Sarah Loschiavo1; Joy Elwell2; Lisa Holle3; Susan Tannenbaum4
1,3,4Neag Comprehensive Cancer Center, UConn Health, Farmington, CT
2School of Nursing, University of Connecticut, Storrs, CT
3Department of Pharmacy, University of Connecticut, Storrs, CT
3,4Department of Medicine, University of Connecticut, Storrs, CT
Background: By 2026, there will be 20 million cancer survivors in the United States. Delivering comprehensive care is the goal of cancer survivorship models. Evidence-based comprehensive survivorship care models are lacking, which is problematic for academic cancer centers who require specific survivorship standards for accreditation. In 2020, The American College of Surgeon’s Commission on Cancer (CoC) updated its survivorship standard. To maintain compliance, a new survivorship model of care was developed and implemented. A follow-up evaluation was conducted to improve care.
Objective: Identify barriers for referral to a new interprofessional cancer survivorship clinic.
Methods: The model for improvement used plan-do-study-act (PDSA) cycles. Plan: Created new survivorship clinic model, interprofessional survivorship team, and referral order; developed workflow, policies, and procedures; opened clinic. Do: Two PDSA cycles completed: barriers identified; changes implemented. Study: Retrospective chart review completed for first month of referral data, 1 month after PDSA cycle #1, and then 3 months before and after PDSA cycle #2. Descriptive statistics and run chart were utilized for data analysis.
Results: Sixty patients had referral order placed between September 2020 and May 2021 (mean age 63 years, 75% White race, 85% non-Hispanic/Latino/Spanish ethnicity, 77% female, 47% Medicare and 35% private insurance, 68% stage I cancer, and 45% breast cancer). Sixty-one percent of patients referred were accepted; however, only 47% were seen. Statistically significant evidence of associations between ethnicity and referral and cancer diagnosis and referral were identified. Run chart showed improvement over time. After PDSA cycle #2, referrals increased by 16%.
Conclusion: Designing and implementing an advanced practice registered nurse–led, interprofessional cancer survivorship model of care meets the needs of a growing population of survivors. This evidence-based model of care serves as a best practice model to improve quality of life of cancer survivors and aligns with national organizations. Referrals improved after PDSA cycles, improving compliance with the CoC survivorship standard to assure continued accreditation.
A report issued by the US Centers for Disease Control and Prevention and the National Cancer Institute, along with data from the American Cancer Society (ACS), estimates that the number of cancer survivors in the United States will reach 20 million by 2026.1 Survivors are often lost in transition once they finish treatment, moving through different systems in which few guidelines exist to assist them through the next stage of their life or help them overcome the medical and psychosocial problems that may arise.2 Many cancer survivors experience physical, psychosocial, financial, and logistical concerns, along with long-term effects of cancer and its treatment, which affect quality of life.1,2 The goal of the cancer survivorship model is to deliver comprehensive care that includes medical and psychosocial services, cancer screening, assessment of and intervention for late effects, and healthy lifestyle counseling. To date, the literature documents only a limited number of models that achieve this comprehensiveness, and few have been evaluated for health outcomes.3 Thus, the establishment of successful, evidence-based survivorship care models remains a work in progress.3 In 2020, the American College of Surgeon’s Commission on Cancer (CoC) updated its Survivorship Standard 4.8 requiring an interprofessional survivorship care team that determines a list of services to address the complex needs of cancer survivors. The current survivorship practice in our academic cancer center did not align with the CoC’s updated survivorship standard.4
Review of the Literature
The Public Health Action Model for Cancer Survivorship provides a framework for meeting the Healthy People 2020 objective: increase mental and physical health-related quality of life of cancer survivors.1 A decreased quality of life was reported in 25% of cancer survivors due to physical problems and 10% due to emotional problems.5 Late effects of cancer treatment were reported in 50% of survivors, with the most common being depression, pain, and fatigue.1 A high level of fear of recurrence was reported in 70% of posttreatment cancer survivors.3 In working-age survivors, 33% went into debt, and 3% filed for bankruptcy.6 Late effects of cancer treatments occur in approximately 50% of survivors.1
