Team Based Care

The Oncology Medical Home assumes responsibility for all aspects of care coordination for the patient.  This includes services ordered for the patient within the patient's oncology practice and services ordered from other physicians and care teams.  These tools focus on communications to the patient and to others assisting with care for the patient. 

Psycho/Social Screening


NCI PDQ Document

Cancer Support Community web tool

Navigating Cancer tool


Survivorship Plan Tools


The minimum components of a survivorship
plan as suggested by the Institute of Medicine
and the Commission on Cancer
from the American College of Surgeons.

* Frequency and/or scheduled appointments with the oncologists and diagnostic testing.
* Listing and schedules of periodic and recommended cancer and other screenings, tests and exams and who would perform them.
* Information on possible long term side effects of treatment, symptoms of such effects, and how to report them. In addition to other reportable signs and
* Recommendations for healthy behaviors. (Wellness, diet and exercise)
* Listing of cancer-related resources and information regarding cancer survivorship.

Cancer Survivorship Training for care teams               

National Coalition for Cancer Survivorship

Journey Forward Tool

Navigating Cancer


Advanced Care Plan Tools


Suggested topics for advanced care plan discussions

* Designated person to make decisions for the patient.
* The types of medical care preferred.
* The comfort level that is preferred.
* Preferred place of care.
* How the patient prefers to be treated by others.
* What the patient wishes others to know.

My Directives

5 Wishes