Survivorship care plans : a work in progress

At an estimated 22.4 million worldwide, the number of people living with and beyond cancer is higher than ever because of advancements in treatment, early detection, screening, and prevention of secondary cancers1–3. In Canada and the United Kingdom, about 1 and 2 million people respectively are currently living with and beyond cancer4–7. In the United States, the number of survivors rose to 11.7 million in 2007 from 3 million in 19718. Of the U.S. survivors, approximately 67% live at least 5 years after receiving their diagnosis, and 10% live 25 years or longer1,8. These survivorship numbers are encouraging, but they also signal a global trend requiring attention. Implicit in that trend is the fact that people continue to face challenges once treatment is complete. Those challenges arise in the physical, psychological, economic, and spiritual domains and include issues such as fatigue, fear of recurrence, and uncertainty regarding next steps2. As a result, research that strives to broaden the understanding of those issues and of how to better support people affected by cancer has been on the increase. One such line of research explores the value of a personalized record of care and a follow-up plan—often called a survivorship care plan (scp)—as a means of improving patient-reported and healthrelated outcomes such as distress, self-efficacy, and quality of life. The U.S. Institute of Medicine (iom) recommends that, as part of optimal survivorship care, a scp should be provided to every patient upon ABSTRACT


INTRODUCTION
At an estimated 22.4 million worldwide, the number of people living with and beyond cancer is higher than ever because of advancements in treatment, early detection, screening, and prevention of secondary cancers [1][2][3] .In Canada and the United Kingdom, about 1 and 2 million people respectively are currently living with and beyond cancer [4][5][6][7] .In the United States, the number of survivors rose to 11.7 million in 2007 from 3 million in 1971 8 .Of the U.S. survivors, approximately 67% live at least 5 years after receiving their diagnosis, and 10% live 25 years or longer 1,8 .
These survivorship numbers are encouraging, but they also signal a global trend requiring attention.Implicit in that trend is the fact that people continue to face challenges once treatment is complete.Those challenges arise in the physical, psychological, economic, and spiritual domains and include issues such as fatigue, fear of recurrence, and uncertainty regarding next steps 2 .As a result, research that strives to broaden the understanding of those issues and of how to better support people affected by cancer has been on the increase.
One such line of research explores the value of a personalized record of care and a follow-up plan-often called a survivorship care plan (scp)-as a means of improving patient-reported and healthrelated outcomes such as distress, self-efficacy, and quality of life.The U.S. Institute of Medicine (iom) recommends that, as part of optimal survivorship care, a scp should be provided to every patient upon completion of treatment 2 .The scp can include summaries of the patient's cancer type and treatment history, schedules for possible follow-up screening, potential post-treatment issues, signs of recurrence, guidelines for lifestyle modifications, and important community resources.This information can offer people direction during the transition from active treatment at a cancer centre back to a primary health care provider (hcp) in the community, a period characterized by many researchers and practitioners as lacking in coordination [9][10][11][12] .Survivorship care plans can also help patients to communicate better with community hcps, ensure that patients receive the appropriate follow-up care in a timely manner, and support patients in dealing with the effects of their disease and treatments 2,13,14 .
The iom recommendations have been echoed, to varying degrees, by select government bodies worldwide, including the Australian Department of Health 15 , the National Cancer Survivorship Initiative (ncsi) in the United Kingdom 5 , and the Dutch Health Council 16 .In 2009, the Canadian Partnership Against Cancer, an independent organization created and funded by the federal government, made survivorship and scps a practice and research priority.In view of the increasing number of organizations throughout the world that have already incorporated or are considering the adoption of scps, and also the strong support from patients in many jurisdictions 14,17,18 , there is a need to understand and describe the many variations in the features of scps from various regions.
We conducted a review of English-language scps for adults with cancer that had been created and evaluated before April 2012.Few reviews of existing scps had been undertaken before this one, and of those that had, most had been limited to scps used in U.S. cancer centres 14,19,20 and to particular cancer types, such as breast cancer 19 .Our review aimed to extend that body of knowledge by including scps used on other continents in both research and clinical settings.We were guided by these questions: • What are the contents of current English-language scps?
• What are their accompanying implementation strategies?• What are the results of any evaluations of the scps after implementation?
This paper reports the findings of our review.It describes the variation in content, methods of delivery, and evaluations of English-language scps offered in various countries, and it compares our findings with the iom's recommended elements of a scp 2 .We conclude by discussing an approach to care that moves the focus from the end of treatment (survivorship) to a broader supportive care approach that incorporates features of scps throughout the cancer care continuum.

