Patient Intake Assessment Tools for Navigation

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Patient Intake Assessment Tools for Navigation Review and utilize the following with new patient referrals to the Navigation program: Psychosocial Distress Screening Tool : Commission on Cancer Standard 3.2, patients with cancer are offered screening for distress a minimum of 1 time per patient at a pivotal medical visit to be determined by the program. Barriers to Care: Commission on Cancer Standard 3.1 under Patient Navigation Process, refers to individualized assistance offered to patients, families and caregivers to help overcome health care system barriers and facilitate timely access to quality medical and psychosocial care and can occur from prior to a cancer diagnosis through all phases of the cancer experience. (example tool attached) Intake Patient Assessment Form (attached) Review of Support Services at Your Cancer Program and Community

Review the Support Staff and Services Available at Your Cancer Program: Nurse Navigator Pastoral Care Pain and Symptom Management Social Worker Health Coaches Financial Assistant Survivorship Program Palliative Care Registered Dietitian Rehabilitation Support Groups Health Psychologist Resource Library Educational programs Genetic Counselor Wig Bank Other: Any specific support staff or services needed right now? What can we help you with right now?

Navigation: Patient Intake Assessment Form: (Use in conjunction with Barriers to Care and Distress Screening Tools) Name: Date of Birth: Address: Cancer diagnosis: Phone number: (home): Can we leave a message? Yes No (cell): Emergency contact: Phone: (home): (cell): Marital Status: Single Married Significant other Divorced Widowed Living Arrangements: Lives Alone with Spouse Significant other Parents Children Caregiver Name: Phone: (home): (cell): Family and Caregiver concerns: Children: yes no Concerns with children related to diagnosis, specify; Religion: Occupation: Preferred Spoken Language: Preferred Written Language Communication: Preferred learning style? i.e. video, written documents, etc. Medical History / Other Medical Conditions:

Surgery: History (list procedure and date): Procedure Date Medications (include name, dose and frequency): Name Dose Frequency Allergies: Smoking: Yes No Quit (Include Smoking History, ppd/ years): Alcohol Use: Yes How Much (drinks/week) No Quit (Include History, Drinks/week/years) Environmental factors/occupational exposure:

Family History: Family History of Cancer (list relationship, type of cancer): Relationship Type of Cancer What do you know about your cancer diagnosis? What has your doctor told you about your cancer diagnosis? What has your doctor told you about your cancer treatment? What specific concerns do you have about your diagnosis and treatment? Do you have an understanding of clinical trials? Other Physicians involved in your care: Primary Care Physician: Surgeon: Plastic Surgeon: Medical Oncologist: Radiation Oncologist: Other:

Pain and Symptom Management Assessment: Pain: Scale of 0-10, (10 is the highest, rate you pain level over the last 24 hours) 0 1 2 3 4 5 6 7 8 9 10 Describe Your Pain: Fatigue: scale of 0-10 (10 is the highest, rate your fatigue level over the last 24 hours) 0 1 2 3 4 5 6 7 8 9 10 Describe Your Fatigue: Other symptoms you would like to discuss? What are your concerns right now? What are your goals for your care? What can we help you, your family and/or caregiver with right now?

Barriers to Care: Please check off any of the following items that you feel could prevent you from getting the care you need Financial concerns High co-pays with insurance High co-pays with medication coverage No medication coverage Inability to pay bills Transportation concerns Homeless or housing concerns Child/Elder care Interpretation concerns, speaks another language, preferred language; Cultural concerns Inability to read or write Fear and fatalism Mistrust of the healthcare system Misconceptions about cancer Lack of knowledge regarding treatment plan Lack of support Pain or symptom management Mental health concerns, specify; Physical Disability Inability to walk Assistive Devices, please list; Substance abuse, specify; Others;

Patient Education: Patient Treatment Journal and Educational Materials Provided: Yes No If so what educational materials were provided? National and Government Oncology Resources for Patients, Families and/or Caregivers, examples: The Cancer Support Community The American Cancer Society The Leukemia and Lymphoma Society National Cancer Institute National Comprehensive Cancer Network Commission on Cancer Other:

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