Michigan Survivorship Care Plan Project

Contact Name: 
Debbie Webster, BSN, RN, LMSW
Name of Institution, Organization or Community Where the Project Was Implemented: 
This project was completed and staffed by the Michigan Department of Health and Human Services. It was conducted in collaboration with the Comprehensive Cancer Agency in the Michigan Cancer Consortium.
Description of Project Setting: 

Twelve organizations, primarily Commission on Cancer (CoC)-accredited cancer centers, with a few other types of organizations.

Survivorship Care Plans
Target Population: 
Project Description: 

Survivorship Care Plans (SCPs) are documents that are given to cancer patients after completion of their treatment. They combine a summary of cancer diagnosis, given treatment, and recommended follow-up care. While most people agree that SCPs are helpful to patients, SCPs are time-consuming and therefore, hard to complete. Many health systems are currently lacking procedures to assure their creation of SCPs. This project aimed to get a consistent policy and procedure into the health care system by using a “learning collaborative” model to teach health care providers best practices in developing and delivering SCPs, and to provide them opportunities to share their experiences. [Collaborative learning is “a method of teaching and learning in which students team together to explore a significant question or create a meaningful project.” Concept to Classroom, Educational Broadcasting Corporation, 2004, http://www.thirteen.org/edonline/concept2class/coopcollab/].

Problem or Issue the Project Was Designed to Address or Improve: 

The project aimed to improve health systems’ and providers’ processes of developing and delivering SCPs to patients completing active treatment. It focused on consistency and implementation across all clinics.

Difficulties Encountered in Planning, Implementing, Evaluating or Sustaining the Project: 
The project faced resource limitations during the planning stage. It was difficult to find an organization that had enough time and experience institutionalizing survivorship care plans to provide guidance to other organizations in terms of how to do SCPs. The project also experienced clinical site drop-out due to changes in the CoC guidelines.
Project Successes: 
• 12 organizations successfully completed this project • Made SCPs a priority • Increased communication • Increased teamwork • Implemented SCPs for more than one cancer type • Focused on the system change process of implementing new programming by breaking down implementation into smaller pieces
Helpful Information Before the Project Started: 
The project would have benefited from contingency planning to address unanticipated events. For example, the project was “scoped” for 10 participants. This plan greatly underestimated demand. Twenty-two (22) organizations enrolled in the learning collaborative.
Project Significance: 
This project created a step-by-step way for organizations to break down the implementation of SCPs into smaller and more manageable pieces. Ms. Webster believed that this was the most important attribute that made the project successful. See MCC’s Survivorship Care Plan Presentation & Implementation Guide.
Lessons Learned for Patients, Caregivers and/or Communities: 
The project did not focus on patients and caregivers.
Lessons Learned for Clinicians or Health Care Professionals: 
Implementing the SCPs in a health system is a complicated process, which requires more than one decision to be made. It ends up being a lot bigger than most of the organizations think it is. Also, creating and maintaining a master list of resources to address survivors’ follow-up care needs is extremely helpful.
Lessons Learned for Researchers or Additional Research Needed: 
Research is needed to understand the implementation of learning collaboratives to institutionalize and improve the development and delivery of SCPs and evaluate this approach. It would be lovely to have some research to become a little bit more standardized so we know what elements about the care plan implementation process are most helpful to the patients.