Cancer Treatment Center: Patient care for malignancy requires a variety of health care professionals for optimal treatment. Interdisicplinary care requires information exchange between care teams to improve patient safety,quality of care and customer service.

Interdisciplinary Care

Cancer Treatment Center staff including Physicians,Social Workers, Technicians, Nurses and Administrative Support

An 82 year old, widowed male , Mr. D is admitted for resection of stomach cancer. He received surgery and had an uneventful recovery. Three months later he is strong enough for follow-up treatment. The treatment plan includes chemotherapy, radiation therapy and consultation services that include nutritional counseling and social services support for his family and caregivers. Functional status and psychosocial assessment information is exchanged within the cancer center to inform the care team of this patient's special needs and allow for monitoring during the entire episode of care. The social worker evaluated his social support, financial status, and screened him for depression using the Geriatric Depression Scale. He scored 9 out of 30 on the GDS which is normal. Social support assessment reveals that he lives alone and his only daughter lives 1,000 miles away. His neighbors all look out for each other, but they too are elderly and frail. Functional status assessment reveals no limitations in actitivities of daily living. He has a housekeeper once a month and does his own grocery shopping. He reported his appetite as fair and he weight 130 pouinds and is 5 foot 9 inches. He received his chemotherapy treatment and returned to his home with instructions to return in three weeks for radiation therapy. This pattern was repeated for several rounds.

Six months later Mr. D. returned to the cancer center for an overnight stay to receive chemotherapy. He appeared to have lost weight and his weight was now 120 pounds. He reported that he "does not have an appetite" and "feels tired all then time and weak."

Had the cancer clinic been documenting fatigue, physical activity and days going outdoors, they may have detected earlier that although he was not limited in basic adl, he was decreasing his activity levels and stairs were becoming difficult to manage. He was worried that he would never be able to return to activities like outdoor walking that he enjoyed and did on a regular basis. An earlier referral was made to establish a home exercise program for strengthening and exercise counseling concerning available community programs for him to engage in once the chemotherapy and radiation treatments were completed and he had improved his endurance and fatigue levels. Given the current status at 6 months, he will likely need more formal strengthening intervention along with the health promotion counseling for physical activity and nutrition. Because of concern over his weight loss and decline in usual activities, the social worker repeated the Geriatric Depression Scale. His score this time was 15 indicating mild depression (10-19 mild, 20-30 severe. He reported that he had a hard time getting going in the morning, he feels worthless the way he is now, he is afraid and not satisfied with life as it is now. The first line of intervention is to suggest he attend a community senior centre or similar organization to assist in improving his mood, support network, and outlook for the future. It may also be useful to involve volunteers from the community to assist in the exercise program or as home visitors. It will of course be important to continue to monitor using the GDS to determine whether medication is indicated to improve mood and outlook, and to investigate whether altenate living arrangements would be beneficial if he continues to decline.

By sharing this information throughout the care team the patient and family's care experience is enhanced and better customer service is provided. The care team can monitor progress or decline through the course of treatment within the cancer center. Identification of challenges and difficulties in function across the care teams results in optimal results for cancer care.