Cancer Survivorship Care Plans Research Articles

Determinants of quality prostate cancer survivorship care across the primary and specialty care interface: Lessons from the Veterans Health Administration.

BackgroundWith over 3 million US prostate cancer survivors, ensuring high‐quality, coordinated cancer survivorship care is important. However, implementation of recommended team‐based cancer care has lagged, and determinants of quality care across primary and specialty care remain unclear. Guided by the theoretical domains framework (TDF), we explored multidisciplinary determinants of quality survivorship care in an integrated delivery system.MethodsWe conducted semistructured interviews with primary (4) and specialty (7) care providers across 6 Veterans Health Administration clinic sites. Using template analysis, we coded interview transcripts into the TDF, mapping statements to specific constructs within each domain. We assessed whether each construct was perceived a barrier or facilitator, examining results for both primary care providers (PCPs) and prostate cancer specialists.ResultsCancer specialists and PCPs identified 2 primary TDF domains impacting their prostate cancer survivorship care: Knowledge and Environmental context and resources. Both groups noted knowledge (about survivorship care) and procedural knowledge (about how to deliver survivorship care) as positive determinants or facilitators, whereas resources/material resources (to deliver survivorship care) was noted as a negative determinant or barrier to care. Additional domains more commonly referenced by cancer specialists included Social/professional role and identity and Goals, while PCPs reported the domain Beliefs about capabilities as relevant.ConclusionsWe used the TDF to identify several behavioral domains acting as determinants of high‐quality, team‐based prostate cancer survivorship care. These results can inform prostate cancer survivorship care plan content, and may guide tailored, multidisciplinary implementation strategies to improve survivorship care across the primary and specialty care interface.

3164 Do cancer survivors understand their risk factors for recurrence and the value of coordinated care between an oncologist and a primary care physician? A survey of endometrial and cervical cancer patients

OBJECTIVES/SPECIFIC AIMS: To evaluate gaps in knowledge for women who are cancer survivors regarding the impact of comorbidities and lifestyle behaviors on endometrial and cervical cancer risk, and to assess prevalence of established care with a primary care physician (PCP) among patients and evaluate acceptability of referral to a PCP METHODS/STUDY POPULATION: Single institution cross-sectional study examining all women aged 18 or older with a diagnosis of cervical or endometrial cancer who present for care by a gynecologic oncologist at Barnes-Jewish Hospital/Washington University in St. Louis School of Medicine. Patients will be invited to complete a survey specific to cancer diagnosis that includes questions on participant background and sociodemographic information, knowledge of risk factors for their specific cancer site, and whether or not the patient has a primary care provider and the acceptability of referring RESULTS/ANTICIPATED RESULTS: Majority of women will be unaware of how comorbidities affect cancer risk and treatment outcomes. For women without a PCP, we anticipate that they will be accepting towards the notion of being referred to one for establishing care. DISCUSSION/SIGNIFICANCE OF IMPACT: Pilot information from this study will 1. Allow providers to improve cancer survivorship care plans by increasing collaboration between PCPs and oncologists to provide ongoing care, and 2. Afford information for providers on where gaps in knowledge exist so as to better education patients.

Cancer survivorship care plans, financial toxicity, and financial planning alleviating financial distress among cancer survivors.

Concomitant with the increasing use of cancer care plans has been an increasing awareness of the potential for oncology care to result in long-term financial burdens and financial toxicity. Cancer survivors can benefit from information on support and resources to help them navigate the challenges after acute cancer treatment. While cancer survivorship plans could be a vehicle for patients to receive information on how to mitigate financial toxicity, cancer survivorship plans have typically not dealt with the financial impact of cancer treatment or follow-up care. Embedding information into cancer survivorship plans on how to reduce or avoid financial toxicity presents an opportunity to address a highly prevalent patient need. Patient-centered qualitative studies are needed to assess the type, format, and level of detail of the information provided.

A cross-sectional population-based survey looking at the impact of cancer survivorship care plans on meeting the needs of cancer survivors in the posttreatment stage.

