Strategies
4.2a Develop a treatment process map that begins with diagnostic testing and continues through post-treatment follow-up care. Include patient navigation in the map. SURVIVORSHIP 4.2b Support community capacity to address non- clinical needs of cancer patients and their caregivers (e.g., spiritual, lifestyle, emotional). PALLIATIVE CARE 4.3a Seek funding and professional consultation to develop palliative care infrastructure. 4.3b Develop a palliative care process map to understand components critical to infrastructure development. END-OF-LIFE CARE 4.4a Address identified EHR limitations associated with communicating daily patient status updates from village CHA/Ps. 4.4b Develop end-of-life care process map in collaboration with CHA/Ps to identify opportunities to strength care.
TREATMENT 4.1a Develop a cancer-specific panel for effective clinical case management and continuity of care. 4.1b Evaluate clinical navigator models (RN) to coordinate and manage clinical aspects of patient treatment and follow-up care. 4.1c Develop job description for a RN clinical cancer navigator, if desired. 4.1d Address continuity of care challenges and related implications when patients receive treatment in a setting other than ANMC. 4.e Establish coordination with AMNC (or other discharge planners) upon patient discharge from treatment. 4.2 Determine patient navigator structure and responsibilities to support IHS beneficiary, non-beneficiary, and non-Medicaid patients. Consider needs associated with transportation, housing, escort requirements and limitations, understanding This could include other health care facilities in Alaska or the Lower 48. and managing insurance coverage, and additional resource information for patients, caregivers, and survivors.
Targets
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• Cancer-specific patient panel developed • Clinical cancer navigator model assessed; position development advanced • Challenges associated with treatment external to AMNC addressed • Coordination with discharge planners established • Patient navigator structure and responsibilities
identified; trained navigator(s) in place • Palliative care infrastructure developed
• EHR limitations related to end-of-life updates addressed • Process maps completed for treatment, palliative care, and end-of life care
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Strategic Cancer Plan | 26
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