Oncology Data Management Systems · 2017-12-12 · accurately reflect the activities of the cancer...
Transcript of Oncology Data Management Systems · 2017-12-12 · accurately reflect the activities of the cancer...
Oncology Data Management Systems
DOCUMENTATION REQUIREMENTS TO
MEET CoC STANDARDS – 2017
Chapter Three: Continuum of Care Services
Tina Evans, RN, BS
Director of Nursing
Sharon Metzger, CTR
Director of Consulting Services
Welcome
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1.0 CEU has been awarded by NCRA
Goals for Today
Identify required documentation for Chapter 3 Continuum of
Care Services
Provide possible sources for the documentation
Share examples and offer suggestions on the types of
documentation required
REQUIRED DOCUMENTATION
CoC-accredited cancer programs document cancer program
activity using multiple sources, including policies,
procedures, manuals, tables and grids; however, cancer
committee minutes are the “primary source” for
documentation of cancer program activities
All meeting minutes should contain sufficient detail to
accurately reflect the activities of the cancer committee as
well as demonstrate compliance with CoC standards.
Consent agendas are not permitted
*CANCER PROGRAM STANDARDS: ENSURING PATIENT-CENTERED CARE PAGE 11
Chapter 3
Continuum of Care Services
3.1 Patient Navigation Process
3.2 Psychosocial Distress Screening
3.3 Survivorship Care Plan
Patient Navigation Process
A patient navigation process, driven by a triennial Community Needs
Assessment, is established to address health care disparities and barriers to
cancer care. Resources to address identified barriers may be provided either
on-site or by referral.
Standard 3.1
Community Needs Assessment
The cancer program’s community and local patient population
Health disparities (numerous factors can contribute to disparities in
cancer incidence and death such as race, ethnicity, gender, underserved
groups, and socioeconomic status)
Barriers to care, which may include patient-centered, provider-centered,
or health system-centered barriers
Resources available to overcome barriers on-site or by formal referral
Gaps in the availability of resources to overcome barriers
The CNA must define/identify
Community Needs Assessment
The results from the CNA serve as the building blocks for the navigation
process development, implementation, and evaluation.
The cancer committee defines the scope, selects appropriate tools to
perform the CNA, and is involved in the assessment and evaluation of
results.
Data and results of the CNA are presented to the cancer committee and
documented in the cancer committee minutes.
A new barrier should be addressed each calendar year.
CNA Tips
Utilize local, regional, state and national resources for data
Partner with your strategic planning and marketing departments to plan how to
gather the data
Gather basic demographic data from the hospital Community Health Needs
Assessment document
The CoC provides some resources on how to develop and conduct a Community
Needs Assessment which can be found on-line at
cancerbulletin.facs.org/forum...gation-process.*
These resources include: Implementing the CoC Standard 3.1: Patient
Navigation Process: A Road Map for Comprehensive Cancer Control
Professionals and Cancer Program Administrators, and Resources for
Implementing the Community Healthy Needs Assessment Process
CNA Tips
Accreditation Committee Clarifications for Standards 3.1 Patient
Navigation Process and 3.2 Psychosocial Distress Screening
Online September 2, 2014
https://www.facs.org/publications/newsletters/coc-source/special-
source/standard3132
❖* Taken from the CAnswer Forum 11-8-17
Navigation Process Requirements
Navigation processes encompass pre-diagnosis through all phases of the
cancer experience.
Address health care disparities and barriers to cancer care.
Manage resources to address identified barriers
Specialized assistance for the community, patients, families, and caregivers
to assist in overcoming barriers to receiving care and facilitating timely access to
clinical services and resources.
Barriers To Care
A barrier to care can be addressed more than one year but
must be discussed by the cancer committee and be of ongoing
importance.
TIP
Programs are allowed to address the same barrier or disparity for more
than one year as long as the cancer committee determines that
addressing the barrier is the most important concern and an ongoing
need for the community.
CAnswer Forum 3-7-17
To continually improve upon the quality of patient navigation, a
new barrier should be addressed each calendar year.
In A Nutshell….
The 3 components of Standard 3.1 are:
Conduct a Community Needs Assessment once in a 3 year
accreditation cycle
Define a patient navigation process based on the CNA findings
Identify barriers to care and how they are being managed
Document all in the minutes
Documentation
The program completes all required standard fields in the SAR
Each calendar year, the program uploads:
A copy of the results and findings of the triennial Community Needs
Assessment
Documentation of the monitoring, evaluation, and findings of the patient
navigation process including the health disparity populations served and the
barrier(s) that are addressed
Health Disparities and Barriers to Navigation:
SAR DOCUMENTATION
Date the CNA was completed Document Name
71/2013
9/12/2016
My Facility 2013 CNA.pdf
My Facility 2016 CNA.pdf
Each calendar year, the program fulfills all of the
compliance criteria:
1. Conduct a Community Needs Assessment at least once during the
three-year accreditation cycle to address health care disparities and
barriers to cancer care.
