INNOVATION FUND Innovation, Integration, & Implementation Cancer Care SHOWCASE 2016 INNOVATION FUND Innovation, Integration, & Implementation Cancer Care SHOWCASE 2016

The Cancer Survivorship Ambulatory Clinic: A Multi-disciplinary, Inter-professional, and Virtual Follow-up Network for Cancer Survivors

Cancer Care


Simron Singh


Matthew Cheung


Sunnybrook Health Sciences Centre, University of Toronto


Advances in the treatment of Hodgkin’s and Non-Hodgkin’s lymphoma (HL/NHL) and colorectal cancer (CRC) have resulted in increasing cure rates and a growing population of long-term cancer survivors. The Transition Care Clinic (TCC), consisting of an ambulatory clinic and automated Survivorship Care Plans (SCPs) created specifically for survivors, was implemented at the Odette Cancer Centre to facilitate survivors’ transition to their primary care physicians (PCPs).  Since 2012, the TCC accumulated 131 visits with 105 of these patients being successfully discharged (80%) to primary care. Using evidence- and practice-based resource savings models, the discharges were estimated to save 210 specialist appointments and 640 visits to the Sunnybrook Health Sciences Centre. Patient surveys suggests that the TCC was effective and clear in providing information and the SCP was thoroughly developed. Interviews with transitioning cancer survivors showed how the TCC contributed to their readiness to transition, which was cited as an important factor during transition. Based on these findings, one of the next steps for improving the transition experience for cancer patients would be the development of a transition readiness instrument. This tool would assess survivors’ appropriateness to receive care from their PCP and would be able to identify survivors that are best-suited for the transition. Lessons learned from the TCC initiative inform future innovations and research during survivors’ transition to primary care. Furthermore, the software developed in the TCC to aggregate and present patient health information in automated SCPs has the potential to aid other patients that are transitioning from acute care.


Advances in the treatment of cancer has resulted in an increasing number of long-term cancer survivors making high quality survivorship care and follow-up necessary for this growing population. The pilot initiative of the Transition Care Clinic (TCC) at the Odette Cancer Centre in Toronto aimed to facilitate survivors’ transition to their primary care physicians (PCPs) in an attempt to alleviate constrained health care resources and to provide high quality cancer survivorship care. The TCC consisted of a nurse practitioner-led ambulatory clinic and automated electronic survivorship care plans (SCPs) to effectively coordinate relevant medical information between primary and acute healthcare providers. Since implementation in 2012, there have been 131 cumulative visits to the TCC and 105 successful discharges (80%) of patients back to their PCP. This translates into the reduction of 210 specialist appointments and the avoidance of 640 visits (401 blood tests and 239 CT scans) to Sunnybrook Health Sciences Centre .Through patient surveys, it was found that transitioning patients found that the TCC provided them with clear information about their prognosis, empowered them and contributed to their confidence during transition. In addition, the TCC was able to provide a method for cancer specialists to safely and effectively transition healthy patients from their care, thus allowing them to better address the growing need for specialized acute cancer services. Next steps involve expanding the usability and adoptability of the automated SCP and developing strategies to optimize the effectiveness of the TCC.

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