An interactive, structured telephone handoff between a survivorship nurse coordinator and community primary care provider (PCP) clinics is a feasible and acceptable way to improve communication about shared patients’ survivorship care needs

Abstract

Communicating with primary care providers (PCPs) could improve rates of childhood cancer survivors (CCS) who receive guideline-recommended survivorship care. We aimed to assess the feasibility and acceptability of an interactive, structured telephone handoff between a nurse coordinator and PCP clinics about survivorship care needs of shared patients who were ≥2 years post-treatment and had attended survivorship clinic. A nurse coordinator successfully contacted 40 (87%) of 46 PCP clinics for a brief (median 5 minutes, range 4–11) handoff, all of whom rated the call helpful. Research is needed to better assess the impact of this handoff on receipt of survivorship care.

Introduction

Over 80% of childhood cancer survivors (CCS) develop at least one serious/disabling or life-threatening chronic condition from cancer therapy by age 45.^1–3 The Children’s Oncology Group (COG) Long-Term Follow-Up Guidelines recommend lifelong risk-based monitoring for late effects of therapy.^4,5 Implementing these guidelines is challenging,^6,7 and <20% of CCS report receiving risk-based survivorship-focused care, despite >88% reporting regular medical care.⁸

While most pediatric oncology centers offer survivorship care, patient barriers include avoidance, travel distance, and costs.^9–11 Nearly half of centers do not follow CCS into adulthood,¹² necessitating alternative care models. PCP-led survivorship care could improve access for CCS, but barriers exist.^13–15 PCPs report inadequate knowledge/training, lack of understanding of the survivorship care plan (SCP), and uncertainty about their role in survivorship care.¹³ CCS are also uncomfortable receiving survivorship care from their PCP, and perceive PCPs lack survivorship care knowledge.¹⁵ Interventions to improve PCP knowledge and comfort with survivorship care are needed to transition survivorship care to PCPs and increase access for all CCS.

To improve communication with PCPs in survivorship care, the regional Yale HEROS Childhood Cancer Survivorship Clinic conducted interactive, structured telephone handoff between a survivorship nurse coordinator and PCP clinic of shared patients. We aimed to assess the feasibility and acceptability of these handoffs.

Methods

Setting:

The HEROS Clinic provides CCS with lifelong surveillance for late effects,^16,17 per COG Long-Term Follow-Up Guidelines.^4,5 During each visit a survivorship nurse coordinator educates patients on their individualized SCP (with their treatment summary and recommended surveillance), confirms if CCS have a PCP, and electronically transmits the patient’s visit summary and SCP to their PCP following the visit, or assists with identifying a new PCP.

Study design/sample:

The nurse coordinator attempted an interactive, structured telephone handoff with the PCP clinic for recent (within past 2 years) HEROS Clinic patients who were ≥2 years post-treatment. Patients were excluded if they did not have any PCP or were ≥18 years old with a pediatrician. All procedures were approved by the Yale Institutional Review Board (HIC #0707002837) as part of a larger protocol for the HEROS Clinic.

Interactive, structured telephone handoff:

The nurse coordinator called eligible patients’ PCP clinics following a HEROS Clinic visit and asked to speak with the patient’s PCP regarding co-management of their survivorship care. If the PCP was unavailable, alternatives could include another provider or designee (e.g. registered nurse). Otherwise, the nurse coordinator left a message with contact information with the receptionist and called back up to 6 times. During the telephone handoff, the nurse coordinator reviewed the patient’s SCP (previously sent by nurse coordinator via electronic transmission) using the Situation, Background, Assessment, and Recommendation (SBAR) communication tool.¹⁸ PCP designees could ask questions and were asked to provide feedback.

