Slides from On Q Health's cancer survivorship webinar on March 6, 2015. Learn more: http://bit.ly/twdemorequest Download here: http://bit.ly/1AiVwmO Topics covered: Models of SCP Delivery and Implementation, Cost/Revenue Analysis How to demonstrate value, including forecasting revenue generation by NP billable visits, using new billing codes, tracking downstream revenue and improved efficiencies How to Overcome Inefficiencies of Gathering Treatment Data Learn about the latest tools to integrate registry data with EMR data Learn about the latest tools to integrate registry data with EMR data to improve efficiency of creating care plans Speakers: Deborah K. Mayer, PhD, RN, AOCN, FAAN, Jennifer R. Klemp, PhD, MPH, Alicia Rosales, LCSW, OSW-C Moderator: Carrie Tompkins Stricker, PhD, RN, AOCN

4. WHY THE EMPHASIS ON
SURVIVORSHIP CARE?
Deborah K. Mayer, PhD, RN, AOCN, FAAN

5. Purpose of Care Plans
Survivor(
PCP(Oncologist(
• Enhance communication
• Coordinate care
• Increase surveillance
• Identify and manage long term/late effects
• Encourage health monitoring and promotion

6. Symptom Burden and
QOL in Survivors
• ~1/3 of survivors experience symptoms after
treatment equivalent to during treatment
• Most common:
– Fatigue
– Depression or mood disturbance
– Sleep disruption
– Pain
– Cognitive limitations
• Greater symptoms and poorer QOL with younger
age, lower SES, increased co-morbidities
» Wu & Harden, Cancer Nurs 5/14/14 epub ahead of print
» Harrington et al (2010) Int J Psychiatry Med, 40: 163

7. Supportive Care Needs of
Survivors Inadequately Addressed
n = 3,129 diverse cancer survivors

8. Survivor Adherence to Surveillance
Recommendations is Low
• Cancer surveillance
– 38% of older breast cancer survivors do
not receive annual mammography
• Late effects surveillance
– Only 14% to 26% of prostate cancer survivors
at risk for osteoporosis are screened/treated
– 80% of Hodgkin s Disease survivors s/p mantle
radiotherapy don t undergo recommended
echocardiograms
1. Salloum et al., 2012; 2. Schapira et al., 2000; 3.Tanvetyanon T. Cancer. 2005;103:237-241.
4. Yee EF, et al. J Gen Intern Med. 2007;22:1305-1310. Oeffinger, K.C., et al., Pediatric Blood &
Cancer, 2010. 56(5): p. 818-824.

9. Survivorship Care Planning:
The CoC Update
Survivorship Care Plan Standard 3.3. Report
Commission on Cancer updated the scope and timing of its standard
based on ASCO work:
– Jan. 1, 2015: Implement a pilot survivorship care plan process involving 10% of
eligible patients
– Jan. 1, 2016: Provide survivorship care plans to 25% of eligible patients
– Jan. 1, 2017: Provide survivorship care plans to 50% of eligible patients
– Jan. 1, 2018: Provide survivorship care plans to 75% of eligible patients
– Jan. 1, 2019: Provide survivorship care plans to all eligible patients
• During the implementation period, cancer programs should initially
concentrate on their most common disease sites, such as breast,
colorectal, prostate, early-stage bronchogenic, and lymphoma.
• Cancer Programs that have fully implemented the Standard by the time
of their on-site visit during the 2015, 2016, 2017 survey cycle, will receive
special recognition in their Performance Reports at the time of their next
survey.
https://www.facs.org/publications/newsletters/coc-source/special-source/standard33

10. CoC Endorses ASCO data elements
- now with fewer diagnosis/treatment
details
http://www.cancer.net/sites/cancer.net/files/cancer_survivorship.pdf
((

11. - BUT more emphasis on a
personalized plan
• Oncology team member contacts
• Schedule of follow up visits*
• Cancer surveillance tests for recurrence
• Cancer screening for early detection of new primaries
• Possible symptoms of cancer recurrence to report
• Late- and/or long-term effects (symptoms to report)
• A list of items (e.g. emotional or mental health,
parenting, work/employment, financial issues, and
insurance)
• Health behaviors and promotion
*who,(how(oUen,(and(where(

12. Stakeholder Perspectives
• Generally positive endorsement of SCPs
– Survivors
• have informational needs that SCPs address
• voice widespread support/desire for SCPs
– Primary care providers (PCPs)
• express lack of comfort in treating survivors
• view SCPs as fostering collaborative care
– Oncology providers
• voice support & value as a communication tool
• express pragmatic concerns about implementation
– Format, time, personnel, resources
Salz et al., 2012.