The purpose of this study was to determine the impact of receiving a survivorship care plan (SCP) on meeting cancer survivors' overall, informational, physical, emotional, and practical needs. Since the recommendation for implementation of SCPs, there have been numerous studies on their effectiveness with mostly inconclusive results. All Nova Scotia survivors meeting specific inclusion and exclusion criteria were identified from the Nova Scotia Cancer Registry and sent the 83-item survey to assess experiences and needs across five domains (overall, informational, physical, emotional, and practical). Descriptive statistics (frequencies, percentages) and chi-square analyses were used to examine and report survey findings. The response rate was 44.6%, with 1514 respondents. SCPs were significantly associated (p< 0.00001) with receiving timely help and support to meet survivors' overall, informational, physical, emotional, and practical needs posttreatment. For the most part, survivors' clinical characteristics, such as cancer type, time since treatment, chronic comorbidities, and metastases, did not result in differences among the five outcomes. Those who received a SCP reported higher agreement on all five outcomes in comparison to those who did not receive a SCP. Further work should evaluate the delivery of SCPs and the components of SCPs that are most likely to contribute to positive survivor outcomes.

Do Breast Cancer Survivorship Care Plans Improve Health Outcomes?

Although they have been widely studied, important questions remain about the impact of breast cancer survivorship care plans on improving health outcomes. The goal of this article was to review published studies on the impact of cancer survivorship care plans on health outcomes and health care delivery among breast cancer survivors. A total of 111 article citations were identified in PubMed and non-duplicates in CINAHL. After screening the abstracts or full texts of these articles and reviewing the references of previous review articles, 7 studies met the eligibility criteria. All of the studies had a randomized controlled design. Early trials of the efficacy of breast cancer survivorship care plans generally showed little or no improvement in health outcomes. The positive findings of recent studies suggest that survivorship care interventions that empower and activate patients to self-manage their follow-up care and improve patient-provider communication may be especially promising.

Rural Primary Care Offices and Cancer Survivorship Care: Part of the Care Trajectory for Cancer Survivors.

Background:A cancer diagnosis is a monumental event in a patient’s life and with the number of cancer survivors increasing; most of these patients will be taken care of by a primary care provider at some point after their cancer therapy. The purpose of this study is to identify primary care physician’s needs to care for a patient who has had cancer.Methods:A cross-sectional survey of the physician members of the Iowa Research Network was conducted. The survey was designed to measure physician confidence in cancer survivor’s care, office strategies regarding cancer survivorship care, and resources available for patients with cancer. Two hundred seventy-four Iowa Research Network members were invited to participate in this survey.Results:Eighty-two physicians (30%) completed the questionnaire with 96% reporting that they are aware of their patient’s cancer survivorship status. Seventy-one physicians reported they were aware of cancer survivorship status by an oncologist sending a note to the office, 68 being diagnosed in their office, 61 by the patient keeping the office apprised, and 15 receiving a survivorship care plan. Physicians reported the top changes in a cancer survivor’s physical health as fatigue (81%) and pain (59%). Sixty-two physicians reported not feeling confident for managing chemobrain, cardiotoxicity (71%), and skin changes (35%). Male physicians were significantly more confident managing patients’ skin changes (P = .049) and musculoskeletal disturbances than female physicians (P = .027), while female physicians were significantly more confident managing early-onset menopause than male physicians (P = .027).Conclusion:Most respondents are aware of their patients who are cancer survivors and are mostly confident in the care they provide for them related to long-term effects and side effects of cancer therapies with limited receipt of cancer survivorship care plans.

Cancer survivorship care plans time and effort.

146 Background: The Lifespan Cancer Institute (LCI) is one program based at three hospitals in the Lifespan healthcare system, a main teaching affiliate of Brown Medical School. All sites are ASCO QOPI certified. In 2017, 1,742 patients from radiation, surgical, and medical oncology were diagnosed and/or treated for cancer. The Commission on Cancer guidelines specify patients with a new diagnosis of cancer treated with curative intent receive a survivorship care plan (SCP) within one year of diagnosis extended to 18 months for those receiving hormone therapy. Methods: The LCI Quality team is a multidisciplinary group comprised of nursing, leadership, physicians, midlevel providers, administrative assistants, and tumor registry staff. Our Quality Improvement Project for 2017 was generation and distribution of survivorship care plans to 50% of eligible patients. Our project underwent 5 plan/do/study/act cycles (PDSA). Prior to the intervention only 271 care plans were prepared and delivered for 2016 diagnoses. Results: For the total 2017 diagnoses, 843 eligible patients were treated within the LCI (medical and radiation oncology). Survivorship Care plans completed by midlevel providers were generated and distributed to 100% of LCI patients during January -April 2018 (244 in total), a 37% increase compared to the same timeframe, one year previous. The electronic medical record provides tools for SCP preparation including auto population of demographics and chemotherapy plan. Staging, radiation, and surgery are manually entered. On average, each SCP required 1 hour to complete for approximately 244 hours of midlevel provider time for January -April 2018. This abstract’s time and effort does not include the time for patient calls, survivorship visits or administrative monitoring. Conclusions: Survivorship care plans provide patients and primary care providers a summary of the treatment plan and recommendations for follow up/survivorship goals in transitions of care. Significant time and effort is required to generate an individual SCP therefore the goal should be to increase electronic efficiencies within the medical record, and focus on the clinically relevant patient population who are most likely to survive 5 years and be impacted by diagnosis and treatment.

