title: Patient-centered support in the survivorship care transition: Outcomes from the Patient-Owned Survivorship Care Plan Intervention.
abstract: BACKGROUND
  To the authors' knowledge, few studies to date have evaluated the effects of survivorship care planning on the care transition process from specialty cancer care to self-management and primary care, patient experience, or health outcomes. The Patient-owned Survivorship Transition Care for Activated, Empowered survivors (POSTCARE) is a single coaching encounter based on the Chronic Care Model that uses motivational interviewing techniques to engage survivors of breast cancer. The current study examined the effects of the POSTCARE intervention on patient outcomes and care coordination.
  
  
  METHODS
  A total of 79 survivors of American Joint Commision on Cancer TNM System stage 0 to IIIB breast cancer were randomized to POSTCARE (40 patients) or usual care (39 patients). Patient outcomes were assessed using the 36-Item Short Form Health Survey (SF-36), Social/Role Activities Limitations, Self-Efficacy for Managing Chronic Disease 6-Item Scale, the Patient Activation Measure-Short Form, and Patient Health Questionnaire depression scale at baseline and at 3-month follow-up. Care coordination was assessed using confirmed primary care physician visits and reported discussion of the survivorship care plan at the 3-month follow-up. Logistic and linear regression analyses were conducted to examine the effect of POSTCARE on selected outcomes.
  
  
  RESULTS
  Participants in the intervention group versus those receiving usual care demonstrated significantly higher self-reported health (F-statistic (3,71), 3.63; P =.017) and lower social role limitations (F (3,70), 3.82; P =.014) and a trend toward greater self-efficacy (F (3,69), 2.51; P = .07). Three quality-of-life domains reached clinically meaningful improvement at the 3-month follow-up, including physical role (P =.0009), bodily pain (P =.03), and emotional role (P =.04).
  
  
  CONCLUSIONS
  The POSTCARE intervention appeared to have a positive impact on patient outcomes and demonstrated promise as a strategy with which to improve survivors' experience, care coordination, and health outcomes. Cancer 2016;122:3232-42. © 2016 American Cancer Society.
authors.affiliation: Department of Medicine, University of Alabama, Birmingham, Alabama. ekvale@uabmc.edu.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Kvale
authors.affiliation: Department of Medicine, University of Alabama, Birmingham, Alabama.
authors.forename: Chao-Hui Sylvia
authors.initials: CS
authors.lastname: Huang
authors.affiliation: School of Nursing, University of Alabama, Birmingham, Alabama.
authors.forename: Karen M
authors.initials: KM
authors.lastname: Meneses
authors.affiliation: Department of Nutrition Sciences, University of Alabama, Birmingham, Alabama.
authors.forename: Wendy
authors.initials: W
authors.lastname: Demark-Wahnefried
authors.affiliation: Department of Medicine, University of Alabama, Birmingham, Alabama.
authors.forename: Sejong
authors.initials: S
authors.lastname: Bae
authors.affiliation: Department of Psychology, University of Alabama, Tuscaloosa, Alabama.
authors.forename: Casey B
authors.initials: CB
authors.lastname: Azuero
authors.affiliation: Department of Medicine, University of Alabama, Birmingham, Alabama.
authors.forename: Gabrielle B
authors.initials: GB
authors.lastname: Rocque
authors.affiliation: Department of Obstetrics and Gynecology, University of Alabama, Birmingham, Alabama.
authors.forename: Kerri S
authors.initials: KS
authors.lastname: Bevis
authors.affiliation: Department of Medicine, University of California San Francisco, San Francisco, California.
authors.forename: Christine S
authors.initials: CS
authors.lastname: Ritchie
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000523:psychology / Q000534:rehabilitation*; D003266:Continuity of Patient Care / Q000458:organization & administration*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008875:Middle Aged; D009367:Neoplasm Staging; D010347:Patient Care Planning; D010358:Patient Participation; D011379:Prognosis; D011788:Quality of Life; D012648:Self Care; D011795:Surveys and Questionnaires; D015996:Survival Rate; D017741:Survivors / Q000523:psychology*
keywords: breast cancer; care transition; chronic illness model; motivational interviewing; self-management; survivorship; survivorship care plan