Outcomes and analysis:

To assess feasibility, the proportion of PCP clinics successfully contacted (defined as a survivorship nurse coordinator speaking with a PCP or clinical team member) was calculated. To assess acceptability, at the end of the call the survivorship nurse coordinator asked PCP designees if the handoff was helpful (yes/no), and the proportion was calculated. All patients <18 years and an unselected subset ≥18 years (post-updated procedures) were systematically asked their confidence and willingness to provide future survivorship care in consultation with a survivorship clinic (yes/no: question developed for this study). Additional process outcomes (number of calls until successful contact, handoff duration, and if PCPs ended the call early) were recorded. Descriptive statistics (medians, ranges, frequencies) summarized survivor and handoff characteristics, and group differences (contacted versus not contacted, pediatric versus adult) were compared using chi-squared and Wilcoxon rank-sum tests. Statistical analyses were performed using R Studio software (Version 2025.09.2+418).

Results

Study population:

Overall, 28 patients <18 years and 18 patients ≥18 years (of 48 total; excluded 20 with pediatricians, 10 without any PCP) were eligible and included (Total N=46). Survivors whose PCP clinics were successfully contacted (N=40) were a median age of 16.2 years (range 6.8–35.6; 24 [60.0%] <18 years), a median of 9.0 years (range 2.0–30.9) post-treatment, and 22 (55.0%) female. PCP clinics were 60% pediatric and 40% adult practices, and 97.5% urban and 2.5% rural practices. Survivor and PCP clinic characteristics overall, and among those contacted versus not contacted are displayed in Supplemental Table 1.

Handoff characteristics:

The nurse coordinator successfully contacted 40 of 46 (87%) PCP clinics, with a median of 1 attempt (range 1–6; Table 1, Fig. 1A). Six PCP clinics were not contacted (a receptionist was reached, but a clinical team member was not available). Most (68%) clinicians contacted were physicians (Table 1). The PCP clinic was reached on first attempt in 22 (55%) cases (Table 1). The handoff lasted a median of 5 minutes (range 4–11; Table 1, Fig. 1B). When calling PCPs of patients <18 years old (versus ≥18 years old), the survivorship nurse coordinator more frequently spoke with physicians (88% versus 38%, p=<.001), but other handoff characteristics were similar between groups (Table 1, Supplemental Fig. 1).

Table 1.

Summary of interactive, structured telephone handoffs from survivorship nurse coordinator to community PCP clinics (N=40 of 46 attempted), overall, and by patient age at time of HEROS Clinic visit

	Overall (N=40)	Current Age <18 Years (N=24)	Current Age ≥18 Years (N=16)	P-Valuea
Respondent in PCP clinic, n (%)  Physician  APP  RN	27 (68%) 8 (20%) 5 (12%)	21 (88%) 3 (12%) --	6 (38%) 5 (31%) 5 (31%)	<.001
Number of attempts to contact PCP, median (range)	1 (1–6)	1 (1–3)	2 (1–6)	0.15
Contact with PCP on first attempt, n (%)	22 (55%)	15 (63%)	7 (44%)	0.33
Duration of handoff (minutes), median (range)	5 (4–11)	6 (5–10)	5 (4–11)	0.25
PCP who stated handoff helpful (yes vs. no), n (%)	40 (100%)	24 (100%)	16 (100%)	-
PCP expressed confidence/willingness to provide survivorship care (yes vs. no),b n (%)	31 (100%)	24 (100%)	7 (100%)	-

PCP; primary care provider, APP; advanced practice provider, RN; registered nurse

^aP-value describes differences between groups “Current Age <18 Years” and “Current Age ≥18 Years,” using fisher’s exact test and Wilcoxon rank-sum tests

^bOnly asked routinely in unselected subset of N=31 PCP clinics after amended procedures

Figure 1.

Frequency Distribution of A. Number of attempts to successfully contact Primary Care Provider (PCP), B. Duration of telephone handoff (minutes) (N=40)

PCP-reported acceptability:

All 40 PCP clinics contacted responded the handoff was helpful. Of the 31 who were systematically asked, 31 (100%) expressed confidence/willingness to provide subsequent survivorship care. No PCP clinics ended the handoff early or questioned speaking with a nurse versus a physician.