Integration of Ongoing Quality Assurance Measures in Colorectal Cancer Survivorship Care Plans

e18858Background: A follow up program for patients with stages II or III colorectal cancer (CRC) after treatment completion was initiated in 2014 at the Cancer Centre of South Eastern Ontario (CCSE...

Self-management Needs of Breast Cancer Survivors After Treatment: Results From a Focus Group Interview.

Recognition of the importance of self-management (SM) for breast cancer survivors (BCSs) is increasing, but evidence from investigations of their needs focusing on SM is limited. The aim of this study was to explore the SM needs of BCSs who had completed treatment. Using a qualitative study design, we interviewed a focus group of 20 BCSs who underwent cancer therapy (mean time since diagnosis 3.4 years) at a university hospital in South Korea. Data were analyzed via conventional content analysis. The focus group interviews revealed 10 subthemes that we organized into 5 themes about the posttreatment SM needs of BCSs: (1) symptom management needs, (2) emotional management needs, (3) information acquisition needs, (4) need for a relationship with healthcare providers, and (5) adaptation needs. Specifically, participants needed to acquire SM skills to relieve symptoms (eg, peripheral neuropathy, insomnia), deal with emotional problems (eg, fear of recurrence, anxiety, depression), and adapt to changes due to cancer treatment (eg, body image, lifestyle, and role changes). In particular, participants expressed a substantial need for a constructive relationship with healthcare providers who, by respecting and communicating with them, would help empower them. Participants placed a high value on building self-confidence for successful SM. Our findings can contribute to the development of breast cancer survivorship care plans by emphasizing posttreatment SM. Future SM support intervention for BCSs after treatment should focus on training SM skills, enhancing the survivor-provider relationship, and building survivor self-confidence.

A conversation approach based on shared goal-setting and shared decision-making for nurses in cancer aftercare: A developmental study

This study aimed to develop and pretest a systematic conversation approach for nurses to tailor aftercare to oncology patient's goals, unmet needs and wishes. We used an iterative developmental process for complex interventions: 1. Identifying problems 2. Identifying overall objectives 3. Designing the intervention 4. Pretesting and adapting the intervention. The main results of the problem identification were: non-systematic and incomplete screening of potential issues, caveats in providing information, and shared decision-making. The overall objective formulated was: To develop a model for aftercare conversations based on shared goal-setting and decision-making. The conversation approach consists of four phases: 1. Preparation of the consultation including a questionnaire, 2. Shared goal-setting by means of a tool visualizing domains of life, and 3. Shared care planning by means of an overview of possible choices in aftercare, a database with health care professionals and a cancer survivorship care plan. 4. The results of the pretest revealed that the conversation approach needs to be flexible and tailored to the patient and practice setting, and embedded in the care processes. The conversation approach was perceived as enhancing patient-centeredness and leading to more in-depth consultations. The conversation approach was developed in co-creation with stakeholders. The results of the pretest revealed important implications and suggestions for implementation in routine care. The aftercare conversation approach can be used by nurses to provide tailored patient-centered evidence-based aftercare. Tailored aftercare should support oncology patient's goals, unmet needs and wishes. Further tailoring is needed.

Integration of ongoing quality assurance measures in colorectal cancer survivorship care plans.

e18858Background: A follow up program for patients with stages II or III colorectal cancer (CRC) after treatment completion was initiated in 2014 at the Cancer Centre of South Eastern Ontario (CCSE...

The value of breast cancer survivorship care plans: Results from a community survey.

e22125Background: Survivorship care plans (SCP) are an integral part of National Accreditation Program for Breast Centers and the Commission on Cancer accreditation, both recommending SCPs for at l...

Systematic Review of the Impact of Cancer Survivorship Care Plans on Health Outcomes and Health Care Delivery.