During the patients’ transition from diagnosis to acute and long-term care, cancer survivors commonly report difficulties accessing quality care, understanding and following posttreatment guidelines, and finding resources to help manage side effects that result from their treatment.7 Survivors may be discharged from the care of their oncologist and feel scared and isolated.8 They often transition their care back to their primary care physicians (PCPs) who may be unfamiliar with the specific needs of cancer survivors, including cancer-related health risks, screening guidelines, and risk-reduction methods.8 Survivorship care requires a variety of approaches to meet the needs of the growing population of survivors. Not all survivors of cancer are alike, and their needs vary across a continuum, from those who have few long-term effects from their treatment to patients with chronic conditions or significant treatment-related health issues.8
As the population of cancer survivors in the United States grows, it will become increasingly essential to optimize healthcare delivery and long-term outcomes among survivors and their caregivers. In 2004, the Institute of Medicine (IOM) convened a panel to make recommendations for improving the fragmentation and absence of coordinated care for cancer survivors in the United States. The number of cancer survivors continues to grow, yet high-quality, coordinated survivorship care is still infrequent.3 Achieving high-quality cancer survivorship care requires evidence-based guidelines for screening and surveillance; a comprehensive, multidisciplinary care infrastructure; coordination between specialists and PCPs; a survivorship care plan (SCP) with a summary of treatment; and a model that enables care assessment with the overarching goal of improving quality of care.9
Survivorship care for patients with cancer has become an essential phase of comprehensive cancer care. In 2005, the IOM released its report, From Cancer Patient to Cancer Survivor: Lost in Transition, focusing on (1) the effect of cancer and its treatments on quality of life, (2) dealing with long-term and late effects of the cancer and its treatments, (3) living with the uncertainty and fears of recurrence, and (4) adjustment and changes in self and relationships with others.10 After this report made the ongoing needs of cancer survivors more prominent, various survivorship care models arose to fulfill the unmet needs of patients and facilitate the implementation of all the essential components of survivorship care, with the hope of improving clinical outcomes and quality of life.1,11 Each model of care has advantages and disadvantages, and no one model is clearly the best for all situations.1 To date, the literature documents only a limited number of models that achieve this comprehensiveness, and few have been evaluated for health outcomes.3 “Although the cancer survivorship care literature describes a wide variety of models, no commonly accepted taxonomy exists.”12 The establishment of successful, evidence-based survivorship care models remains a work in progress.3
The Healthy People 2020 cancer survivor objective focuses on increasing the mental and physical health-related quality of life of cancer survivors.13 In addition, the American Society of Clinical Oncology (ASCO), ACS, the National Comprehensive Cancer Network (NCCN), and the CoC have developed specific survivorship guidelines to be used as a foundation for creating a comprehensive survivorship clinic model of care. However, there is no standardized best practice model of survivorship care. Publications on care models highlight the value of team-based approaches to survivorship, and national best practice guidelines serve as the foundation for providing high-quality comprehensive survivorship care. In fact, cancer survivorship needs are best addressed through interprofessional collaboration consisting of multiple cancer care professionals.14 Interdisciplinary teamwork is recognized as a gold standard for the management of cancer patients and is promoted by leading organizations such as ASCO and the CoC.15 Neither the IOM report nor the ASCO report designated the ideal survivorship care provider, indicating that teams of providers sharing specific expertise enhanced patient outcomes.14
Advanced practice registered nurses (APRNs) have the skills and training to lead survivorship clinics, fulfilling the recommendations of the IOM’s report, The Future of Nursing: Leading Change, Advancing Health.3 The development of doctor of nursing practice (DNP)-directed clinics providing evidence-based survivorship care as recommended by the ACS and ASCO guidelines can enhance quality, patient satisfaction, and population health and reduce per capita healthcare costs.16 Survivorship care delivered by nurse practitioners has been linked with cost-effectiveness, improved patient satisfaction, and quality of care.16 With adequate education, nurse practitioners will be well prepared to manage the unique needs of cancer survivors, fill the gap in the care continuum, and improve overall outcomes for long-term survivors.16
Recent changes in accreditation requirements have put cancer survivorship on the radar.3 The unique survivorship model of care created at our academic cancer center incorporates 2 key elements identified in the literature to create a new model of care. Our APRN-led interprofessional cancer survivorship model of care meets national accreditation guidelines focused on delivering comprehensive survivorship care and the Healthy People 2020 objective. This model or parts of the model of care can be implemented in cancer programs across the country and serve as a best practice model of care, ultimately filling a gap in the literature.