Search Strategies
We used several methods to identify Englishlanguage scps or organizations or authors that have used or produced scps.Our approach was inclusive and strategic; we strived to collect scps representative of diverse locations, while working within a limited time frame (3 months) and with limited resources.To locate scps, we conducted Google Scholar, medline, and cinahl searches using the key words "survivorship care plans," "follow-up care," "treatment summaries," and "post-treatment."We searched for any English-language scps from Canada, the United States, Europe, the United Kingdom, Australia, and New Zealand.We examined the Web sites of all Canadian provincial cancer agencies and treatment centres, and the Web sites of all 2011 U.S. National Cancer Institute-designated comprehensive cancer centres in the United States.In addition, we probed the Web sites of key cancer organizations and foundations, including the Canadian Cancer Society, the American Cancer Society, the American Society of Clinical Oncology, the livestrong Foundation, U.S. National Cancer Institute, the Australian Cancer Survivorship Centre, and Macmillan Cancer Support.

Identifying and Locating SCPs
We created a working definition of a scp based on the iom's "elements of a survivorship care plan" criteria 2 : written documents designed for use by adult cancer patients that contain at least one element from each of the record of care and follow-up care plan components.Using this working definition as the inclusion criteria, we separated general patient information materials (such as general post-treatment information booklets [21][22][23] ) from documents that had the elements of a scp, and we focused our attention on the latter.
Once we identified existing scps, we attempted to collect the actual scp documents and any available information on their method of delivery and evaluation by contacting the applicable author or organization by e-mail or telephone.We assured all contacts that any unpublished information would not be linked to their specific institution.We fully analyzed only scps for which we could obtain a copy of the plan, information about delivery, and information about evaluation.Figure 1 summarizes the search strategies and inclusion/exclusion process.This study was considered quality assurance work and was exempt from research ethics board review.

Analysis of SCPs
We performed a content analysis 24 of the scps, their methods of delivery, and their evaluation data, tracking the content categories on a spreadsheet.Two groups of researchers analyzed and verified the analyses, one group performing the initial analysis, and the second group acting as reviewer.The resulting spreadsheet was used to summarize the data and to extract and interpret common themes.

Context
Of the 47 scps identified, 16 for which we could ascertain content, delivery, and evaluation information were examined in detail.Table i summarizes the general characteristics of the analyzed scps.Although usually titled "survivorship care plan" and generally covering similar content, the details of each plan varied.Each site instituting a scp created a plan that met their unique needs, and there were often specific versions for particular cancer types.Although for the purpose of summarizing the plans, we examined the content of the scps separately from the methods of delivery, the content and method of delivery of most scps are linked and should not be viewed independently.Nearly all the documents that we examined were part of an approach that involved, at minimum, a conversation with a hcp.Information might not have been included in the content of the written scp document, but might have been discussed during the post-treatment meeting or attached in a pamphlet.

Content of SCPs
We analyzed content based on our interpretation of the 18 sections of the iom framework (p.152-3) 2 .Table ii summarizes the 18 sections of the iom framework, the criteria that we developed to determine if each component was present, and the number of scps that included the particular component.Table iii summarizes our findings for each component.

Methods of Delivery of SCPs
There was considerable variability in delivery style for the 16 analyzed documents.However, most plans were delivered at face-to-face clinic visits or discharge meetings by a nurse or nurse practitioner after the patient had completed active treatment.Many organizations provided additional materials to supplement the care plan document, including brochures, booklets, and a list of answers to frequently asked questions.In most cases, the resources given depended on particular patient concerns expressed at the post-treatment meeting.Table iv summarizes the main characteristics of the various delivery approaches.

