A multidisciplinary model of care for childhood cancer survivors with complex medical needs

J Pediatr Oncol Nurs. 2008 Jan-Feb;25(1):7-13. doi: 10.1177/1043454207311741.

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.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Child
  • Health Services Needs and Demand*
  • Humans
  • Models, Organizational*
  • Neoplasms / classification
  • Neoplasms / nursing
  • Neoplasms / therapy*
  • Nurse's Role
  • Patient Satisfaction
  • Philadelphia
  • Referral and Consultation
  • Survivors*
  • Treatment Outcome