The purpose of this quality improvement project was to design, implement, and evaluate an interprofessional cancer survivorship clinic in an academic cancer center. The goals included (1) create a survivorship program that meets the 2020 CoC Survivorship Standard 4.8 requirements, and (2) identify barriers for referrals to a new interprofessional cancer survivorship clinic. Innovative survivorship models integrate holistic psychosocial care into survivorship care to meet the physical, emotional, psychosocial, and spiritual needs of cancer survivors.
Transition from cancer patient to cancer survivor requires a change in approach of both healthcare provider and survivor. In a perfect world, the emphasis changes from protocol-driven cancer treatment and disease surveillance to personalized care that meets all the physical, mental, and social health needs of the survivor, thus respecting survivors’ preferences and health values. The patient becomes an active participant in managing their health. Cancer survivors report that the first year after treatment is more difficult than the treatment due to a decline in social support.10 The consequence of this transition is unmet needs. Unmet needs of survivors can contribute to poorer quality of life, including greater physical impairment and symptom burden, more anxiety and depression, and persistent supportive care requirements over time.10 A high number of unmet needs is associated with low satisfaction with care, poor adherence to treatment and surveillance, and reduced perceived physical and mental health. The lower the survivor’s resilience, the worse their negative outcomes.10 During the first year after the end of treatment, most survivors have at least 1 unmet need, including the absence of emotional or social support, fear of recurrence, uncertainty about future cancer care, work issues, financial concerns, or managing side effects and complications from the cancer or its treatment.10
The transitions theory is easily applicable to use as a framework for cancer survivors transitioning to an interprofessional survivorship care model. The purpose of the middle-range transition theory is to describe, explain, and predict human beings’ experience in various types of transition.17 The basic assumption is that all nursing phenomena involve a type of transition.18 Im defined transition as “passage from one life phase, condition, or status to another.”17 The human experiences, the responses, the consequences to transitions on the well-being of people are areas of scholarship that have become central to the discipline of nursing.19 Since nursing phenomena related to cancer survivors frequently involve different types of transitions, such as situational transitions, health-illness transitions, developmental transitions, or organizational transitions, the transition theory can be easily adopted and used in nursing research, education, and practice.20 Oncology nurses frequently find themselves involved in various transitions that cancer patients and their families are experiencing throughout the process of a cancer diagnosis, treatment, and survivorship and attest to changes of nursing care needs that such transitions bring about in the lives of cancer patients and their families.20 Therefore, transition theory could provide a theoretical perspective through which cancer survivors’ transition experience and needs could be systematically and comprehensively explained and understood.20
Interdisciplinary Cancer Survivorship
Interprofessional teamwork is recognized as the gold standard for the management of cancer patients and is promoted by leading organizations such as the CoC and ASCO.4,8 This APRN-led interprofessional model of care was designed to align with the updated 2021 CoC Survivorship Standard 4.8, including the recommended survivorship program services. The foundation of the model is based on the cancer center’s APRN-led interdisciplinary palliative and supportive care program in conjunction with concepts from limited survivorship models of care found in the literature. The primary survivorship team consists of 1 survivorship coordinator (required), 1 palliative care–certified APRN, 1 licensed clinical social worker (LCSW), 1 registered dietitian (RD), 1 physical therapist (PT), 1 clinic office assistant (COA), and 5 oncology nurse navigators (ONNs). The ONN plays an integral role in the transition from cancer patient to cancer survivor by identifying patients eligible for survivorship clinic through a tracking system and notifying the primary team’s registered nurse (RN). Secondary members of the survivorship team include 1 health psychologist, 1 psychiatrist, 1 mental health counselor, primary oncology teams, and specialty care teams. All team members work in the cancer center. The survivorship clinic is embedded within the cancer center, utilizing this space for clinic days; the clinic is held twice per month. Patient appointment slots are double-booked for 2 hours to allow team members to rotate between patients.
