Exploring survivorship care coordination between primary care providers and cancer care clinicians.

Abstract

e13873 Background: Survivors are at an increased risk of recurrence, subsequent primary cancers, comorbidities, physical and psychosocial long-term and late-effects. As survivors transition from regular oncology follow-up to management by their PCPs and , they require care focused coordination between these clinics. oncologists and primary care providers (PCPs) However, this receipt of care is a known gap within care coordination, and bridging the gap can be critical for survivors’ health. Methods: We used semi-structured interviews with oncology advanced practice providers (APPs) and PCPs. APPs were recruited via email and at monthly in-service meetings whereas PCPs were recruited via emails and flyers at UMass Primary Care clinic sites. Participants took part in 30-minute remote interviews. Qualitative interviews were recorded, transcribed and managed using NVivo. Coding was done by two team members using open coding and coding checks on > 10% for inter-rated reliability. Themes were identified for each group of participants (APPs and PCPs) and placed into two categories: current state of survivorship workflow and preferences to improve care coordination. Results: Key themes in the current state of survivorship workflow included 1) lack of direct communication with PCPs during or post cancer treatment, 2) sending /receiving survivorship care plans (SCPs) were challenging, 3) lack of awareness regarding SCPs and gaps within support services and follow up treatment. Among APPs and PCPs, APPs reported struggling with SCP dissemination to PCPs while PCPs mainly lacked knowledge of SCP and survivorship resources. Both groups noted difficulty in communication using electronic health records (EHR). Care coordination also had some main themes including 1) earlier knowledge of survivorship visits among patients and providers, 2) focusing on regular communication with PCPs during and after treatment, and 3) stronger integration of SCP into EHR. APPs and PCPs had very similar thoughts regarding care coordination and noted that more efficient SCP dissemination was needed, with PCPs asking for point of contact on cancer care teams. Conclusions: Implementation of strategies to streamline workflow and communication between oncology clinics and PCPs and addressing knowledge gaps and facilitating sharing of SCPs (via EHRs) may be potential enhancements to the current survivorship care workflow.