2. Establish a navigation process and identify resources to address
barriers that are provided either on-site or by referral.
3. Each calendar year, barriers to care are identified and assessed, the
navigation process is evaluated and documented. Findings are reported to
the cancer committee.
4. Each calendar year, the patient navigation process is modified or
enhanced to address the barrier or additional barriers identified by the
Community Needs Assessment
Standard 3.2
Each calendar year, the cancer committee develops and implements a
process to integrate and monitor on-site psychosocial distress screening
and referral for the provision of psychosocial care.
Psychosocial Distress Screening
2007 IOM report
Screening patients for distress and psychosocial health needs is a critical first
step to providing high-quality cancer care
Referral for the appropriate provision of high quality psycho-social cancer care
that includes systematic follow-up and reevaluation
Cancer programs must develop a process to incorporate the screening of
distress
Provide patients identified with distress the appropriate resources and/or
referral for psychosocial needs.
Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs
Process Requirements
Timing of Screening
All cancer patients must be screened at least one time at a
pivotal visit.
Method
Mode of administration is determined by the cancer committee.
The person must be trained.
Must include assessment and treatment or referral.
Tools
Cancer committee approved screening tool
Screening results must be reviewed and discussed with patients face-
to face
Assessment and referral
Results must be discussed at a medical visit by a member of the
healthcare team
Documentation
Process documented in policy and procedure
Psychosocial Services Coordinator oversees and reports
annually to the cancer committee.
many questions and answers posted there
11-07-17
Standard 3.2 requires that all cancer patients be screened at least once
during a pivotal medical visit; this does not prevent a program from
doing more frequent distress screenings. A program can convert from
the Distress Thermometer and Problem List to the Patient Health
Questionnaire for Depression PHQ-9 as long as the move is approved
by the cancer committee. The experience of patients with cancer
screened by this tool should be evaluated separately from all other
patients to ensure that they are receiving appropriate interventions
TIP
CAnswer Forum Response
Documentation
The program completes all required standard fields in the SAR.
Each calendar year, the program uploads:
The annual psychosocial services summary that documents the
methods used to monitor and evaluate the psychosocial distress
screening activities
Cancer committee minutes that document discussion of the
process and tools implemented to provide, monitor,
and evaluate the psychosocial distress screening.
SAR DOCUMENTATION
Date the annual psychosocial services summary was presented to the
cancer committee
Document Name
12/1/14 PDSCCRPT2014.pdf
12/5/15 PDSCCRPT2015.pdf
12/12/15=6 PDSCCRPT2016.pdf
Screening
Assessment
Year 1 Year 2 Year 3
Timing of screening
(Pivotal Medical visit
Transitions during
treatment (start of tx or
from chemo to RT)
Transitions during
treatment (start of tx or
from chemo to RT)
Transitions during
treatment (start of tx or
from chemo to RT)
Method (mode of
administration
Patient administered
questionnaire
Patient administered
questionnaire
Patient administered
questionnaire
Tools (Screening
tools)
Modified NCCN Modified NCCN Modified NCCN
Assessment and
Referral Process
Med or Rad Onc nurse
reviews questionnaire
w/ pt. Any score of >7
is referred to Onc SW
Med or Rad Onc nurse
reviews questionnaire
w/ pt. Any score of >7
is referred to Onc SW
Med or Rad Onc nurse
reviews questionnaire w/
pt. Any score of >7 is
referred to Onc SW
Compliance
Each calendar year, the program fulfills the compliance criteria:
The cancer committee develops and implements a process to integrate,
provide, and monitor on-site psychosocial distress screening and referral for the
provision of psychosocial care that includes all of the standard process
requirements.
All cancer patients must be screened for psychosocial distress a minimum of
one time during a pivotal medical visit as determined by the cancer program.
The psychosocial distress screening process is evaluated, documented, and
the findings are reported to the cancer committee by the Psychosocial Services
Coordinator.
Standard 3.3
The cancer committee develops and implements a process to
disseminate a treatment summary and follow-up plan to patients
who have completed cancer treatment. The process is monitored
and evaluated annually by the cancer committee.
Survivorship Care Plan
Cancer programs must develop and implement processes to monitor the formation
and dissemination of a SCP
Stage I,II, III treated with curative intent
Initial cancer occurrence
Completed active treatment
Policies and procedures identify the appropriate healthcare provider(s) from
patients’ oncology care team responsible for approving and discussing the
SCP.
