Developing a survivorship care plan (SCP) delivery process for patients and primary care providers serving poor, rural, and minority patients with cancer

Abstract

Background Survivorship care plans (SCPs) summarize patients’ treatment and act as an education and communication tool between oncologists and primary care providers (PCPs). But creation and delivery of SCPs are challenging, labor intensive, and costly. The University of New Mexico Comprehensive Cancer Center (UNM CCC) treats a poor, rural, and minority patient population, and our purpose was to implement and evaluate a process to create and deliver SCPs to patients and PCPs. Methods Providers placed an electronic SCP order, basic information was imported, and staff compiled treatment details. Flagged SCPs were then ready for delivery, providers approved of and delivered the SCP at the next encounter, and the SCP was sent to the PCP. Results By April 2020, 283 SCPs were ordered, 241 (85.2%) were created by the designated staff, and 97 (34.2%) were given to patients after definitive therapy for breast cancer (59.1%), gynecological cancers (10.8%), prostate cancer (7.4%), colorectal cancer (5.1%), and lymphomas (4.8%). Of 97 SCPs eligible to be sent to PCPs, 75 (77.3%) were mailed or sent via EMR. Of the 41 (48.9%) SCPs sent via mail or fax, only 8 (8.3%) were received and 5 (5.2%) integrated. Conclusions This study shows that SCPs can be delivered to patients in a poor, rural, and minority patient population but that PCP receipt and integration of SCPs are poor. Future efforts need to ensure that an oncologist to PCP education and communication tool is able reach and be integrated by PCPs.

Adolescent and Young Adult (AYA) Cancer Survivorship Practices: An Overview

“…According to the IOM, survivorship should be recognized as a distinct phase in cancer care in which survivors’ concerns should be addressed [ 118 ]. SCPs are aimed to inform, support communication, and facilitate self-care of the cancer survivor regarding their cancer diagnosis, treatment, and follow-up [ 149 , 150 ]. It provides an overview of the survivor’s diagnosis and treatment, including follow-up schedules, recommendations for early detection, and management of treatment-related effects and other health problems [ 118 , 151 ].…”

“…It provides an overview of the survivor’s diagnosis and treatment, including follow-up schedules, recommendations for early detection, and management of treatment-related effects and other health problems [ 118 , 151 ]. Despite widespread effort, the use of SCPs in practice remains suboptimal, and evidence regarding their impact on survivors’ outcomes is limited [ 150 , 151 , 152 , 153 ]. Hill and colleagues performed a systematic review and meta-analysis of care plan outcomes suggesting that SCPs seem feasible and can have a positive impact on HCPs’ knowledge (e.g., regarding late effects, survivorship care), but there is a lack of evidence that SCPs have an impact on the patient-reported outcomes of survivors [ 151 ].…”

Characterizing Low-Risk Breast and Gynecological Cancer Patients for Transition into an Oncology/Primary Care Coordinated Care Model: Findings from a Survey of Diverse Survivors in a Rural U.S. State

“…In others, they reference a PCP that has left their clinic, and they have yet to re-establish care with a new provider. Such insights reveal the importance of gathering specific data on the context of care access as precursors to engaging PCPs in continuous and coordinated care management for cancer patients [30].…”

Utility of survivorship care plans: A mixed‐method study exploring general practitioners’ and cancer specialists’ views

“…13 In research settings, the rate of SCP receipt ranged from 8% to 74%. 19,20 One strategy would be to use a secure notification sys-tem to raise awareness and inform cancer specialists and GP SCP are available and provide guidance on how they can access it. We used a similar strategy to address our previous audit results of SCSC attendees, where the review of the SCP with survivors became an important part of the initial consultation to improve awareness and promote SCP use.…”