title: A multidisciplinary model of care for childhood cancer survivors with complex medical needs.
abstract: Long-term survival for children with cancer is often achieved at a considerable cost in terms of medical and psychological sequelae. Although many survivors are well and require only routine follow-up and surveillance, a cohort of survivors require comprehensive management of complex, chronic medical issues by multiple subspecialists. For these survivors, care delivered within the context of an annual visit to a traditional hospital-based late effects clinic or by a primary care physician in the community is often not adequate. A specialized clinic was implemented at The Children's Hospital of Philadelphia that crosses disciplines and provides same-day, same-clinic access to oncology/survivorship, endocrinology, pulmonology, cardiology, nutrition, and psychology. This multidisciplinary approach supports clinical efficiency and fosters seamless patient-centered care both for patients with identified late effects and for those with the highest risk for problems because of intense treatment exposures. The model is described with a focus on clinic structure/process, clinical outcomes, and benefits to survivor, health care provider, and institution. The diverse roles for nursing within this model are highlighted.
authors.affiliation: Cancer Survivorship Program, The Children's Hospital of Philadelphia, PA 19104, USA. carlsoncl@email.chop.edu
authors.forename: Claire A
authors.initials: CA
authors.lastname: Carlson
authors.forename: Wendy L
authors.initials: WL
authors.lastname: Hobbie
authors.forename: Melinda
authors.initials: M
authors.lastname: Brogna
authors.forename: Jill P
authors.initials: JP
authors.lastname: Ginsberg
mesh_terms: D002648:Child; D006301:Health Services Needs and Demand; D006801:Humans; D017146:Models, Organizational; D009369:Neoplasms / Q000145:classification / Q000451:nursing / Q000628:therapy*; D024802:Nurse's Role; D017060:Patient Satisfaction; D015143:Philadelphia; D012017:Referral and Consultation; D017741:Survivors; D016896:Treatment Outcome