Must contain input from the principal physician and oncology care team who
coordinated the oncology treatment
Process Requirements
Process Requirements
Continued
Given and discussed with the patient upon completion of active, curative
treatment
Delivery of the SCP is within one year of the diagnosis of cancer and no later
than six months after completion of adjuvant therapy (other than long-term
hormonal therapy)
The ‘one year from diagnosis’ requirement to have a SCP delivered is extended
to 18-months for patients receiving long-term hormonal therapy.
Providing the SCP by mail, electronically, or through a patient portal without
discussion with the patient does not meet the standard.
Treatment summary and follow-up care plan
The Survivorship Care Plan (SCP) is a record that:
Summarizes and communicates what transpired during active cancer treatment
Makes recommendations for follow-up care and surveillance such as
testing/examinations
Makes referrals for support services the patient may need going forward
Provides other information pertinent to the survivor’s short- and long-term
survivorship care.
At a minimum, all SCPs must include ASCO’s recommended elements
describing treatment summary and a follow-up care plan to meet compliance for
this standard.
Additional resources to assist with the development of SCPs are available
through the National Coalition for Cancer Survivorship, Journey Forward,
American Cancer Society, and LIVESTRONG
Foundation.
ASCO has defined the minimum data elements to be
included in a treatment summary and SCP.
Minimum Data Elements
Health Care Providers-Name and Institution
Cancer Type/Location/Histology/Date of Diagnosis
Stage
Treatment-Surgery/Systemic Therapy/Radiation Therapy
Procedure/Agents/body Area Treated
Ongoing Treatment
Follow-up Care Plan-Clinical Visits/Cancer Surveillance
Late and Long-term Side Effects
Psychosocial Concerns
Lifestyle Recommendations
Resources
ASCO Templates
ASCO Templates
Available for download…..
Breast
Colorectal
Prostate
Diffuse Large B-Cell Lymphoma
Lung
Generic
Documentation
The program completes all required standard fields in the SAR.
Each calendar year, the program uploads:
Policies and procedures to generate and disseminate a comprehensive
treatment summary and survivorship care plan to eligible cancer patients who
have completed cancer treatment.
The documented processes must include, at a minimum:
≫ Defined patient eligibility
≫ Identify appropriate mechanisms for generating the survivorship care plan
≫ Identify the appropriate individual(s) for delivering the survivorship care plan
≫ The method and timing of delivery of the survivorship care plan
≫ Tracking and reporting the number of SCP’s provided to patients
2016 CoC Standards Manual pg. 59
.
Documentation
A sample of a treatment summary and survivorship care plan that is used by
the cancer program
Cancer committee minutes that document the annual number of eligible
patients that were provided a SCP
Cancer committee minutes that document the annual evaluation of the SCP
processes and the outcomes of the evaluation
During the on-site visit, the surveyor will discuss with the cancer committee
the process implemented to create and disseminate SCPs for eligible
patients.
2016 CoC Standards Manual pg. 59
Compliance: Effective January 1, 2018
1. A survivorship care program (SCP) with a designated leader is in
place.
2. The cancer committee has policies and procedures in place for the
generation and dissemination of a SCP to all eligible cancer patients who
have completed cancer treatment.
3. The number of patients who received a SCP equals or exceeds 50
percent of all eligible patients (or a corrective written action plan is
developed and implemented that can demonstrate compliance with the
standard over time).
4. The SCP process is monitored, evaluated, and presented to the
cancer committee and documented in the cancer committee minutes.
Details regarding the revisions will be published in the January
issue of the Bulletin.
All requirements for the revised Standard 3.3 will become
effective on January 1, 2018, with the sole exception of the
establishment and implementation of the survivorship care
program (including the appointment of a program leader),
which will not go into effect as a requirement until January 1,
2019.
TIPS
Keep it simple until you have a working process in place
Leverage your electronic resources such as the cancer registry
Dedicate specific position(s) to manage the SCP process
Use your navigator(s) or navigation process to gather data
throughout the active treatment phase of care
There is a formula for calculating percentages at
http://cancerbulletin.facs.org/forum…AR%20( CoC).pdf
SAR Documentation
Resources to assist you in meeting
documentation requirements:
CAnswer Forum http://cancerbulletin.facs.org/forums/
Standards Resource Library
http://cancerbulletin.facs.org/forums/CAnswerForumHome/StandardResource
Library
CoC Webinars in CoC Datalinks
Cancer Program Standards: Ensuring Patient-Center Guidelines 2016
Onco-Nav.com webinar series
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