Prior to the survivorship visit, the COA sends the patient the Cancer Survivorship Patient Screening Form, NCCN Distress Thermometer and Problem List screening tool, and Survivorship Symptom Assessment Screening Form to complete and bring to the appointment. The screening forms are reviewed and discussed by the team prior to initiating the visit. The patient is evaluated by the APRN, LCSW, RD, and PT and spends approximately 30 minutes with each specialist for a total of 2 hours. An individualized SCP and treatment summary (prepared by the APRN prior to the visit) are reviewed with the patient. Health screenings, follow-up care, and health maintenance recommendations are reviewed. Physical symptoms, and psychosocial, emotional, financial, and other needs identified during the visit are evaluated and addressed by the team members. Referrals to specialty care providers are completed as indicated. The survivorship visit progress note with embedded SCP is sent via Epic MyChart to the patient, primary oncologist, oncology team, PCP, and specialty care providers. A copy is also printed for the patient. At the completion of the visit, the patient is asked to complete a post-visit NCCN Distress Thermometer score and patient satisfaction survey.
Cancer survivorship follow-up care varies significantly based on several factors, including type of cancer, cancer stage, treatment received, and cancer-specific surveillance guidelines. In this survivorship model, personalized surveillance plans and scheduled follow-up appointments are reviewed during the visit. The patient is instructed to follow up with their primary oncology team for ongoing surveillance, screening for recurrence or secondary cancers, and their PCP for health maintenance. Patients have the option to schedule a survivorship clinic follow-up visit after the initial appointment or in the future as needed.
The Model for Improvement Utilizing PDSA Cycles
The model for improvement utilizing plan-do-study-act (PDSA) cycles was utilized to evaluate outcomes of the new interprofessional survivorship clinic model, referral patterns, and systems of care to determine variances in practice outcomes and population trends (Figure 1). The Model for Improvement has 2 parts. In the first part, the survivorship team was created, including survivorship coordinator, survivorship APRN, LCSW, RD, PT, ONN, cancer center service chief, oncology physicians, APRNs, and nursing leadership. Next, the team identified the aims, established measures, and selected changes. In the second part, changes were tested utilizing PDSA cycles. The PDSA model was created utilizing the Institute of Healthcare Improvement PDSA Tracker form.
The PLAN Phase Part 1
- Survivorship program coordinator was appointed per CoC Survivorship Standard 4.8.
- Existing survivorship process reviewed and determined not to meet the new CoC survivorship standard.
- Survivorship team established utilizing existing cancer center healthcare providers (APRN, LCSW, RD, PT).
- Electronic medical record (EMR) referral process developed and approved by the Supportive Care Program director and cancer center director.
- Referral criteria established (all patients in the Neag Comprehensive Cancer Center who complete curative treatment for stage I-III cancer should be offered a referral).
- New workflow created and approved by leadership. ONN initiates the Oncology History in the EMR; team RNs update the Oncology History during treatment. Once patient is eligible for survivorship visit, the ONN will notify the team RN, who will complete the SCP and send the referral order to the oncologist/APRN, who will approve or decline the referral.
- SCP guidelines updated to reflect the new workflow.
- Survivorship work que created under the Supportive Care (SC) department in the EMR for referrals and tested.