Evaluations of SCPs
Evaluation of scps is an emerging area of research, and many projects are still in their early stages.In addition to the 16 scps for which we obtained evaluation data, we also communicated with researchers and practitioners from 9 other organizations who were in the process of conducting evaluations, but did not have data to share as of spring 2012.
The 16 evaluation reports that we analyzed varied in sample size and method of evaluation 17,25,26 .Most of the evaluation data were obtained through nonvalidated surveys.Only 7 of the 16 organizations that shared their evaluation data had published their results; the other 9 organizations shared unpublished data.
Usefulness ratings for the scps varied between 80% and 95% in the published studies 25,27,28 .Interestingly, some of the feedback emphasized the need for patients to be provided with this information earlier in the cancer treatment trajectory, suggesting that the information and support given to people at the end of treatment would also be useful to them throughout their treatment [29][30][31] .Table v summarizes the evaluation data.
Among the 16 scps analyzed, only 1 had been delivered as part of a randomized controlled trial.That study, by Grunfeld et al. 32 , found that the only difference between the control group (who received "usual care") and the intervention group (who received the scp) was that people receiving the scp were more likely to correctly identify their primary care provider as being responsible for their follow-up care.The trial results did not support the authors' hypothesis that scps are beneficial for improving patientreported outcomes of people with breast cancer 32 .However, many researchers, including the authors who designed and implemented the intervention, have suggested a number of alternative explanations and interpretations of the findings [32][33][34][35][36][37][38][39] .Rather than "signalling the end of scps" (p.1392) 33 , the study by Grunfeld and colleagues raises questions that point to the need for additional research.For 2 scps, the evaluations were particularly extensive and yielded positive reviews from patients and hcps alike.Those plans were the ones designed by livestrong (United States) 25,40,41 and the ncsi (United Kingdom) 27,29,42 , organizations that have been involved in survivorship care planning for longer than most others.As a result, they have been able to conduct repeated evaluations 25,27,29,[40][41][42][43][44][45][46][47][48][49] and to make changes to their scps and delivery processes based on the results of those evaluations.

A Different Approach
Our analysis revealed that scps, including their method of delivery, have more shared features than differences.One common feature is timing: that is, their development and delivery after treatment.However, one model stands out because of its u n ique approach a nd it s exten sive evalu ation 27,29,42,49 .Undertaken by the ncsi in the United Kingdom 5 , the plan that we call the ncsi model is not limited to post-treatment, but encompasses the entire cancer trajectory.Most provide space for a general description of treatment.One plan asked only for medications and general medical history, but was not specific to cancer treatment; some offered details of treatment such as cycles administered per regime, drug name, and regions of the body treated (for radiation therapy).Only two made reference to clinical trials.
Supportive services provided (psychosocial, nutrition, and other) 2 ( 13) One recorded a detailed psychosocial assessment, and one had space to record psychological challenges and supportive care providers.Information on the delivery of another plan suggested that these issues were sometimes covered in the post-treatment meeting.
Full contact information for treating institutions and key individual providers 15 (94) Most plans provided contact information for multiple health care providers: some plans distributed names and telephone numbers throughout the treatment summary, and others listed contact information for up to nine health care providers in a separate care team contact section.

Identification of a key point of contact
and coordinator of continuing care 1 (6) The primary care provider was identified in one plan.Half the plans mentioned various contacts such as a general practitioner or primary care provider, nurse practitioner, team coordinator, clinical nurse specialist, surgeon, or oncologist, but were not specific about who should be contacted.

