Two-thirds of cancer patients live at least 5 years after diagnosis and many live for decades after treatment. The number of cancer survivors in the U.S. is estimated to be 14 million and is expected to increase to 18 million by 2020. An aging Texas population as well as continued improvements in early detection and treatment will further increase the number of Texans who will have been successfully treated. The expected increase in the number of cancer patients will be cared for by what is predicted to be a declining number of oncology specialists. Evidence based
preventive services are an important component of care intended to maximize survival and improve quality of life, however, ...

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Two-thirds of cancer patients live at least 5 years after diagnosis and many live for decades after treatment. The number of cancer survivors in the U.S. is estimated to be 14 million and is expected to increase to 18 million by 2020. An aging Texas population as well as continued improvements in early detection and treatment will further increase the number of Texans who will have been successfully treated. The expected increase in the number of cancer patients will be cared for by what is predicted to be a declining number of oncology specialists. Evidence based
preventive services are an important component of care intended to maximize survival and improve quality of life, however, they are utilized at less than recommended levels.

The
aim of this proposal is to improve evidence based prevention service delivery to those who have survived cancer diagnosed in adulthood being cared for in primary care practices. This innovative intervention is expected to promote the adoption of changes in practice systems associated with improved coordination and delivery of recommended services. It will enhance the capabilities and self-efficacy of clinicians to address the primary domains of survivorship care and will ultimately result in reduced morbidity and mortality while maximizing the quality of life for cancer survivors.

The setting is primary care training program clinical practices that care for underserved priority patient populations. The intervention utilizes a comprehensive approach to engage cancer survivors, oncology specialists and the primary care clinical team. Practice system changes will be implemented to identify cancer survivors currently receiving general medical care in the practices. The clinicians will obtain or develop treatment summaries and survivorship care plans for those patients based on best evidence and guidelines developed by recognized organizations. Procedures will be implemented to promote communication with treating oncologists or cancer centers to coordinate delivery survivorship care management to reduce duplication of effort and eliminate gaps in care.

This proposal aims to address primary prevention and lifestyle counseling, secondary prevention with surveillance and screening as well as tertiary prevention psychosocial, late and long term effects. The knowledge base of primary care clinicians related to survivorship care management will be assessed and any gaps addressed through an existing CPRIT funded online curriculum. Further online education materials and support programs will be offered as needed.

Tele-mentoring will be provided through regular interactive sessions. Led by cancer center faculty content experts and collaborating partners, this will facilitate case based problem solving, sharing of best practices provide targeted educational programming and support process improvement initiatives.

Overall goals include: Engage family medicine residency program practices in practice system change initiatives serving identified survivors by providing treatment summaries and establishing care plans coordinated with treating cancer specialists. Knowledge gaps will be addressed and practice systems interventions will be implemented to promote survivors adherence to recommended preventive services.

The intervention will also reach family members and the general patient population in the practices with prevention information and improved level of prevention service delivery. The program also serves faculty, trainees and staff members and improves the level of self-efficacy in delivery of survivorship care.

This proposal is highly innovative in addressing persistent barriers to optimal care of cancer survivors. It establishes durable practice changes that integrate use of the Treatment Summary and Survivorship Care Plan and fosters discussion among the primary care clinicians, oncology specialists and patients to better coordinate care. The program will use a tele-mentoring process to support service delivery and guideline driven management. Existing education and practice change programs developed under previous CPRIT grants will be leveraged.

Regular assessment of program outcomes will be combined with continuous improvement methodologies to promote further enhancements and sustainability.

Building on the knowledge and skills of primary care clinicians and implementing practice system changes, the project will enable the establishment of a more effective model of care delivery. Focusing on training program practices will improve delivery of recommended services while introducing trainees to the knowledge and management skills that can be carried with them into practice. Successful implementation will allow survivors to gain the maximum benefit from their treatment leading to longer duration of survivorship and optimal quality of life.

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