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ASSESS
Activity 1: Defining Your Patient Population
Instructions: The goal of this activity is to help you describe the patient population for which you will be
establishing a navigation and/or survivorship program. Think about your different stakeholders (e.g., patients,
providers, administrators, board of directors, funders) and what information would be most important to
share with them. If you do not know the answers to some of the questions, try to answer them to the best of
your ability if they are important to your stakeholders. Your institution may have compiled some of this
information, or you may need to look at available city or state data.
Race/Ethnicity:
1. Please indicate the % or # of your patient population that is:
_____ American Indian and Alaska Native _____ Native Hawaiian & Other Pacific Islander
_____ Asian _____White/Caucasian
_____ Black or African American _____ Other
_____ Hispanic/Latino
Age:
2. Please indicate the % or # of your patient population that is:
_____ 0 to 17 years _____ 50 to 64 years
_____ 18 to 34 years _____ Over 65
_____ 35 to 49 years
Gender:
3. Please indicate the % or # of your patient population that is:
_____ Male _____ Female ______ Transgender
Socio-economic status (income, occupation, education, wealth and environmental factors):
4. Please indicate the % or # of your patient population that is:
_____ Low SES _____ High SES
_____ Middle SES _____ Unsure
Program Development Workbook Center for Advancement of Cancer Survivorship, Navigation and Policy
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Insurance:
5. Please indicate the % or # of your patient population with the following insurance:
_____ Private insurance _____ Other
_____ Medicaid _____ Uninsured
_____ Medicare
Disease Specification:
6. Please indicate the % or # of your patient population with the following cancer type within the last year:
_____ Bladder Cancer _____ Lung Cancer
_____ Blood Cancer _____ Melanoma
_____ Breast Cancer _____ Pancreatic
_____ Cervical Cancer _____ Pediatric Cancer
_____ Colorectal Cancer _____ Prostate Cancer
_____ Endometrial Cancer _____ Thyroid
_____ Kidney (Renal Cell) Cancer _____ Other specific cancer type(s):
7. Please indicate the % or # of abnormal screening findings in the last year: _____
8. Please indicate the % or # of cases lost to follow-up that required medical treatment:____
9. Please indicate the no-show rate for your patient population: ____
Health Barriers and Needs:
10. What are the barriers to quality cancer care for your primary patient population that make it difficult to
access care or manage their health care needs? (Check all that apply)
_____Availability of health services _____Fear/anxiety (mistrust of health system)
_____Communicating between care providers _____Fragmented care
_____Cultural/Language _____Gaps in financial/health Insurance coverage
_____Employment/School concerns _____Lack of knowledge of late and long-term
effects
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_____Lack of long-term follow-up _____Literacy barriers
_____Lack of PCP _____Patient and caregiver education needs
_____Lack of support groups _____Physical (location of
facility)/Transportation
_____Lack of survivorship care plan
_____Transition from oncologist to PCP
11. What percentage of your patient population does not speak English? ____________________
12. What are the most common primary languages spoken by your patient population?
1. _______________________________________________________
2. _______________________________________________________
3. _______________________________________________________
4. _______________________________________________________
5. _______________________________________________________
13. Where along the cancer continuum are the greatest needs of your patient population? (Check all that
apply)
_____Outreach/health promotion _____Treatment
_____Screening _____Post-treatment/survivorship
_____Diagnosis _____End of Life
14. Is there additional information that would be helpful to gather, such as:
Obesity rates: ________________________________________________________________
Smoking Rates: _______________________________________________________________
Other: ______________________________________________________________________
Other: ______________________________________________________________________
Other: ______________________________________________________________________
Program Development Workbook Center for Advancement of Cancer Survivorship, Navigation and Policy