- Referral “ambulatory referral to cancer survivorship” created in the EMR and tested (if approved by physician/APRN), referral routed to the SC work que, and patient scheduled.
- Patient scheduled for a 2-hour visit and seen in 30-minute intervals by 4 specialty providers (APRN, LCSW, RD, PT).
- Screening forms are mailed 2 weeks in advance, and patient is instructed to complete the forms and bring them to the visit.
- Visit note templates, personalized treatment summary templates, and a symptom assessment flowsheet created in the EMR.
- SCP smart link created to embed the SCP and treatment summary into the APRN visit note to create 1 comprehensive note in the EMR.
- Patient provided a printed copy of the SCP and treatment summary at the end of the visit.
- Recommended referrals to specialty care providers/services ordered in the EMR.
- Copy of the visit note, SCP, and treatment summary sent electronically in the EMR to the patient, referring providers, PCP, and care team.
- Survivorship clinic opened on October 13, 2020.
The PLAN Phase Part 2
The PLAN Phase Part 3
The DO Phase
In the DO phase, PDSA cycles were completed to identify and improve barriers to referral. Barriers identified prior to PDSA cycle #1 included low number of referrals and survivorship clinic running over scheduled times. On January 7, 2021, PDSA cycle #1 was completed, which included moving the clinic to the first and third Thursday of the month with 2 appointment slots parallel at 9:30 am and 10:30 am to allow extra time in the afternoon to accommodate visit delays. Barriers identified prior to PDSA cycle #2 included lack of patient understanding of the survivorship clinic, patient lack of knowledge about the referral or the reason for referral, lack of provider understanding of the referral process, and process and workflow did not align with goals of all oncology teams. On February 22, 2021, PDSA cycle #2 was completed to assess changes to survivorship workflow. The survivorship workflow, policy/procedure, and process were updated with nurse education task added (clinic RN calls the patient to provide education on survivorship and reason for referral, then enters a telephone encounter in the EMR). Next, the survivorship workflow and policy/procedure were updated to offer survivorship clinic referral to all eligible breast cancer patients to assist in meeting an additional accreditation standard. Finally, a new workflow was created where the COA calls the patient 1 day prior to the visit to confirm the appointment.
The STUDY Phase
In the STUDY phase, retrospective chart reviews were completed for the first month of referral data from October 13, 2020, to November 13, 2020. Data were reviewed 1 month after PDSA cycle #1 to identify improvement from January 7, 2021, to February 21, 2021. Next, retrospective chart reviews of referral data 3 months prior to PDSA cycle #2 were completed from November 21, 2020, to February 21, 2021. Finally, retrospective chart reviews of referral data 3 months after PDSA cycle #2 were completed from February 22, 2021, to May 22, 2021.
In each chart review, the following information was collected: demographics (race, ethnicity, age, gender, PCP, insurance); referring provider; cancer stage; and cancer diagnosis. Inclusion criteria consisted of adults >18 years of age; ethnicity: no restrictions; gender: no restrictions; history of stage I-III cancer who completed curative treatment within the past year; established oncology patient in the cancer center; patient referred to the interprofessional survivorship clinic in the cancer center; patient will have an order placed by APRN/MD in Epic “ambulatory referral to cancer survivorship”; referrals placed between September 2020 and May 2021. Exclusion criteria included Department of Corrections patients.
The ACT Phase
In the ACT phase, portions of this project were adopted and adapted. The cancer center adopted the embedded interprofessional cancer survivorship clinic and model of care as part of comprehensive cancer care. The cancer center also adapted portions of the project, including updating the survivorship policy & procedure to meet the needs of all the oncology teams by creating 2 referral pathways for survivorship referrals: directly to cancer survivorship clinic or through the primary oncology team (Figure 2). The clinic was also moved to a full day on Thursdays to accommodate morning/afternoon appointments and provider scheduling challenges.