13. The Future of SCPs
“Helpful, but not good enough”
• Study evaluating SCP delivery in n = 9
academic & community cancer centers
• Key patient perspectives on SCPs from
qualitative interviews (N = 30)
– Information helpful; “wish I had received it
sooner”
– So much information is overwhelming
– Desire for more personalized information
– Need for more actionable information
• What to do, what to report
Stricker, Jacobs, Palmer et al. Unpublished preliminary data

14. WHAT IS OUR MODEL OF
SURVIVORSHIP CARE?
Alicia Rosales, LCSW, OSW-C

15. An Integrated, Multidisciplinary
Visit Model
• All staff at MSTI is responsible for understanding
the process for survivorship care
• Survivorship discussions should begin at diagnosis
– RN/MD identify patients who will likely need a
treatment summary and care plan and
implement tracking and discussions through
treatment
• All nurse practitioners, physician assistants and
social work staff participate in survivorship visits
– Ensures long term sustainability and opportunity
for program growth

16. Survivorship Delivery Model

17. Multi-Disciplinary Referrals Made to
Address Survivor Needs/Concerns
0%(
10%(
20%(
30%(
40%(
Weight(/(Physical(
AcOvity(
FaOgue(
Sexuality/Body(
Image(
Anxiety(
Caregiver/(Family(
Stress(
Depression(
35%(
30%(
27%(
23%(
17%( 16%(

18. Survivorship at MSTI:
Personnel
• Service Delivery (Integrated Approach)
• Absorbed by NP/PA staff and social
work staff
• 1.0 FTE Survivorship Program Navigator
• Responsible to develop and implement
survivorship services across the MSTI
system
• 0.5 FTE Data Integrity Analyst
• Registered Health Information
Technician (RHIT) credentialed staff who
completes all treatment summaries in
the EMR

19. Current MSTI Survivorship
Economics
Investment of Resources
! Estimated salary cost
for 90 min SW time, 75
min NP time, and 1
hour of RHIT time per
survivorship clinic
patient+ 20% indirect
cost = $141.73
Reimbursement
• Average Professional/
Facility Fee
• $272.67
• Level 3 or 4
professional fee with
extended time for
education and level 3
or 4 facility charge
Reimbursement
$150.69 or 55% of billed
amount =
6% Return on Investment

20. Reimbursement by Payer Supports
Sustainability
$150.96((
$112.14((
$153.87((
$187.18((
$0.00((
$20.00((
$40.00((
$60.00((
$80.00((
$100.00((
$120.00((
$140.00((
$160.00((
$180.00((
$200.00((
38%(
55.3%(
59%(
70%(

21. Survivorship Visit:
Improving Return on Investment
• Higher level billing (Level 4, 5) supported by
documentation of complex visit
• Technology creates opportunity for clinician
time savings
• Manual entry of treatment summaries
• Personalization of care plan template
• Reducing hidden costs
• Cost of clinician build and maintenance of
content
• Cost of IT team build and maintenance of
survivorship care plan template/content in EMR

22. WHAT IS OUR MODEL OF
SURVIVORSHIP CARE?
Deborah K. Mayer, PhD, RN, FAAN

23. Overview of UNC Model
Dr. Mayer provided a verbal overview of multiple approaches used at UNC.

24. New Billing Codes for SCPs
• Medicare has assigned CPT code 99490
• $42.60 per 30-day period for 20
minutes of chronic care activity
*Assumes you bill 12 months out of the year

25. WHAT IS OUR MODEL OF
SURVIVORSHIP CARE?
Jennifer Klemp, PhD, MPH

26. A “Modern Family”, Advanced
Practice Provider Model
26

27. 27
Health(System(
(
Clinical(Informa,on(Systems(
EHR,(Care(Plan(
Self(Management(
(&(Decision(Support(
Informed(
Ac,vated(
Pa,ent(
Prepared(
Proac,ve(
Providers(
Community(Resources(
&(Policies(
NonNprofits,(advocacy(groups(
Wellness(communi,es(
Government(agencies(
Produc,ve(
Interac,ons(
Func,onal(&(Clinical(Outcomes(
(
Delivery(System((
Design(
Cancer(Survivorship(
Care(
Adapted from: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2. Accessed July 25, 2011.
Survivorship “Chronic” Care Model

28. Opportunities for Continuing
Education: Survivorship Care Training
Web/Mobile Training Program
• Cancer Survivorship Training for Healthcare
Professionals
• CE and content matter expert developed
curriculum
www.cancersurvivorshiptraining.com

29. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ! !
!
!
!

30. Breast Cancer Model at KUMC:
Empirically Driven Services
• Follow-up clinic for survivors
– Survivorship care plan delivered as part of clinic
– Advanced practice provider led
• Goals of clinic
– Monitor risk of breast & related cancers
– Evaluate for and manage ongoing and late effects
– Reproductive health (fertility) & sexuality
– Cardiac risk & evaluation (Cardio-oncology)
– Endocrine/menopausal symptoms
– Psychosocial/cognitive function
– Genetic counseling and testing
– Weight management: diet & exercise
– Cancer Rehab/PT
30