Follow-up care plan
Treatment-related side effects (short-term) 11 (69)  Five plans did not distinguish short-term effects of treatment from long-term or late effects.The delivery of one plan included a discussion of effects of treatment at the post-treatment meeting.Few offered suggestions for how to deal with these effects.
Periodic tests and schedule 15 (94) One plan did not provide a list, but prompted people to ask the doctor about periodic tests and schedule.
Late and long-term side-effects 13 (81) Five plans did not distinguish short-term from long-term effects.Some plans provided a list of possible long-term effects as points of discussion, or provided symptoms that should prompt people to call their doctor.Only a few provided information beyond a list of symptoms.
Signs of recurrence or second tumour 12 (75) Some plans included signs of recurrence under late effects, screening guidelines, or a "frequently asked questions" section.Some described this section as "specific signs and symptoms to look for."In the delivery of one plan, there was an assessment to detect recurrence, but no mention was made of what people need to pay attention to in the future.
Psychosocial concerns 11 (69)  Only one provided a general list of topics as considerations to be brought up with a doctor.In the remainder, detail was minimal.Of the five that did not deal with psychosocial concerns, two listed resources, but provided no information.
Financial concerns 6 (38)  Financial concerns were minimally mentioned.One plan provided information in the post-treatment meeting, but the information was not included in the written plan.
Recommendations for healthy behaviour Several key features distinguish the ncsi approach.The primary goal is to be "intelligent" about how services are provided by offering care and support to each person in the way that meets the needs of that particular person, rather than by providing a homogenous approach to everyone that is not always effective 50 .A complementary goal is to support people to engage in self-management to the best of their ability and to offer services accordingly.The extent to which people can engage in self-management is determined through the "holistic assessment and care planning" 51 process that begins at diagnosis, continues up to 5 years past active treatment, and takes into consideration all aspects of a person's life: physical, social, psychological, and spiritual 51 .
In evaluating their original end-of-treatment approach, the ncsi realized that many of the issues that arose at that time could have been handled earlier in the treatment trajectory 50 .A clinical nurse-specialist is assigned to each new patient and remains the constant point of contact.In consultation with the care team, that nurse conducts assessments at or near the point of diagnosis, throughout treatment if  were more likely to correctly identify their primary care provider as being responsible for their follow-up care.
No statistically significant differences were observed between the groups in any other patient-reported outcome investigated.necessary, and beyond.Those assessments serve as a starting point for discussion and use tools such as the Distress Thermometer and the Sheffield Assessment Instrument 51 .
As treatment nears completion, the care team stratifies patients into a follow-up care plan based on the level of support they need and the self-management they can achieve-an approach called the "risk stratified pathway" 52 .At the end of treatment, the multidisciplinary team completes the treatment summary (record of care) and the follow-up care plan.The treatment summary is sent to the primary care provider with a copy to the patient.It is at this point that the ncsi's approach merges with all the others that we examined, which consider survivorship a distinct phase of care.
This approach is not so much survivorship care as supportive care that begins at diagnosis and culminates in an individualized follow-up plan.The ncsi's practice of stratifying each patient eliminates the generic one-size-fits-all approach to end-of-treatment survivorship care that has everyone visiting for follow-up appointments at pre-determined times 50 .The ncsi is convinced that few recurrences are found that way and that that method is ineffective and inefficient for follow-up care 53 .Multiple evaluations conducted by the ncsi have shown that their broader, personalized approach can lead to improvements in several outcomes, including patient satisfaction [54][55][56] , patient confidence in self-managing their own health 56 , cost effectiveness 42,54 , and reduced demand for acute care and outpatient resources 54,57,58 .