A series of tests were run to evaluate statistical significance of potential associations between patient characteristics and their acceptance of referral. For 5 characteristics (age, insurance, race, ethnicity, and cancer diagnosis), the statistical testing method utilized was the Fisher-Freeman-Halton Exact Test. The analyses for the association between gender and “acceptance of referral” were run in 2 separate ways. This occurred because an “extra patient” had been incorrectly included in the tabulations. The analyses were run twice because it was unknown if the “extra patient” in the “did not accept” group was male or female. When 1 female patient was removed from the group that “did not accept,” the P value was calculated using the Pearson Chi-Square Test. When 1 male patient was removed from the group that “did not accept,” the Fisher Exact Test was utilized. Finally, for the test that evaluated statistical significance of the difference in the number of referrals between the preintervention and postintervention periods, the P value was determined from a Bivariate Poisson Regression Analysis in which the independent variable was “time period” (preintervention vs postintervention) and the dependent variable was “number of referrals.”
Run charts are one of the most important tools for assessing the effectiveness of change.21 The run chart examining referrals to the cancer survivorship clinic showed improvement over time. The study started September 2020, the clinic opened October 2020, PDSA cycle #1 was completed January 2021, PDSA cycle #2 was completed February 2021, and study was completed May 2021.
Overall, 60 patients had an order “ambulatory referral to cancer survivorship” in the EMR placed to the cancer survivorship clinic between September 2020 and May 2021.
Identified Barriers and Implemented Changes
Barriers were identified prior to PDSA cycle #1, including small number of referrals and survivorship clinic providers running over scheduled times. On January 7, 2021, the clinic moved to the first and third Thursday to allow extra time in the afternoon if needed to accommodate visit delays. Barriers were identified prior to PDSA cycle #2, including lack of patient understanding of survivorship clinic, patient lack of knowledge about the referral or the reason for referral, lack of provider understanding of the referral process, and process and workflow did not align with the goals of the breast cancer team. On February 22, 2021, the following changes were implemented: (1) survivorship workflow, policy/procedure, and process updated with nurse education task added (clinic nurse calls the patient to provide education on survivorship and reason for referral, then enters a telephone encounter in EMR); (2) survivorship workflow and policy/procedure updated to provide 2 pathways for referrals (directly to the cancer survivorship clinic or primary oncology team with optional referral to cancer survivorship); and (3) COA calls the patient 1 day prior to the visit to confirm the appointment (Figure 2).
Survivorship Clinic Patient Characteristics
The mean age was 63 years, with 83% of patients between 50 and 79 years of age; 75% were White race, and 85% were of non-Hispanic/Latino/Spanish ethnicity. The majority (77%) of patients were female. Forty-seven percent of patients had Medicare, and 35% had private insurance. APRNs and physician assistants referred more patients (52%) compared with physicians. Most patients (68%) had stage I cancer; 45% of patients had breast cancer, and 22% had melanoma. All patients had a PCP listed in the EMR (Table).
Survivorship Clinic Referral Comparison and Analysis
Sixty-one percent of patients referred to the cancer survivorship clinic accepted the referral, and 47% of patients were seen. Six scheduled patients cancelled; reasons included not feeling well; transportation issues; childcare issues; term “survivorship was distressing”; no show; and error in referral (patient inadvertently scheduled in wrong clinic—referral was for smoking cessation). Hispanic patients were more likely to accept the referral than other ethnic groups (P <.03). Patients with melanoma were less likely to accept than other groups (P <.002).
Survivorship Clinic Run Chart
Figure 3 shows improvement of referrals to cancer survivorship clinic over time. Following PDSA cycle #2, the number of referrals increased by 16% (37.5% accepted before vs 53.3% accepted after; P <.001).
This study showed that designing and implementing an APRN-led interprofessional cancer survivorship model of care meet the needs of the growing population of survivors and aligns with the 2020 CoC Survivorship Standard 4.8 requirements. This evidence-based model of care can serve as a best practice model to improve quality of life of cancer survivors and aligns with national organization standards. Referrals improved after PDSA cycles, enhancing compliance with the CoC standard to assure continued accreditation.
