TABLE 2.

Summit Recommendations for Immediate Next Steps for Oncology and Primary Care Clinicians to Lay the Groundwork for Delivery of Personalized Follow-Up Care Pathways

ACTIONS ONCOLOGY CLINICIANS CAN PURSUE NOW	ACTIONS PRIMARY CARE PROVIDERS CAN PURSUE NOW
• Examine current patient rosters, clinic utilization patterns, and new patient visit slots and consider how shifting care of low-risk/low-need survivors to primary care or advanced practice practitioners would affect these factors	• Ask patients about their cancer history, request oncology treatment records and survivorship care plans, and document treatments and care needs in the electronic health record
• Begin to triage patients who need specialized follow-up to survivorship clinics as they are developed	• Participate in formal (eg, continuing medical education) and informal training to increase understanding of cancer-related chronic and late effects
• Clearly communicate to patients from the time of diagnosis that they will be expected to continue to be followed by their primary care provider and likely will transition back to predominately primary care or a follow-up clinic after treatments ends	• Learn how to co-manage patients during active treatment and ongoing oncology-based follow-up care (eg, with a focus on providing routine care, treatment of chronic disease and respective risk factors, as well as health promotion)
	• Participate in educational activities to increase comfort and skills in providing follow-up care for patients with cancer who are transitioned from oncology care
• Reinforce expectations about follow-up by ongoing communication throughout cancer treatment	• Refer patients who previously received extensive cancer treatment and/or those experiencing chronic and late effects of cancer for specialized survivorship care
• Work toward supporting patients who are doing well in self-managing their health outside of clinic visits	• Work toward supporting patients who are doing well in self-managing their health outside of surveillance visits
• Build bridges with primary care to better equip primary care providers with information they need to care for their patients who are cancer survivors, coordinate care, and facilitate referrals back to oncology if needs arise	• Build bridges with oncology to understand survivors’ risks and ongoing health care needs, better coordinate care, and facilitate referrals back to oncology if needs arise