Table 2.

Chronic Care Model qualitative evaluation questions

Health system organization—create a culture, organization, and mechanisms that promote safe, high-quality care; use strategies aimed at organizational change; obtain support from leadership

1. How committed do you think the leadership of (cancer center) is to cancer survivorship?

2. What barriers exist that inhibit the organizational changes necessary at (cancer center) to focus more on the care of cancer survivors?

3. What challenges have you witnessed at (cancer center) in adding survivorship care to the treatment model?

Delivery system design—assure the delivery of effective, efficient clinical care and self-management support, case management, treatment summary, care plans, regular follow-up, culturally appropriate care, referral systems

1. What models of care are being used at your COE?

2. In what ways, if any, have these models changed over time?

3. How are survivors evaluated medically and psychologically?

4. Who does medical record abstraction?

5. How are patients referred to the survivorship program?

6. What treatment summary is used to compile data for survivorship care plan?

Decision support—promote clinical care consistent with scientific evidence and patient preferences; use evidence-based guidelines in daily clinical practice, integrate primary and cancer care, provide education on survivorship

1. What guides recommendations for clinical surveillance?

2. How have you engaged other health professionals at your cancer center/hospital in survivorship issues?

3. What new programs have been developed and added because of the COE, e.g., education for providers?

Clinical information systems—organize patient and population data to facilitate efficient and effective care; provide reminders for providers and patients re: survivorship care, identify populations in need of survivorship care, use data to track and provide survivorship care

1. What methods and data systems have you used successfully to track the needs of cancer survivors in the populations your cancer center serves?

2. How have you evaluated or do you plan on evaluating your survivorship programs?

Self-management support—empower and prepare patients to manage health and health care; use effective self-management strategies and internal and external community resources to provide self-management support

1. What guides recommendations for health and wellness education?

2. What are the most successful health promotion strategies used in your survivorship program?

3. What new programs have been developed and added because of the COE, e.g., patient education, health promotion?

Community linkages—mobilize community resources to meet needs of patients; participate in community programs, partnerships with community organizations

1. What barriers have you found to working with the community?

2. What experiences has the COE had in working with the community?

3. What new community programs have been developed and added because of the COE, e.g., clinic, education?

4. What has been the most helpful strategy for community involvement?