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National Cancer Survivorship Initiative

The Recovery Package

The Recovery Package- supporting commissioning

 

The ‘Recovery Package’ is a combination of different interventions, which when delivered together, will greatly improve the outcomes and coordination of care for people living with and beyond cancer.  These are:

  •  Holistic Needs Assessments and care planning at key points of the care pathway,
  •  A Treatment Summary completed at the end of each acute treatment phase, sent to patient and GP
  •  A Cancer Care Review completed by GP or practice nurse to discuss the person’s needs, and
  •  A patient education and support event, such as a Health and Wellbeing Clinic, to prepare the person for the transition to supported self management, which will include advice on healthy lifestyle and physical activity.

The Recovery Package has been developed and tested by the National Cancer Survivorship Initiative (NCSI) (NHS Improvement 2012) to assist people living with a diagnosis of cancer to prepare for the future, identify their individual needs and support rehabilitation to enable people to return to work and or a near normal lifestyle.

The Recovery Package has been designed to complement the stratified care pathway (NHS Improvement 2012) which enables individualised follow-up care as a supported self management programme, shared care or complex care.

The Recovery Package

The Recovery Package

What is the recovery package?

  • The recovery package includes a holistic needs assessment (HNA) (NCAT 2010) which is carried out at two key points in the care pathway and if health and social needs change. The HNA should be conducted using a standard assessment tool and process within the care pathway (Macmillan 2012). The assessment identifies the individual needs of the person affected by cancer and contributes to a consultation. The consultation can then be focused on the needs identified, a care plan can be developed and an appropriate referral can be made to services that support patients, such as lymphoedema, psychological and services dealing with the consequences of treatment.  This ensures that care is proactive and support services are planned and accessed appropriately. The assessment can be used to inform the treatment summary. The patient receives a copy of the care plan to enable self management; further copies are stored in the medical records and can be sent to the GP.
  • The treatment summary is developed by the multidisciplinary team to inform the patient and the GP of the care and treatment received (NCSI 2012). The summary includes possible treatment toxicities and /or late effects, alert symptoms that require referral back to a specialist team, an ongoing management plan, and a summary of information given to the patient about their cancer and future progress and any required GP actions to support the patient.  The Treatment Summary informs the GP database and can also be used to inform the Cancer Care Review. The patient receives a copy to share with other family members and health care providers. Further copies are stored in the medical records and inform emergency/unplanned admissions.
  • A Cancer Care Review is carried out by the GP practice three months (from April 2014 this will change to six months) following a diagnosis of cancer (Macmillan 2012), and covers post-treatment support, financial impact of cancer, patient awareness of prescription exemptions, possible late effects of cancer and cancer treatment and the information needs to enable self management.
  • Health and Wellbeing Clinics are education events to give the person affected by cancer all the information they need to enable rehabilitation and self management. This may include the opportunity for advice about work or finance, physical activity and local services that offer help and support for people living with a long term condition.

What can you do?

The NCSI would like the following provided and commissioned:

  • Cancer services providing access to rehabilitation and self management programmes.
  •  Services improved to include the elements of the Recovery Package as defined above to enable rehabilitation and self management.
  •  Cancer teams to be able to identify local providers for financial and work advice, psychological, social and psychosocial services.
  • Directories of local services in line with the holistic needs assessment tool.
  • The use of the Macmillan triplicate pack paper assessment tool to ensure a standardised approach.
  • The use of the Macmillan electronic HNA tool to ensure a standardised paperless process.
  • Appropriately trained clinical staff with advanced communication skills to effectively assess people’s needs and refer to clinical or non-clinical services and ensure suitable use of resources.
  • Provision of support to address the individual needs of people surviving or living with cancer as a chronic disease as identified in the holistic assessment.
  • Cancer teams providing services that improve outcomes for those patients who experience the consequences of cancer as identified in the holistic needs assessment.
  • Cancer teams engage with local facilities to ensure that they can provide appropriate physical activity programmes for people affected by cancer.
  • Every patient given a standard Treatment Summary which is shared with the GP.
  • Cancer teams offering people the opportunity to be involved in an education event such as a Health and Wellbeing Clinic or self management course.

After Cancer Treatment: A guide for professionals is a short guide that provides practical ideas and suggestions for how healthcare professionals can support patients in their recovery from cancer using elements of the Recovery Package.

References cited:

NHS Improvement (2012) From Concept to Innovation

National Cancer Survivorship Initiative (2012) Risk Stratified Pathways of Care

National Cancer Action Team (2010) Holistic Needs Assessment for people with cancer: A practical guide for healthcare professionals (online)

Macmillan (2012) Holistic Needs Assessment and Care Planning

Macmillan (2011) Treatment Summary: A tool to improve Communication between cancer services and primary care

National Cancer Survivorship Initiative (2012) Treatment Summary User Guide and Templates

Macmillan (2012) Evaluation of Macmillan’s cancer care review template

 

 

Last updated on February 5, 2014