DISCUSSION
The iom recommendation that scps be provided to patients at completion of treatment has been the impetus behind the creation and implementation of such plans in research and clinical settings in many jurisdictions.However, the recommendation poses a challenge to hcps, because there is little or no consensus on the key features of scps or how to operationalize plan delivery.Previous reviews focused on scps in the United States 14,19 , but we extended our search to gain a comprehensive view of how scps are used in other parts of the world.Nevertheless, most of the plans identified in our searches came from the United States.Our study indicates many similarities between the approaches used by different institutions.Most scps were used in clinics and provided after treatment at an in-person meeting (in most instances with a nurse), with a copy given to a primary hcp.Despite those similarities, we also uncovered noteworthy features (such as providing scps before the end of active treatment) used by some sites that either adapted the iom recommendations to suit their needs or brought their own interests and evaluation results to bear on their scp design and implementation plan.
The contents of the scps that we examined reflect many of the iom's recommendations, although the details vary considerably.However, inattention to support services such as psychosocial services and to the identification of a key point of contact and coordinator of continuing care reveal important deviations from the iom's recommendations and potentially suggest that these services are not components of standard practice in some care settings.The followup portions of the scps vary even more in terms of how they follow through with the iom's recommendations.For example, in our study, only 50% of the scps provide a list of cancer-related information and resources and fewer than 50% address genetic testing or financial concerns.Our findings mirror those of Stricker et al. 19 , who reviewed breast cancer scps from 13 U.S. centres within the livestrong Survivorship Centres of Excellence Network (livestrong Network), and Salz et al. 14 , who reviewed breast and colorectal cancer scps from 22 U.S. National Cancer Institute-designated cancer centres in the United States.Those U.S. reviews differ from our own in that they included scps regardless of whether the plans had been evaluated.Nevertheless, as in our review, they observed the same pattern of deviations from the iom's recommendations.
It appears that many organizations providing scps as part of end-of-treatment survivorship care do not follow all of the current iom recommendations, which raises questions about why they do not 14,19,36 .Saltz et al. 14 argued that one cause of variation in content of scps might be a lack of clarity within the iom framework.In an attempt to start addressing that issue and to refine the essential elements of the framework, the livestrong Foundation in September 2011 convened a meeting that included community leaders, hcps, administrators, people with cancer, and advocates from North America (mostly from the United States).They agreed on a list of 20 essential elements of survivorship care, which included the development and delivery of scps 59 .After that meeting, the livestrong Foundation and the livestrong Network refined the definitions of those 20 essential elements 60 , which included defining scps as incorporating a patient-specific treatment summary that includes medical and psychosocial components such as information about treatment, potential long-term and late effects, and potential complications and their signs and symptoms 60 .Meeting participants also agreed on the need to conduct research evaluating the impact and effectiveness of various models of survivorship care delivery 59 .We strongly support the latter recommendation.In our study, only half the organizations identified to be using scps and responding to our communication (16 of 33) had evaluation data that they were able to share, and fewer than half of those (just 7) had published their results.In addition, most of the available evaluation data were obtained using non-validated tools and small sample Current OnCOlOgy-VOlume 21, number 3, June 2014 Copyright © 2014 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).
sizes, making it difficult to compare and generalize the results.We argue that identifying or creating reliable instruments to evaluate scps and survivorship programs should be a priority.In addition, most of the evaluation data we analyzed focused on satisfaction and came from patients only.Although a patient focus has huge merit, investigating other outcomes such as distress and quality of life, and involving a broader range of stakeholders such as family members, nurses, oncologists, and administrators might provide a more comprehensive view of survivorship care interventions.
We agree that evaluating survivorship care planning and disseminating findings will assist in determining best approaches, including the essential elements of survivorship care.Many jurisdictions, particularly in North America, have already recognized the value of providing scps to patients.However, we argue that the focus of care planning should not be limited to scps and survivorship at the end of treatment, but should include broader supportive care strategies starting near diagnosis.Most of the North American initiatives we analyzed address survivorship as a distinct phase of care and see scps as tools to be provided to patients at the completion of treatment, as stated by the recommendations 2 .The ncsi's approach in the Kingdom expands the of survivorship to cover the entire cancer care continuum, reflecting the important findings from some of the published 29,30 and unpublished evaluations of scps included in our review: people want and need information, individualized support, and care planning from diagnosis onward, not just after treatment completion.The ncsi recognizes that assessing the needs that accompany the transition to post-treatment care reveals a number of issues, many of which could be addressed earlier in the trajectory and thus ease the transition process at the time of treatment completion.The ncsi's care plans are therefore created at or near the time of diagnosis and amended as necessary throughout the cancer care trajectory.That approach to survivorship-or rather, supportive care-by the ncsi puts into practice what others have begun to articulate.Furthermore, their ongoing evaluation through pilot studies and population surveys has resulted in positive findings, demonstrating the success of their approach, independent of cancer group.
We wonder whether, by using the language and concepts of "navigation," [61][62][63][64][65] "case management," 66 or "care coordinator," 67,68 hcps and researchers from many jurisdictions are already trying to address the need for supportive care throughout treatment and beyond.The tools, language, and timing might be different from those used by people speaking in terms of "survivorship" and using scps as defined by livestrong and the iom, but there are features in common.However, these approaches point to a change in thinking about how people can best be supported.For example, the Australian state of Victoria has a statewide Supportive Cancer Care Initiative 69 that aims to provide a coordinated approach to supportive care, beginning at diagnosis and continuing throughout the care trajectory-an approach similar to that of the ncsi.Because we used "survivorship" in our search of the literature and practice settings, the Victoria state initiative did not arise in our search.
We propose that, by expanding the scope of survivorship care planning to provide individualized supportive care from the time of diagnosis through the entire cancer care trajectory, cancer care settings might begin to address most of the challenges faced by people living beyond the completion of active treatment and might improve their overall cancer care experience.Used within the context of this broader approach to supportive care, care plans can be a powerful support tool for people during their cancer care trajectory.We caution, however, that care plans must be considered not as standalone documents, but as tools that are part of a larger holistic care-planning approach.That holistic approach to supportive care planning not only attends to the original goals of the iom's recommendations-to facilitate the transition to the next stage of life and to ensure that people receive the appropriate follow-up care in a timely manner 2but also expands on the recommendations to improve the experience of cancer care from the beginning.

