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

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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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