University of Colorado at Denver by nikeborome


									University of Colorado at Denver

                    FALL 2010

                      GINGER BORGES
                         TIM BYERS
                        LORI CRANE
                       JEAN KUTNER
                        AL MARCUS
                      JACK WESTFALL

                     BETSY RISENDAL
                    KRISTIN KILBOURN
                    KATHY JANKOWSKI
                     BILL THORLAND

                 Overall Goal

“Promote the long-term health and well-being
 of cancer survivors by facilitating the delivery
   and uptake of evidence-based, sustainable
   strategies at the patient, provider, system,
             and community level.”
                   Cancer Survivorship

 Cancer survivors are at increased risk for co-morbidities and
    new cancers
   Late and long-term side effects require ongoing surveillance
   Psychosocial morbidities are common in this population
   Specialty care needs such as fertility, genetic counseling, and
    physical therapy are also common
   Emerging evidence suggests that physical activity and weight
    management are important in reducing risk of recurrence and
    managing side effects
                 A time of opportunity….

 Communication and coordination between the patient, provider, and
  community to properly address these issues are therefore of keen
  interest in cancer survivorship.

 Primary care well-situated to coordinate these health issues in this
  population, with input from Oncology

 Patient-centered medical home provide incentives and infrastructure
  for coordination of quality cancer survivorship care

 Self-management is a key component of both Patient-Centered Medical
  Home and Chronic Care Models (“How do I talk to my family doctor
  about my cancer diagnosis?” What do I need to know as a cancer
  survivor about my health and healthcare?”)
    Chronic Disease Self-Management Program (CDSMP)

Facilitating the translation, implementation, and dissemination of this
evidence-based strategy to cancer survivors in Colorado.

Key components:
 Six week educational intervention
 Peer-led
 Produces measurable changes in self-efficacy, physical activity, and
  trend toward reduction in hospitalizations and cost effectiveness

 Evidence-based, recommended by Surgeon General
 Promotes physical activity through CDC recommended strategies
  such as goal setting and social support
 Community-based and embedded in several healthcare systems
  (0ver 300 trainers in Colorado)
 High fidelity (Master Trainer and Lay Leader, must be certified to
  deliver, manual)

 Cancer survivors throughout Colorado
 Dr. Kate Lorig (Professor, Stanford, creator of
 Consortium for Aging and Wellness (holds state-
  wide license, multiple collaborators throughout state
  including 320 certified trainers)
 Initial discussions with CDPHE, Texas A&M about
         Plans and Activities Underway

 First training of cancer survivor leaders in U.S. to
  take place in Colorado (Jan 2011) with Dr. Lorig and
  Dr. Rick Seidel (UVa, currently piloting the program)
 CPCRN mini grant to COAW to recruit trainers and
 Randomized controlled trial of curriculum to
  demonstrate effectiveness in cancer survivor (new
  target population)
           Project WIN (What is Next) –
       Cancer “Transition” Healthcare Delivery
Partnership with healthcare providers and public health to facilitate transition
  care and health promotion strategies to cancer survivors
Key components
 Series of billable group medical visits led by primary care in partnership with
  oncology, with cancer survivor themes
 Group medical visits as a model of care delivery has been successfully used in
  geriatrics, diabetes in primary care setting, with cancer patients such as with
  prostate cancer seed implementation
 Deploys evidence-based strategies of goal setting, social support, and tailored
  one-on-one counseling for increasing physical activity
 Emphasis on preventive/primary care including cancer prevention and control
 Patients will complete a Survivorship Care Plan
 Multi-disciplinary, coordinated care delivery (PT, Psychology, Primary Care,
  Oncology, Nutrition providers) billable under high level provider
 Uses social marketing theory and is “problem-focused” rather than
  “information driven”

 Clinical “Champions” at the University of Colorado
  Cancer Center and Hospital as well as Providers
  throughout Colorado
 Coordination with LAF Center of
  Excellence/THRIVE Clinical Team (Survivorship
  Clinic at UCH)
 Area Health Education Centers and Practice Based
  Research Networks in Colorado (eventual)
 Cancer survivors throughout Colorado
         Plans and Activities Underway

 Clinical leadership team sets goals and content for
 Developing Facilitator Guide for high fidelity
 Coordinate with Oncology to implement
 Disseminate through Practice Based Research
  Networks in Colorado (High Plains Research
  Network – also leader in CRC dissemination)
                Additional Efforts

 R25 submitted 9/2010 to provide cancer
 survivorship education to primary care practice-
 based research networks in Colorado

 Survivorship Survey and Scoping Study -Colorado
 site specific activity but based on interest in effort
 has grown to a workgroup activity.

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