Discussion

This study demonstrated feasibility and acceptability of a brief, interactive, structured telephone handoff between a survivorship nurse coordinator and PCP clinics. Among 46 recent survivors with PCPs from the HEROS Clinic, a nurse coordinator successfully contacted 87% of their PCP clinics, who all found the handoff helpful.

A key finding was the feasibility of a nurse-led intervention. Nurse-led interventions in survivorship care are increasing and improve patient outcomes.^19–21 Re-Engage and Engage, developed to educate and engage CCS not receiving survivorship care in survivorship care, were nurse-led telehealth interventions that increased CCS’s satisfaction with care and self-efficacy.^19,20 The Transitioning Adolescents off Cancer Treatment (TACT) intervention, a nurse-led video consult developed to ease transition from active therapy to survivorship care, was also feasible and acceptable.²¹ As nurse-led interventions are increasingly used for survivors, another extension of the nurse’s role may be engaging PCP clinics.

Another promising finding was that PCP clinics found the handoff helpful. Previous studies show PCPs feel uncomfortable taking responsibility for survivorship care.^13,14 Among 134 PCPs of HEROS Clinic patients surveyed in an older study (without a handoff), only 31% were very comfortable providing survivorship care with guidance from the SCP.¹³ In interviews with PCPs of CCS, unmet communication needs was a barrier to providing survivorship care.¹⁵ The handoff may help address these communication needs. In the current study, all PCP clinics found the handoff helpful and, among those asked, expressed confidence/willingness to provide survivorship care following the handoff in consultation with the survivorship clinic. We acknowledge a limitation is that these questions were asked by the nurse administering the handoff. This was done to maximize the response rate, but further research is needed to confirm acceptability and uptake among PCPs. Since survivors are uncomfortable receiving survivorship care from their PCP for reasons including lack of PCP communication with the oncologist,^13,22,23 future research should also assess whether this handoff is acceptable to survivors as a way to improve communication and transition to PCP-led or shared survivorship care.

When comparing handoff processes in pediatric and adult PCP clinics, the number and duration of calls were similar. However, 63% of adult survivors were excluded from the study because they did not have an adult PCP, higher than a prior study reporting 11% of CCS did not receive general medical care.⁸ We ultimately hope to use this handoff as a communication tool that will aid in a shared survivorship care model between the oncologist and PCP, or in a model in which post-therapy survivorship care is transitioned to the PCP. ^24,25 This finding underscores the importance of standardly asking adult CCS if they have a PCP. Support to adult CCS to identify PCPs will be needed in addition to the communication tool, to create a viable model for PCP-led survivorship care.

Our study has potential limitations in addition to those already noted. This was a sample of only 46 survivors from a single institution. This study took place in a clinic with a survivorship nurse coordinator, which could limit generalizability to sites with limited staffing. However, nurse coordination is increasingly incorporated into oncology care, and the handoff could be completed by another member of the oncology team. In large centers, these handoffs may also require a large time commitment. Recent coverage of nurse navigator services could make these billable services,^26,27 making it easier to allocate staff to this task, but further cost-analysis research is needed. The handoff was done with any member of the patient’s clinical care team because there is often shared care of patients. The survivorship nurse coordinator used a standardized script to request the information be shared with the PCP, and transmitted the clinic note and survivorship care plane directly to the PCP, but we could not guarantee all information from the handoff was relayed to the PCP.

This study demonstrated that a brief, interactive, structured telephone handoff from a survivorship nurse coordinator is a feasible and acceptable method of engaging PCP clinics in survivorship care. Further research is needed to better assess the impact of this intervention on PCPs, CCS, and receipt of guideline-recommended survivorship care.

Glossary

APP

Advanced Practice Provider

CCS

Childhood cancer survivor(s)

COG

Children’s Oncology Group

CNS

Central nervous system

PCP

Primary care provider

SCP

Survivorship care plan