Purpose: In 2013, 21 new cases of kidney cancer were diagnosed at the New Mexico VA Health Care System (NMVAHCS). It is essential that cancer care be proactive and veteran-centered, empowering the veteran to be involved through coordination of continuity and integration of care, safeguarding all the veteran’s health care needs. The NMVAHCS is paving the way to enhance survivorship care of veterans diagnosed with kidney cancer through the remainder of life by using the National Comprehensive Cancer Network (NCCN) guidelines.
Methods: A kidney cancer survivorship care plan note was developed, using the NCCN guidelines to provide a plan of cancer follow-up care for veterans diagnosed with kidney cancer. The care plan note is designed to communicate treatment guidelines to each member of the treatment team, including the veteran and his or her family. The plan is completed by the surgeon in the CPRS at a pivotal medical visit. The survivorship plan is auto-populated with searchable data objects that can be located and used in the medical record, reports, and at the conveyance of future medical care. The urology cancer care coordinator reviews the 7-year cancer care plan with the veteran and addresses any questions or concerns at that pivotal medical visit. The veteran is then given a copy of the care plan, which includes disease-specific information, late and long-term adverse effects, treatment and follow-up recommendations, recommended lifestyle changes, and available community resources with contact information. The care plan serves as a communication tool using the NCCN recommended follow-up standards for all multidisciplinary team members.
Results: Completion of disease-specific standardized care plans will be the benchmark of excellence in cancer care at the NMVAHCS. By using individualized care plans, which adhere to NCCN guidelines, provider inconsistencies of follow-up care will be avoided. Providing veterans with knowledge regarding the survivorship recommended plan of care promotes veteran satisfaction. Health factors incorporated into the care plan identify veterans not completing recommended follow-up; preventing veterans from being lost in the transition of care and avoiding potential adverse outcomes.
Conclusions: By the end of the fourth quarter fiscal year 2014, 100% of veterans diagnosed with kidney cancer will have a survivorship care plan completed at their postsurgical visit.
