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Survivorship

Gold Standard  Employer: Trinitas Regional Medical Center

Here at Trinitas Regional Medical Center/Trinitas Comprehensive Cancer Center we follow the NCCN definition of survivorship. Patients are survivors from the day of diagnosis throughout their lives. In order to meet the complex needs of these individuals a multidisciplinary team approach is vital. Care is consistently coordinated within the team involving Oncologists, Navigator, APN, Social Worker, Dietician, Physical Therapists, Complementary Therapist and Nursing. Quality of Life is evaluated and a care plan is developed with a focus on the patient’s current needs as well as the standards set by ACOS, NAPBC, ASCO and ONS. We have designed our Survivorship Program specifically to provide value added features to all participants.  

Our core team consists of the Cancer Center Medical Director, Navigator, Hospital Administration, APN, Social Worker, Nutritionist and Physical Therapy. Prior to initiation of treatment the patient is seen by the APN who educates them regarding their treatment plan and the supportive services available including Social Work, Nutrition Services and Physical Therapy. Supportive care services are offered throughout the treatment period including palliative care, social support, nutritional evaluation and follow-up as well as physical therapy support including exercise and fitness programs. Our “Stay Well Survivorship Program” consists of formal visits initially involving the APN, Social Worker and Nutritionist. The first visit includes a physical assessment, QoL/Distress evaluation, Survivorship Care Plan Review using the Journey Forward Care Plan and Nutritional Counseling. Potential for referrals include Genetic Counseling, Complementary Therapy Services, Rehab/Fitness Services and Financial Counseling. Patient education for this program is introduced at the initial treatment planning visit with the presentation of a survivorship information packet, as well as through continuous educational /support programs for patients and their families. The patients are provided with two copies of their care plan once they have completed treatment and are instructed to give one copy to their PCP on their next visit. Here at the Trinitas Comprehensive Cancer Center/Trinitas Regional Medical Center we are focused on a wellness promotion perspective for our cancer survivors. 

Using current evidence we have developed a program of quality survivorship care for our patients and their families.