Purpose Numerous organizations recommend that patients with cancer receive a survivorship care plan (SCP) comprising a treatment summary and follow-up care plans. Among current barriers to implementation are providers' concerns about the strength of evidence that SCPs improve outcomes. This systematic review evaluates whether delivery of SCPs has a positive impact on health outcomes and health care delivery for cancer survivors. Methods Randomized and nonrandomized studies evaluating patient-reported outcomes, health care use, and disease outcomes after delivery of SCPs were identified by searching MEDLINE, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library. Data extracted by independent raters were summarized on the basis of qualitative synthesis. Results Eleven nonrandomized and 13 randomized studies met inclusion criteria. Variability was evident across studies in cancer types, SCP delivery timing and method, SCP recipients and content, SCP-related counseling, and outcomes assessed. Nonrandomized study findings yielded descriptive information on satisfaction with care and reactions to SCPs. Randomized study findings were generally negative for the most commonly assessed outcomes (ie, physical, functional, and psychological well-being); findings were positive in single studies for other outcomes, including amount of information received, satisfaction with care, and physician implementation of recommended care. Conclusion Existing research provides little evidence that SCPs improve health outcomes and health care delivery. Possible explanations include heterogeneity in study designs and the low likelihood that SCP delivery alone would influence distal outcomes. Findings are limited but more positive for proximal outcomes (eg, information received) and for care delivery, particularly when SCPs are accompanied by counseling to prepare survivors for future clinical encounters. Recommendations for future research include focusing to a greater extent on evaluating ways to ensure SCP recommendations are subsequently acted on as part of ongoing care.

Assessing Key Stakeholders' Knowledge, Needs, and Preferences for Head and Neck Cancer Survivorship Care Plans.

Cancer survivorship care plans (SCPs) are endorsed to support quality care for cancer survivors, but uptake is slow. We assessed knowledge, needs, and preferences for SCP content and delivery from a wide variety of stakeholders. We focused SCP content for head and neck cancer as it is a disease prone to long-term side effects requiring management from multiple providers. We conducted telephone-based, qualitative interviews. We purposively sampled head and neck cancer survivors (n = 4), primary care physicians in the community (n = 5), and providers affiliated with a large academic medical center (n = 5) who treat head and neck cancer, cancer specialists (n = 6), and nurse practitioners/supportive care staff (n = 5). Interviews were recorded, transcribed, and analyzed using direct content analysis. Few participants reported personal experience with SCPs, but most supported the concept. Several key themes emerged: (1) perceived ambiguity regarding roles and responsibilities for SCPs, (2) a need to tailor the content and language based on the intended recipient, (3) documentation process should be as automated and streamlined as possible, (4) concerns about using the SCP to coordinate with outside providers, and (5) that SCPs would have added value as a "living document." We also report SCP-related issues that are unique to serving patients diagnosed with head and neck cancer. Effort is needed to tailor SCPs for different recipients and optimize their potential for successful implementation, impact on care outcomes, and sustainability. Many cancer survivors may not receive a SCP as part of routine care. Survivors could engage their health care team by requesting a SCP.

Comparison of two breast cancer survivorship treatment summary and care plan (TSCP) documents.

49 Background: The 2005 Institute of Medicine report recommended providing a cancer TSCP, but barriers including time needed to complete these documents led to limited implementation. In 2014, in order to facilitate delivery, ASCO released a streamlined version of a TSCP. The current prospective, randomized study compares a Breast Cancer ASCO 2014 derived template (concise TSCP) with a facility derived Breast Cancer TSCP template based on the “old” ASCO version and NCCN guideline recommended elements (detailed TSCP). Methods: Female breast cancer survivors who completed therapy at Gundersen Health System were randomized between a concise TSCP and a detailed TSCP. Subjects received a survey prior to their survivorship visit assessing their baseline knowledge of their breast cancer diagnosis and treatment (pre visit knowledge). After the visit, participants completed the same survey (post visit knowledge) and a satisfaction survey. Pre and post visit knowledge survey scores, patient satisfaction scores and time needed to complete the TSCP were compared between the two study groups. Results: Both TSCP groups showed significant improvement in patient-specific disease and treatment knowledge scores (% of applicable knowledge questions answered correctly) after their survivorship visit. There was no significant difference between the concise and detailed groups’ pre-visit knowledge score (mean 78% vs. 79%, p=0.88). Calculated difference between the groups’ post knowledge scores met the pre-determined threshold for non-inferiority (p=0.013). Conclusions: Our study demonstrates the value of a cancer TSCP and Survivorship visit in improving breast cancer survivors’ knowledge of their disease characteristics and treatment. The concise version was found to be non-inferior to the detailed TSCP in terms of patient knowledge and satisfaction and required less time to complete. These results assist us and other institutions in choosing a more streamlined version of TSCP without compromising patient knowledge or satisfaction. [Table: see text]

Impact of cancer survivorship care plans (SCPs) on health outcomes and health care delivery: A systematic review.

