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Moving forward after cancer: successful implementation of a colorectal cancer patient–centered transitions program

  • Benjamin A. GoldenbergEmail author
  • Tara Carpenter-Kellett
  • Joel R. Gingerich
  • Zoann Nugent
  • Jeffrey J. Sisler
Article

Abstract

Purpose

Cancer survivors transitioning between academic comprehensive cancer systems and community general practice settings are vulnerable to discontinuity, inconsistency and variation in care, inappropriate surveillance testing, and a sense of isolation and loss. Though these issues have been well recognized for over a decade and a half in the survivorship, oncologic, and health services literature, there remains a dearth of positive examples of models that have been well received by both the transitioned patient and the providers on either side of the handoff. We herein describe a sustained positive example of a transitions program. This program centers on standardized and personalized survivorship care plans (SCP) to guide follow-up care and recovery.

Methods

Following the province-wide introduction of a transitions program for treated stages II and III colorectal cancer (CRC) patients, a post-implementation survey was mailed to transitioned patients with the primary outcome evaluated the patients’ perception of improved continuity of care and the main instrument used the Patient Continuity of Care Questionnaire. This was compared against a previously published pre-implementation historical control.

Results

The data presented comparing pre- and post-implementation patient cohorts reflect significantly improved patient-reported perceptions regarding the enhanced continuity and coordination of their follow-up and survivorship care after the province-wide introduction of a formal transitions process. This SCP intervention has been sustained post implementation.

Conclusions

Using, as a starting-point, a standardized electronically SCP, CancerCare Manitoba has successfully facilitated a jurisdiction-wide implementation of a scalable, reproducible, and adaptable transitions program.

Implications for Cancer Survivors

This intervention at the time of transition back to the community has enhanced CRC survivor perception of continuity and coordination of follow-up care.

Keywords

Delivery of health care Continuity of care Patient-centered care primary care Patient handoff colorectal neoplasms 

Notes

Author contribution

All authors contributed to the study conception, design, data collection, analysis and drafting and revision of the final manuscript.

Compliance with ethical standards

Conflict of interest

All authors declare they have no financial conflict of interest related to this work; however, they all are or have been employees or contracted consultants of the comprehensive Cancer Agency where this work was undertaken.

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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Medical Oncology and Hematology CancerCare ManitobaWinnipegCanada
  2. 2.Community Oncology ProgramCancerCare ManitobaWinnipegCanada
  3. 3.Department of Medical Oncology and Hematology and Community Oncology ProgramCancerCare ManitobaWinnipegCanada
  4. 4.Department of Epidemiology and Cancer RegistryCancerCare ManitobaWinnipegCanada
  5. 5.Department of Family MedicineUniversity of ManitobaWinnipegCanada

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