FUTURE RESEARCH
The parameters of our study limited the scope of our findings, which draw attention to future research possibilities.It is possible that our search strategy has not identified scps from all English-speaking countries.In addition, expanding the analysis to include supportive care initiatives in non-English speaking jurisdictions could potentially yield interesting results.As organizations engage in strategies beyond the iom recommendations (for example, the ncsi model), the limitations inherent in conceptualizing survivorship as a distinct phase of care could be challenged, providing opportunities for further research.When we completed our study in April 2012, many organizations with whom we had communicated were in the process of evaluation and publication of their findings.As those publications become available, they will expand the current literature base on both survivorship and supportive care beyond what has been described here.We look forward to seeing published research that examines the implementation not only of the iom framework, but also of strategies that move beyond it.

SUMMARY
In early 2012, we conducted a review of English-language scps that had been evaluated, including those Current OnCOlOgy-VOlume 21, number 3, June 2014 Copyright © 2014 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).used on different continents in both research and clinical settings.The approaches to delivery and the extent to which the documents followed the original recommendations from the iom varied considerably.However, more research that evaluates and compares the effectiveness of these different approaches is needed.In most settings, survivorship is considered a distinct phase at the end of treatment, and scps are documents created and delivered after primary treatment is complete.Our findings point to an approach to care that goes beyond the iom recommendations, incorporating assessments and care from the point of diagnosis to beyond treatment.A holistic assessment and planning process for supportive care that is not limited to the treatment of illness, but that appreciates the need for physical, psychological, social, and spiritual care for people with cancer and their families will allow for levels of support and care appropriate to each person.The result can be improved quality of life for people affected by cancer.

figure 1
figure1 Flow of survivorship care plan (scp) search strategies and inclusion decisions.

15
Not tumour-specific; delivered right after completion of active treatment, but may vary.Paper survey 157 Patients Most patients (more than 90%) found the scp useful and felt that it helped them to make at least one positive lifestyle change; 47% shared their scp valued the program and suggested the introduction of survivorship during the treatment phase.Current OnCOlOgy-VOlume 21, number 3, June 2014 Copyright © 2014 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).

table i
General characteristics of survivorship care plans e470 Current OnCOlOgy-VOlume 21, number 3, June 2014 Copyright © 2014 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).

table ii
Content of survivorship care plans: categories of analysis Follow-up care planTreatment-related side effects (short-term) Mention of any short-term (side) effects of treatment or the likely course of recovery Periodic tests and schedule Suggestions of tests that are needed in the coming months and years Late and long-term side-effects Mention of late or long-term effects and how to deal with them Signs of recurrence or second tumour Mention of signs and symptoms of recurrence Psychosocial concerns Reference in the care plan to effects on sexual functioning, relationships, anxiety, fatigue, sadness, depression Financial concerns Any mention of financial issues (insurance, cost of medication, work) Recommendations for healthy behaviour Any mention of variations in after-treatment care, self-management, or lifestyle Genetic counselling, if appropriate Mention of genetic testing as part of follow-up care, including referrals Chemoprevention, if appropriate Any mention of possible future cause for preventive pharmaceutical therapies (for example, tamoxifen, aspirin) Referrals Any referrals to specific care providers (including primary care providers or support groups) Resource lists Any lists of cancer-related information and resources (Internet-or telephone-based) a Based on recommendations from the U.S. Institute of Medicine 2 .e471 Current OnCOlOgy-VOlume 21, number 3, June 2014 Copyright © 2014 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).
Many suggested the person to contact within specific sections of the plan.Two organizations provided referrals in the discharge meeting, although they did not record these in the plans.Listed resources included Web sites, seminars, telephone listings, books, and videos.Of the organizations that did not list resources within the care plan, several provided separate lists to patients.