2 Background: In 2006, the Institute of Medicine recommended that patients at or near completion of active treatment be provided with a SCP (treatment summary, relevant health information, and follow-up care plan) to improve care delivery and outcomes in the post-treatment period. We systematically reviewed published research to determine if SCPs have a positive impact on health outcomes and healthcare delivery. Methods: Randomized and nonrandomized studies evaluating patient-reported outcomes, healthcare utilization, and disease outcomes after delivery of SCPs were identified by searching MEDLINE, Embase, PsycINFO, and Cochrane Library. Data were extracted by independent raters and summarized based on qualitative synthesis. Results: Eleven nonrandomized and 13 randomized studies met inclusion criteria. Variability was evident across studies in cancer diagnoses, timing of SCP delivery in relation to treatment completion, SCP delivery method and recipients, SCP content, SCP-related counseling, and outcomes assessed. Findings from nonrandomized studies yielded descriptive information only on outcomes such as satisfaction with care and reactions to SCPs. Among randomized studies, findings were near uniformly negative for the impact of SCPs on the most commonly assessed outcomes (physical, functional, and psychological well-being); findings were positive in single studies for other outcomes including amount of information received, satisfaction with care, and physician implementation of recommended survivorship care. Conclusions: Existing research provides minimal evidence that SCPs improve quality of life in cancer survivors. Possible explanations include heterogeneity in study designs and the low likelihood that SCP delivery alone would influence distal health outcomes. Findings are very limited but more positive for proximal outcomes (e.g., information received) and for care delivery, especially when SCPs are accompanied by counseling to prepare survivors for future clinical encounters. In light of current findings, future research should focus to a greater extent on evaluating ways to ensure SCP recommendations are subsequently implemented as part of ongoing care.

Assessing key stakeholders' knowledge, needs, and preferences for cancer survivorship care plans.

30 Background: Survivorship care plans (SCPs) are individualized documents that summarize cancer treatment received and provide guidelines for monitoring and maintaining survivors’ health. While SCPs are intended to facilitate care coordination, they are rarely used in the primary care setting. We aimed to understand the informational needs and delivery preferences of PCPs, cancer survivors, cancer specialists, and nurses related to SCPs. Methods: We conducted semi-structured interviews with a purposeful sample of PCPs (n = 10), cancer specialists (n = 5), nurses (n = 5), and cancer survivors (n = 5). After reviewing a sample SCP based on the published ASCO template, participants were asked about acceptability, appropriateness, feasibility, fidelity, implementation, and sustainability. De-identified transcripts were qualitatively analyzed using NVivo software. Results: 25 interviews were completed (RR 45%). Emergent themes included informational needs and delivery preferences. Informational needs include clarifying roles and responsibilities of allied professionals; the roles of the PCP for follow-up care should be clear, outlined and with content summarizing their responsibilities regarding screening, and surveillance. Additionally, SCPs should emphasize side and late effects of cancer treatment for the benefit of patients and providers. Delivery preferences include using sustainable and accessible electronic formats to improve provider communication and streamlining documentation for the intended audience. Electronic SCPs could be frequently updated with pertinent information about patient needs and care over time. Conclusions: Understanding the needs and preferences of PCPs may address current limitations of SCPs in coordinating survivor care. Future SCPs may be electronic and accessible, with content and guidance targeted to the PCP’s role.

Breast cancer survivorship care plan: Patient satisfaction with a web-based application.

