Care Plan Demonstration Project

Project Background

Cancer has become a chronic disease with many patients either living disease-free for many years after diagnosis and treatment or experiencing repeated episodes. However, research has shown that though the cancer has been treated, survivors may face ongoing difficulties in daily living. These difficulties can include returning to work, financial issues, coping issues, social issues, living a healthy lifestyle, and changes in physical abilities. However, there is little research to document cancer survivors’ needs once acute treatment has ended. The CancerBRIDGES team has created a document called a “care plan” in order to help reduce this confusion for everyone.

A small literature is developing related to care planning for cancer survivors. Many of these articles advocate for the use of care plans, describe optimal qualities of care plans, or describe the views of key stakeholders on the possible use of care plans, but perspectives from published studies of the implementation of care plans is extremely limited. The CancerBRIDGES team hopes to contribute to and advance this literature.

Description

Through this project, care plans will be created and delivered to 40 women with primary breast cancer and 20 people with head and neck cancer at the end of active treatment. At this time, measures of satisfaction with, feelings toward, usefulness of, or uptake of care plans is non-existent or in development. This lack of precedent means that the team has designed its own care plans based on a template developed by one of its members, Beth Kapusta, that includes all of the features recommended in this invitation to bid and other published recommendations. The care plans developed, which have been endorsed by oncologists at the cancer centre, contain basic diagnostic information, a treatment summary, as well as follow-up plans, coping and adjustment recommendations, healthy living recommendations, resources available for survivors, and care team contact information.

The current project uses a provincial approach with 4 types of nurses delivering the care plans for survivors in both rural and urban, cancer centre-, clinic-, and community-based programs. For breast cancer survivors, a nurse practitioner onsite at cancer centre, virtual nurse navigators in urban and rural settings, chronic disease nurse in community setting. For head and neck cancer survivors, a clinical nurse specialist will be delivering care plan in the clinic. A copy of the care plan will be given to the survivor, the patient’s family physician, and will be included in the survivor’s health record at the cancer centre. This design creates many learning opportunities for understanding barriers to implementation and assessing the success of differing delivery mechanisms. It also increases the potential range of dissemination across Canada because of these differing strategies.

Once this project is completed, recommendations will be made to Alberta Health Services and to the National CPAC Cancer Journey Action Group about implementing the care plans into every cancer patient’s treatment. In order to make informed recommendations, our team will collect and analyze feedback from the participating survivors, family physicians and the nurses delivering the care plans. This will provide information about:

• Contact summary information -time it takes to create the care plan and toolkits and deliver the care plan, process information about how the survivor medical team contacts about care plans went;
• Summary statistics on both quantitative and qualitative measures of Satisfaction, Usefulness, Emotional Reaction to, and Communication Aspects of the care plan for survivors, nurse/oncologist delivery team, and family physician.
• Cost analysis of the real costs of implementation within each of our diverse settings and estimated cost of health care utilization based on an average care plan.

Care Plan Tools

For the purposes of this project, we developed a set of tools. We offer these for use with the understanding that we do not believe our development work is done. We intend to better our care plans, using the feedback from our implementation study. We also intend to continue to collect data on the use of our Care Plan Evaluation measures. Please email Janine Giese-Davis, Ph.D. (jgieseda(at)ucalgary.ca) to obtain the password.

Once you have the password, CLICK HERE to download materials. Leave the Username field blank when entering password.

We provide the following:

For Survivors and Professionals:
1.    Care Plan Template for Breast Cancer Survivors
2.    Care Plan Template for Head and Neck Cancer Survivors

For Professionals:
1.    Care Plan Evaluation Form (Survivor Version)
2.    Care Plan Evaluation Form (Medical Professional Version)
3.    Nurse Training Manual

Results

A summary of the results for this project will be posted following completion (estimated data Febuary 2011).