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The program is targeted for adults over the age of 80 with a biopsy-proven malignancy. Program providers and team members have special expertise in caring for patients who may have other multiple health problems in addition to the cancer diagnosis. These other health problems or conditions due to aging may interfere with cancer therapy, tolerance to treatment and or outcomes of treatment.
After diagnosis, the team conducts a comprehensive geriatric assessment of the person’s physical, mental and social status. This assessment is conducted by a variety of team members, including:
- Medical oncologist
- Geriatric nurse practitioner
- Oncology certified RN’s
- Medical social worker
- Geriatric mental health provider
Included in the assessment are
- Pathology review by tumor type specialist
- Complete physical and functional status
- Memory and depression screening
- Psychosocial and caregiver support needs
- Dietary and nutritional status
- Medication review and counseling
- Educational needs
Team members may include physical and/or occupational therapy, chaplains, medical residents, medical, nursing and social work students.
Commitment to Patients, Families and Referring Providers
- The primary care physician is kept informed regarding the plan of care for the cancer diagnosis and may participate on the team, if desired.
- After the assessment is completed, the team meets with the patient and family to develop a treatment plan unique to the needs of the patient and family. The cancer treatment plan is based on current evidence-based protocols specifically considering the physical, mental and emotional needs of the older adult.
- The plan will be comprehensive, addressing all health and social needs, and mutually developed with the patient and family. The plan will also address the patient developing a Health Care Power of Attorney and Advanced Directives, if not previously complete.
- After the plan is developed and treatment is started, the team will meet routinely to discuss the patient’s progress and plan of care. The patient and family will be invited to participate in this conference. At any time during the course of treatment, the patient and/or family may request a team conference to address special needs. The PCP will be kept informed of the patient’s progress through regular written or verbal communication.
- The Geriatric Nurse Practitioner (GNP) will act as the case manager for the patient while the patient is undergoing active treatment. After treatment is completed, the GNP will coordinate the patient’s care with the community providers and/or the patient’s family.
- The team will follow the patient during inpatient or long-term care stays even if it is related to another non-cancer condition. Coordination of care is a foundation of this program.
- The GNP and social worker will provide ongoing education and support to the patient and family and will coordinate the care across the continuum.
- The program will include ongoing research in geriatric oncology in both treatment and prevention of cancer in older adults.
- The program will include community education, outreach, caregiver and patient support groups.