1. Survivorship Pathway Template
Oncology Roundtable
Survivorship Pathway Template
During Treatment
How is the survivorship phase of care introduced to the patient?
Who educates and sets expectations with the patient?
Treatment Summary, Care Plan Creation
Who creates the documents?
When do they create them?
How do they create them?
If needed: which clinician reviews, finalizes documents?
Post-Survivorship Visit
Who shares the plan with the primary care physician? When?
Who makes support service referrals?
Who documents the care plan discussion in the medical record?
Active Treatment
Survivorship
Instructions: Use this template and the embedded questions to outline the ideal survivorship pathway at your organization. Consider completing this template with a variety of key stakeholders, including survivors, cancer program physicians, PCPs, advanced practice providers, nurses, navigators, providers of support services, and cancer program administrators.
Treatment Conclusion
Who discusses next steps with patients? When do conversations take place?
What steps do you take to ensure patients feel supported, not abandoned?
If applicable: Who makes the survivorship visit referral?
If applicable: When and how does the referral happen?
Treatment Summary, Care Plan Delivery
How long after the conclusion of active treatment does delivery happen?
Is delivery timed the same for all patients?
Does delivery happen in the context of a clinical visit?
What is the agenda for the delivery meeting? (e.g. discussion of late- and long-term effects, importance of follow-up care, healthy living advice)
Which clinicians, staff members participate?
How are patient priorities included in the care plan?
Source: Oncology Roundtable interviews and analysis.