32. Examples of Survivorship
Research and Quality Measures
(
32(
(
Delivery(of(
Care(
• Health(care(professional(knowledge/access(to(survivorship(care(
• Rural(vs(Urban(access(to(care(
• Transi,on(of(CareN(AYA,(Adult(survivors(of(childhood(cancers(
• Chronic(disease(management((including(metasta,c(disease)(
LongNterm(
Risk(Factors(
• Heart(and(Bone(Health(
• Lymphedema(
• Late/Long(Term(Effects(
Diet(&(
Exercise(
• Weight(gain(
• Nutri,onal(Support(
• DeNcondi,oned/lack(of(exercise(
Adherence(
LongNTerm(
Therapy(
• Focus(Groups(
• Side(Effects(
• Cost/Compara,ve(effec,veness(
Quality(of(
Life(
• Cogni,ve(Impairment(
• Distress/Depression(
• Fa,gue(
Sexual(
Health(
• Menopausal(symptoms(
• Loss(of(fer,lity(
• Loss(of(in,macy(
ROI:(((Quality(
Improvement,(meeOng(
naOonal(standards,(
improved(care(
coordinaOon(and(
reimbursement.(

33. Model Challenges/Solutions
CHALLENGES
• Time and resource
challenges to personalize
assessment and referrals
• Risk-based and need-driven
clinical pathways difficult to
operationalize and integrate
into EMR
• Clinical content must be
continuously updated and
maintained
• Outcome data difficult to
extract from EMR
SOLUTIONS
• Electronic patient self
assessments and screening
• Externally maintained
pathways and resources
• External content generation/
maintenance and referrals/
order sets
• Prospective, discrete data
collection on SCP outcomes
• Coordinated billing to
support level of care

34. Preventive
Service
% BCSC
(n referred)
% Primary
Care Only
% Oncology
Specialist
Only
% Neither
PCP nor
Onc
Specialist
% Both
PCP & Onc
Specialist
Colonoscopy 77 (43) 12.6 (2,466) 10.8 (203) 1.4 (221) 21.2 (3,075)
Bone Density 100 (77) 7.0 (2,466) 8.9 (203) 1.4 (221) 9.9 (3,075)
(
Klemp(JR,(et.al.,.((Breast(cancer(survivorship(care:(A(conOnuity(of(care(model(of(delivery.((J(Clin(Oncol(32,(
2014((suppl(26)(
(
Improving Surveillance Outcomes
and Downstream Referral Revenue
N=424(
100%(of(Survivors(
received(a(followN
up(Mammogram(

35. ROI and Better Risk Management
• Average age: 57.8 ± 11.0 years
• All female, non-metastatic breast
cancer
• Most common risk factors for those
seen by cardio-oncology were BMI
>25, low HDL, exercise <150 min/wk
and exposure to anthracycline
• Most common outcomes for those
seen by cardio-oncology included
further diagnostic tests, medication
changes or a return visit
92% of those
referred attended
the cardio-onc
screening visit
Klemp,(et.al.,(Prevalence(of(Cardiovascular(Risk(Factors(Among(
Breast(Cancer(Survivors(and(Appropriateness(of(Cardiology(
Referrals,C.((JCO,(31,(2013.((

36. Patient Reported Outcomes
of Risks/Ongoing Needs
(
36(
SUPPORTIVE SERVICES
NEEDS ASSESSMENT
Treating the whole person and not just the disease helps our patients recover faster.
We want to assist you throughout your cancer experience. Help us identify how to best support you.
Please complete the 3 steps below.
STEP 1
How distressed are
you feeling today?
Circle below to show
your level of distress,
10 being the highest,
0 being the lowest:
10
9
8
7
6
5
4
3
2
1
0
STEP 2 STEP 3
Please mark YES if any of the following are concerns
you have had in the PAST MONTH:
Would you like to meet with a
supportive service professional?
Please mark all that apply to you.
NO YES Practical concerns Social worker
I am interested in preparing an advance directive/living will. Psychologist
I am interested in travel or lodging information. Dietitian
I want to discuss social security or work issues. Chaplain
NO YES Emotional concerns Wellness provider
I am feeling anxious, worried or irritable. Financial counselor
I am feeling sad and crying more.
I am concerned about my relationship with people close to me. Would you like information about
other services?
Please mark all that apply to you.
NO YES Nutrition concerns
I have lost at least 5 pounds without trying.
I am eating less than I used to eat. Support group (disease, peers)
I have a physical problem or pain that keeps me from eating. Wellness group (coping, yoga, etc.)
NO YES Spiritual concerns Educational opportunities
I have religious beliefs that impact my treatment.
I have spiritual worries or concerns related to my illness. OFFICE USE ONLY
I consider prayer/meditation/worship as important to my treatment.
NO YES Physical concerns
I have a problem with pain and/or fatigue. Physician Signature
I have a physical symptom that is new for me.
I have a physical symptom that is getting worse. Nursing Signature
We want to hear your feedback. Please note any other concerns you may have:
Supportive Service Signature
Patient Information:

46. On Q Health
• Learn more about our care planning
system (On Q CPS™)
• Request a Demo
• Participate in a research study
• Call us: 800-460-3790