The Johns Hopkins Primary Care for Cancer Survivor Clinic: lessons learned in our first 4 years

Youngjee Choi, Archana Radhakrishnan, Darshan Mahabare, Shalom Patole, Sydney M. Dy, Craig E. Pollack, Zackary D. Berger, Kimberly S. Peairs

Research output: Contribution to journalArticle

Abstract

Purpose: We established the Primary Care for Cancer Survivor (PCCS) Clinic in 2015 to address transition and care delivery challenges unique to cancer survivors. We describe the clinical program, detail patients from the first 4 years of implementation, and discuss lessons learned during the process. Methods: We abstracted relevant patient information from the electronic medical record, administered a needs assessment survey at initial visits, and collected relative value unit (RVU) data. Results: Between August 2015 and May 2019, we saw 230 PCCS patients with an increasing number of referrals yearly; nearly half were breast cancer survivors. At the initial visit, patients reported a median of 9 needs, with emotional needs most prevalent; over a third received at least one referral. PCCS patients generated higher billing codes and average RVUs compared with general patients. Conclusions: In its first 4 years, the PCCS program has thrived as a unique model of cancer survivorship centered in primary care. PCCS patients reported numerous needs, emphasizing the critical need for a multi-disciplinary approach in this population. With increasing referrals, we have considered different risk stratification and staffing models for capacity and expansion. By generating more RVUs per visit compared with the general clinic, PCCS has demonstrated financial sustainability. Buy-in from our oncology colleagues, divisional support from general medicine, along with our collaboration of like-minded internists have allowed us to be a robust program. Implications for Cancer Survivors: Models of survivorship care embedded in primary care can provide meaningful, patient-centered care for cancer survivors.

Original languageEnglish (US)
JournalJournal of Cancer Survivorship
DOIs
StateAccepted/In press - Jan 1 2019

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Survivors
Primary Health Care
Neoplasms
Referral and Consultation
Survival Rate
Patient-Centered Care
Needs Assessment
Electronic Health Records
Medicine
Breast Neoplasms
Population

Keywords

  • Cancer survivors
  • Continuity of patient care
  • Primary care

ASJC Scopus subject areas

  • Oncology
  • Oncology(nursing)

Cite this

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title = "The Johns Hopkins Primary Care for Cancer Survivor Clinic: lessons learned in our first 4 years",
abstract = "Purpose: We established the Primary Care for Cancer Survivor (PCCS) Clinic in 2015 to address transition and care delivery challenges unique to cancer survivors. We describe the clinical program, detail patients from the first 4 years of implementation, and discuss lessons learned during the process. Methods: We abstracted relevant patient information from the electronic medical record, administered a needs assessment survey at initial visits, and collected relative value unit (RVU) data. Results: Between August 2015 and May 2019, we saw 230 PCCS patients with an increasing number of referrals yearly; nearly half were breast cancer survivors. At the initial visit, patients reported a median of 9 needs, with emotional needs most prevalent; over a third received at least one referral. PCCS patients generated higher billing codes and average RVUs compared with general patients. Conclusions: In its first 4 years, the PCCS program has thrived as a unique model of cancer survivorship centered in primary care. PCCS patients reported numerous needs, emphasizing the critical need for a multi-disciplinary approach in this population. With increasing referrals, we have considered different risk stratification and staffing models for capacity and expansion. By generating more RVUs per visit compared with the general clinic, PCCS has demonstrated financial sustainability. Buy-in from our oncology colleagues, divisional support from general medicine, along with our collaboration of like-minded internists have allowed us to be a robust program. Implications for Cancer Survivors: Models of survivorship care embedded in primary care can provide meaningful, patient-centered care for cancer survivors.",
keywords = "Cancer survivors, Continuity of patient care, Primary care",
author = "Youngjee Choi and Archana Radhakrishnan and Darshan Mahabare and Shalom Patole and Dy, {Sydney M.} and Pollack, {Craig E.} and Berger, {Zackary D.} and Peairs, {Kimberly S.}",
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AU - Choi, Youngjee

AU - Radhakrishnan, Archana

AU - Mahabare, Darshan

AU - Patole, Shalom

AU - Dy, Sydney M.

AU - Pollack, Craig E.

AU - Berger, Zackary D.

AU - Peairs, Kimberly S.

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AB - Purpose: We established the Primary Care for Cancer Survivor (PCCS) Clinic in 2015 to address transition and care delivery challenges unique to cancer survivors. We describe the clinical program, detail patients from the first 4 years of implementation, and discuss lessons learned during the process. Methods: We abstracted relevant patient information from the electronic medical record, administered a needs assessment survey at initial visits, and collected relative value unit (RVU) data. Results: Between August 2015 and May 2019, we saw 230 PCCS patients with an increasing number of referrals yearly; nearly half were breast cancer survivors. At the initial visit, patients reported a median of 9 needs, with emotional needs most prevalent; over a third received at least one referral. PCCS patients generated higher billing codes and average RVUs compared with general patients. Conclusions: In its first 4 years, the PCCS program has thrived as a unique model of cancer survivorship centered in primary care. PCCS patients reported numerous needs, emphasizing the critical need for a multi-disciplinary approach in this population. With increasing referrals, we have considered different risk stratification and staffing models for capacity and expansion. By generating more RVUs per visit compared with the general clinic, PCCS has demonstrated financial sustainability. Buy-in from our oncology colleagues, divisional support from general medicine, along with our collaboration of like-minded internists have allowed us to be a robust program. Implications for Cancer Survivors: Models of survivorship care embedded in primary care can provide meaningful, patient-centered care for cancer survivors.

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