Advances in cancer treatment therapies, coupled with the growing population of cancer survivors, highlight the need for healthcare systems to embrace survivorship care as a critical component of comprehensive cancer care. The literature reveals considerable heterogeneity in models of survivorship care without a standard model of care because “one size doesn’t fit all.” The recent focus of leading organizations to improve survivorship care has forced academic cancer centers across the country to examine their existing programs and attempt to create a model of care that aligns with the standard without a framework or best practice model of care to use as a guide.
Cancer survivorship needs are best addressed through interprofessional collaboration consisting of multiple cancer care professionals with the goal of improving patient quality of life and survival. A DNP-led interprofessional cancer survivorship model of care can serve as a best practice model, providing comprehensive survivorship care as recommended by several national organizations along with meeting the Healthy People 2020 objectives for cancer survivorship. Anticipated shortages in the oncology workforce may require the expanded use of APRNs to deliver survivorship care to the growing number of survivors. Survivorship care provided by APRNs demonstrated improvement in satisfaction, quality of life, and process/cost efficiency.22 APRNs have had prominent roles in leading survivorship clinics, fulfilling the recommendations of the IOM's report The Future of Nursing: Leading Change, Advancing Health.23 The development of DNP-directed clinics providing evidence-based survivorship care as recommended by ACS and ASCO guidelines will enhance quality, patient satisfaction, and population health, and reduce per capita healthcare costs.16
Most patients being referred to our cancer survivorship clinic identified as White race and non-Hispanic/Latino/Spanish ethnicity. It is critically important to advance health equity in survivorship care. The number of cancer survivors who are members of underserved groups is growing, with members of racial and ethnic minorities increasing significantly by 2030.12 The data revealed a high number of referrals between the ages of 50 and 79 years, which is consistent with the data from cancer prevalence and projections in US population from 1975-2040 showing the “Silver Tsunami” of cancer survivors whose health needs we are unprepared to meet.24
A key strength of this study is that it outlines a comprehensive cancer survivorship model of care that can be applied in various healthcare settings to align with national accreditation standards. A few important limitations need to be considered. First, the time frame occurred during the COVID-19 pandemic. Patient and staff illnesses, workflow changes, implementation of telehealth visits, safety restrictions, and patient choice to prioritize essential visits could have impacted the data and statistical analyses. Secondly, a lack of diversity impacts analyses and generalizability to a broader population. The sample size for racial and ethnic minority patients was small. However, when comparing our cancer center patient demographics and the study participants, there are several similarities. The cancer center is 88% White race compared with 75% White race in the study. Cancer center ethnicity is 92% non-Hispanic compared with 85% non-Hispanic in the study. The cancer center has 52% females compared with 77% females in the study.25
Next steps include (1) provider and staff education to increase referrals across all cancer sites, (2) explore barriers to male referrals, (3) retrospective chart review of patient distress levels using the NCCN Distress Thermometer scores before and after the interprofessional cancer survivorship visit to identify if this model of care increases or decreases distress levels, and (4) expansion to “METavivors” to improve survivorship care for patients living with advanced cancer as a chronic illness.
- Sanft T, Denlinger CS, Armenian S, et al. NCCN guidelines insights: survivorship, version 2.2019. J Natl Compr Canc Netw. 2019;17:784-794.
- Institute of Medicine of the National Academies. Cancer survivorship care planning. https://apos-society.org/wp-content/uploads/2016/06/factsheetcareplanning.pdf. 2005.
- Kline RM, Arora NK, Bradley CJ, et al. Long-term survivorship care after cancer treatment – summary of a 2017 national cancer policy forum workshop. J Natl Cancer Inst. 2018;110:1300-1310.
