DOCUMENTATION REQUIREMENTS TO MEET CoC STANDARDS – 2017Chapter Three: Continuum of Care Services Tina Evans, RN, BS Director of Nursing Sharon Metzger, CTR Director of Consulting Services
Welcome Thank you for joining us today for our webinar We will take questions and comments at the end of the presentation You may enter your questions into the gray question box in the webinar tab This webinar is being recorded and the recording, slide deck and Q&As will be made available 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 3Continuum of Care Services • 3.1 Patient Navigation Process • 3.2 Psychosocial Distress Screening • 3.3 Survivorship Care Plan
Patient Navigation Process Standard 3.1 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.
Community Needs Assessment The CNA must define/identify 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
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
CNA Tips 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 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 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. 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
Barriers To Care To continually improve upon the quality of patient navigation, a new barrier should be addressed each calendar year. 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
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
SAR DOCUMENTATION Health Disparities and Barriers to Navigation:
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 processand 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 Psychosocial Distress Screening 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.
2007 IOM report Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs 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.
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. The number of eligible patients and number who received a SCP constitutes the numerator and denominator. For more information on understanding how to calculate the numerator and denominator, go the the CAnswer Forum. There are many questions and answers posted there about this topic. The number of eligible patients and number who received a SCP constitutes the numerator and denominator. For more information on understanding how to calculate the numerator and denominator, go the the CAnswer Forum. There are many questions and answers posted there about this topic.
TIP CAnswer Forum Response 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
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.
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 Survivorship Care Plan 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.
Process Requirements 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 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.
ASCO has defined the minimum data elements to be included in a treatment summary and SCP. 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 Templates 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 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 .
SAR Documentation There is a formula for calculating percentages at http://cancerbulletin.facs.org/forum…AR%20( CoC).pdf
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
Thank you We appreciate your time today. To schedule a demo of Oncolog Registry software or speak to someone, please call 800-345-6626. Visit us at: www.oncolog.com To schedule a demo of OncoNav Nurse Navigation software or speak to someone, please call 888-369-1791 Visit us at: www.onco-nav.com