survivorship update january 2015 the royal wolverhampton nhs trust james owen senior cancer services...
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Survivorship Update January 2015The Royal Wolverhampton NHS
TrustJames Owen
Senior Cancer Services Manager
Patient Held Care Planning Document
Urology transfer of follow up to community
CQUINs
Patient seen Discuss Treatment options and / or diagnosis Copy of document goes to patient Document scanned and saved on shared
drive Somerset Cancer Register updated Put onto patients electronic record and sent
electronically to GP
Patient Held Care Planning Document
Cancer Long Term Follow Up
Radically treated prostate cancer patients who are group are those who are: 18 months or more on from completion of
radiotherapy, surgery or other radical treatments. On-going hormonal therapy is not a contraindication.
With a stable PSA (as judged by the clinician) and no other symptoms of metastatic disease
Stable toxicity of treatment with any appropriate investigations completed (e.g. proctoscopy for rectal bleeding)
Patients receiving palliative therapy
Biochemically and clinically stable (as judged by the clinician)
Maintained on current therapy for 6 or more months No uncontrolled symptoms of malignancy Patient given information on MSCC.
Patients with Prostate Cancer on Active Surveillance Patients initially assessed by the urologists and felt to
be suitable for community follow up. PSA criteria for re-referral defined and documented on
transfer of care document (see appendix C)
Month Seen Discharge to GP Other Grand Total
May 2 2
Jun 10 10
Jul 18 1 19
Aug 18 18
Sep 34 1 35
Oct 32 32
Nov 16 16
Dec 12 12
Grand Total 142 2 144
Cancer Site No Yes% With HNA
Completed on SCRNo Yes
% With HNA Completed on SCR
No Yes% With HNA
Completed on SCRBreast 9 16 64% 4 12 75% 9 18 67%Lung 9 11 55% 2 14 88% 2 16 89%
Upper GI 9 7 44% 3 14 82% 7 7 50%
Jan-14 Feb-14 Mar-14
Table to Show the Number of Patients Diagnosed at New Cross Hospital and the Proportion of those that have had a Holistic Needs Assessment completed on the Somerset Cancer Registry System (Jan - March 2014)
Paper based HNA
eHNA• Reviewed use of paper HNA
• Visited Coventry to see it in action
• Submitted bid 14/4/14
• Bid Accepted June 2014
• Met with I.T, Macmillan and Governance July 14
• Final Agreement on kit and Governance August 14
• Ordered equipment and Mapped out pathways and surveyed
signal strength September 14
• Ipads arrived October 2014, configured Ipads and double
checked all areas for signal strength
• Correct Infection Prevention Ipad Cases arrived November 14
• Pilot Started December 14
How does eHNA work?
• Patient undertakes eHNA on Ipad
• Individual Careplan document
template created on web
• Nurse runs through Careplan
document with patient
• Careplan put on portal and SCR
updated
SCR vs Letters Talked to Oncologists and Macmillan GP
Representative Audit Letters in Oncology Design Template (with Macmillan GP
Representative) for reference when dictating letters
End of Treatment Summary
Patient DetailsLetter DateDiagnosisDiagnosis DateStage of diseaseTreatment undertakenGP actions requiredOngoing management RequiredSymptoms for referral back to the serviceRisk/late effects of TreatmentDoes the patient have a Prescription charge exemption?Is the patient on the Palliative Care or Supportive Register?Has the patient had a DS1500 form completed?Details of referrals made to other servicesSummary of patient information given (i.e. leaflets etc)Additional information relating to lifestyleTrust Contact for queries regarding the patient
End of Treatment Summary
Colorectal Pilot End of Treatment supply HNA and Personalised
management Plan Prescribe relevant workshop Tailored, Nurse led, follow up coupled with
workshop attendance
Health and Wellbeing Event / Follow Up
Health and Wellbeing Event / Follow Up
Review how this could work with other MDT teams
Operational Policy and Annual Report Update
MQUISS Standards
Volunteer Training Events
Possible Refurbishment (MQUEM)
Macmillan Information centre
Release Strategy Document (and keep to it)
New Macmillan Funded Post
Going Forward