- American College of Surgeons. Commission on Cancer. Optimal Resources for Cancer Care. 2020 Standards. www.facs.org/-/media/files/quality-programs/cancer/coc/optimal_resources_for_cancer_care_2020_standards.ashx. Updated 2020.
- American Cancer Society. Cancer Treatment & Survivorship: Facts & Figures 2019-2021. Atlanta, GA: American Cancer Society; 2019.
- “I learned to live with it” is not good enough: Challenges reported by post-treatment cancer survivors in the Livestrong surveys. A Livestrong Report, 2010. https://prod-io.livestrong.org/sites/default/files/rs/images-email/downloads/flatfiles/what-we-do/our-approach/reports/challenges/LSSurvivorSurveyReport_final.pdf. Updated 2010.
- Rohan EA, Miller N, Bonner F 3rd, et al. Comprehensive cancer control: promoting survivor health and wellness. Cancer Causes Control. 2018; 29:1277-1285.
- American Society of Clinical Oncology. Challenges to implementing a survivorship program. www.asco.org/practice-policy/cancer-care-initiatives/prevention-survivorship/survivorship/survivorship-4. Updated 2020.
- Loonen JJ, Blijlevens NM, Prins J, et al. Cancer survivorship care: person centered care in a multidisciplinary shared care model. Int J Integr Care. 2018;18:4.
- Mayer DK, Nasso SF, Earp JA. Defining cancer survivors, their needs, and perspectives on survivorship health care in the USA. Lancet Oncol. 2017;18:E11-E18.
- Powel LL, Seibert SM. Cancer survivorship, models, and care plans: a status update. Nurs Clin North Am. 2017;52:193-209.
- Halpern MT, McCabe MS, Burg MA. The cancer survivorship journey: models of care, disparities, barriers, and future directions. Am Soc Clin Oncol Educ Book. 2016;35:231-239.
- Healthy People 2020. Objective C-14 (developmental) increase the mental and physical health-related quality of life of cancer survivors. www.healthy people.gov/2020/topics-objectives/topic/cancer/objectives.
- Rosenzweig MQ, Kota K, van Londen G. Interprofessional management of cancer survivorship: new models of care. Semin Oncol Nurs. 2017;33:449-458.
- Tremblay D, Roberge D, Touati N, et al. Effects of interdisciplinary teamwork on patient-reported experience of cancer care. BMC Health Serv Res. 2017;17:218.
- Pandey P, Nguyen V. Achieving the triple aim through doctor of nursing practice–directed breast cancer survivorship care. Journal for Nurse Practitioners. 2017;13(4):277-283.
- Im E. Situation-specific theories from the middle-range transitions theory. ANS Adv Nurs Sci. 2014;37:19-31.
- Meleis AI, Sawyer LM, Im EO, et al. Experiencing transitions: an emerging middle-range theory. ANS Adv Nurs Sci. 2000;23:12-28.
- Meleis AI. Transitions Theory: Middle-Range and Situation-Specific Theories in Nursing Research and Practice. New York, NY: Springer Publishing Company; 2010.
- Kantor D, Suzan Z. Issues of Cancer Survivorship: An Interdisciplinary Team Approach to Care. New York, NY: Wolters Kluwer; 2015.
- Institute for Healthcare Improvement. QI Essentials Toolkit: Run Chart & Control Chart. www.upstate.edu/nursing/documents/qi_tool_runchart_controlchart.pdf.
- Spears JA, Craft M, White S. Outcomes of cancer survivorship care provided by advanced practice RNs compared to other models of care: a systematic review. Oncol Nurs Forum. 2017;44:E34-E41.
- Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press (US); 2011.
- National Cancer Institute. Study Forecasts “Silver Tsunami” of Cancer Survivors. www.cancer.gov/news-events/cancer-currents-blog/2016/cancer-silver-tsunami. Updated 2016.
- UConn Health. 2020 Annual Cancer Report. https://health.uconn.edu/cancer/wp-content/uploads/sites/180/2020/12/CancerReport2020_201229.pdf. 2020.