50 Background: The American College of Surgeons Commission on Cancer Standard 3.3 mandates that by 2018, oncologists provide Survivorship Care Plans (SCPs) to more than 75% of Stage 1-3 breast cancer survivors. Preparation and delivery of SCPs is time-consuming and requires dedicated staff commitment. Working with PatientsWithPower(PWP), a digital health company supporting patient decision-making for breast cancer, we developed a web-based SCP and surveyed patients regarding their satisfaction with the SCP. The objective of this study was to assess patient satisfaction with the PWP SCP. Methods: SCP’s were prepared using data extracted from the electronic medical record (EMR) and PWP software. A one-page SCP was presented to each patient by the Nurse Practitioner (NP) during a routine visit after patients completed active treatment. Results were reviewed after all surveys were completed. Fifty women with Stage 0-3 breast cancer participated in the IRB approved study and reported their satisfaction with the PWP SCP via online survey. Results: Using patient data in the EMR, the PWP plan took about 45 minutes to prepare. Once completed, NPs spent 10-15 minutes with each patient reviewing the SCP. Patient surveys indicated that 98% of patients felt it was important to receive a SCP, 84% planned to use it to plan follow up management, and 75% intended to share the SCP with their primary care physician. According to patients, the most valuable parts of the SCP were diagnosis and treatment history, and the follow up schedule. More than 70% of women requested additional information about future screening for recurrence, nutrition, and long-term side effect management. 92% of women appreciated the electronic “living document” that can be easily updated at subsequent visits. Conclusions: Presenting SCPs to patients is an essential component of high-quality cancer care. PWP’s online platform facilitates the development and delivery of SCPs by organizing and storing on-going patient data to make future SCP updates easy and efficient. Our patient satisfaction survey results underscore the value of SCPs, particularly for follow-up management and communications with primary care doctors.

Survivorship care plans in safety net: Bridging the barriers.

68 Background: Survivorship care plans (SCPs) are considered an important tool in survivorship care. SCP should include treatment summaries and follow up care plans and are intended to improve survivorship care. Despite the institute of medicine (IOM) recommendation regarding SCPs, the uptake has been low in community cancer centers. The safety net hospitals face additional challenges to SCPs including patient who may have low health literacy and limited English proficiency. In addition, resources and personnel constraints can be important barriers for implementation of SCPs. Methods: Zuckerberg San Francisco General Hospital is a safety net hospital in the City and County of San Francisco. We created SCPs for breast cancer survivors, as it is our largest group of cancer survivors. Patients, who were within 5 years of completion of treatment with curative intent for breast cancer were candidates for receiving SCPs. We used ASCO survivorship template to create a survivorship care plan. ASCO breast cancer SCP was discussed in the focus groups and modified to match the needs of our patients. SCP committee and patient advisory board evaluated the SCP prior to a pilot of the SCPs in the clinic. We piloted the SCPs initially in English and Spanish to assess feedback from clinic providers. After requested modifications SCP was then translated in to simplified Chinese. The SCP delivery was embedded in the clinic flow and was done at time of routine clinic visit to reduce the burden of additional visits. Results: 104/175 eligible patients have already received the SCP over one year period. All providers in the clinic participated in delivery of SCPs. Conclusions: SCP in multiple languages can be implemented successfully in safety net setting in a patient population with low health literacy and limited English proficiency. Availability in multiple languages, provider buy–in and embedding SCPs in clinic flow appears to be important factors in implementation. We are evaluating the optimal process of SCP delivery with an ongoing randomized pilot study of SCPs with and without navigation with breast cancer related quality of life and self-efficacy measures. We are also evaluating the usefulness of SCPs in meeting the informational needs of primary care providers.

Implementation of a survivorship clinic in a medically underserved comprehensive community cancer center.

54 Background: Historically, preparation of Survivorship Care Plans (SCPs) had been a cumbersome challenge that resulted in a limited number of plans delivered to eligible patients. In 2015, eleven breast SCPs were prepared and delivered by an RN. Upon review, it was determined the process of preparation and delivery of SCPs required refinement. Methods: Initially, we identified the barriers to our practice, which included limited knowledge, process, personnel, and software interfacing. We implemented a quality improvement project with the goal of delivery of SCPs to an increased number of cancer survivor patients. The project targeted staff education to identify eligible patient populations, create awareness of the Commission on Cancer accreditation requirements, and the knowledge necessary to create a SCP. We coordinated with the information technology department to attempt interfacing software programs, track the delivery of plans, and use provider notes to export data. We increased communication between departments to identify eligible patient populations. A nurse practitioner was assigned the responsibility for preparation and delivery of the document during a scheduled appointment, which focused on review and education in relation to the patient’s diagnosis, treatment plan, sequelae and recommended surveillance. Results: Through close coordination of interdisciplinary teams, we were able to implement strategies to develop a streamlined process to create and deliver SCPs. These interventions resulted in the Survivorship Clinic going from 11 breast cancer SCPs delivered in 2015 to 98 and counting, of all types of cancer, delivered in 2016. Patients requested follow up visits to the Survivorship clinic. Conclusions: We have successfully developed a Survivorship Clinic within a federally designated medically underserved community setting. Implementation of best practices resulted in nine-fold increase in delivery of SCPs. Most importantly, we have increased patient education and satisfaction. Our practices can be replicated by other programs and thereby curb the disparity of cancer survivorship care in rural areas.