Strong messaging must occur from providers to patients about the importance of the SCP visit, delivery of the plan should be documented, and data and metrics must be collected to ensure Commission on Cancer (CoC) compliance. However, she noted, many providers get caught up in simply meeting CoC requirements for SCPs and forget about the real goal of survivorship care: navigating the patient.

“Put less emphasis on the SCP document presentation and focus more on patient-specific lifestyle strategies and follow-up,” said Ms Leighton. “These patients need this guidance and education, and they need you to make the important referrals behind that education. And of course, one size doesn’t fit all.”

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Last modified: November 15, 2022

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