The purpose of conducting a service assessment is not only to identify and address deficiencies but also to recognize resources that may already be available. The assessment should be conducted as part of the survivorship care program planning process to establish:

  • A clear picture of which services are readily available
  • Who can provide the services
  • Which resources are necessary but not in place

It is important to understand that while the model of care delivery will define which resources are needed, the needs assessment will help determine which model of care delivery is most feasible for your facility. Further, the patient population served by your facility will significantly define which services are needed within your survivorship care program. The needs of cancer survivors will vary based on their malignancy type and stage, treatment received, time from diagnosis, comorbidities, and other factors. The vital first step in the process is to identify the stakeholders who can most appropriately and fully answer the questions. You are encouraged to include patients or patient advocates in the process to ensure the program will best suit the needs of your survivor population.

The questions within the service assessment are designed to assist with the identification of strengths and weaknesses that exist within the practice or care center, and the surrounding community which can then be used to develop the strategy to plan and implement a survivorship care program. Although this assessment can give some guidance, there exist unmet needs and inadequacies in current models and additional key principles should be considered and incorporated into new models.

Complete Service Assessment

In addition to the service assessment, determining if the patient can transition to a survivorship-care focus is also important. Things to consider include, but are not limited to:

  1. Does the patient have an established relationship with a PCP?
  2. Has the survivorship care plan (SCP) been transmitted to the PCP or provider in charge of long-term follow-up care?
  3. Have additional resources, such as guidelines, been provided to the PCP? Have roles been agreed upon between the PCP and oncology providers?
  4. Has the patient received the SCP?
  5. Has the patient been given the opportunity to review the SCP with a member of the care team?
  6. Has the transition of care been clearly communicated to the patient so that they understand who will be the lead in the coordination of care?

Based on responses to the above questions and service assessment, this flowchart can help determine which model is best for your program.

Advantages & Disadvantages of Different Models of Care
Each model has advantages and disadvantages which are described in the below links.

Oncology Specialist Care
Multidisciplinary Survivorship Clinic
Disease/Treatment Specific Survivorship Clinic
General Survivorship Clinic
Consultative Survivorship Clinic
Integrative Survivorship Clinic
Community Generalist Model
Shared-care Survivorship Model

Potential Barriers & Solutions to Implementing Different Models of Care
Numerous challenges may exist when implementing a survivorship care program. These include barriers related to providers, survivors, community resources, and the healthcare delivery system. Although not all of these issues may be addressed here, the more common barriers to implementation and potential solutions are highlighted below.

System-Level Challenges
Provider-Level Challenges
Patient-Level Challenges

Models of Long-Term Survivorship Follow-Up Care
Providing survivorship care requires approaches that both meet the needs of the growing population of survivors and are sustainable for practices and health systems. Several models of care delivery have been studied in randomized controlled trials (Halpern et al 2015). while other models have not been rigorously evaluated.  Reflecting on successful implementation models outside of the United States, the American Cancer Society (ACS) and ASCO convened a summit in 2018 (Alfano et al 2019) to address inadequacies in current models and recognized key principles that must be incorporated into existing models and addressed in new models going forward:

  • Algorithms to triage patients to pathways.  The following factors should inform individual needs for healthcare:  risk of recurrence, new cancers, late effects; ongoing chronic effects of cancer treatment; time since cancer treatment; comorbid conditions; psychological health; health literacy and the ability to self-manage; social and economic issues; geography; and capacity of health care systems to deliver care.
  • Methods to assess patient issues to guide care utilizing patient-reported assessments (Gordan and Chen 2017)
  • Remote monitoring systems to develop systems of care that utilize telemedicine with careful attention to populations that may have limited access and literacy to technology
  • Methods to support patients in self-management with consideration to identify populations that can self-manage aspects of their care
  • Ways to coordinate care and information exchange between oncology, primary care, specialists, and patients
  • Methods to engage all stakeholders and secure their ongoing buy-in.  Ingrained practice patterns of longer term follow-up in low-risk recurrence patients need to be reexamined acknowledging provider barriers (see Potential Barriers and Challenges to Implementation) but also recognizing the focus on optimal care of the cancer survivor.