moving forward after cancer: successful implementation of a colorectal cancer patient–centered transitions program

Cancer survivors transitioning between academic comprehensive cancer systems and community general practice settings are vulnerable to discontinuity, inconsistency and variation in care, inappropriate surveillance testing, and a sense of isolation and loss. though these issues have been well recognized for over a decade and a half in the survivorship, oncologic, and health services literature, there remains a dearth of positive examples of models that have been well received by both the transitioned patient and the providers on either side of the handoff. we herein describe a sustained positive example of a transitions program. this program centers on standardized and personalized survivorship care plans (scp) to guide follow-up care and recovery. following the province-wide introduction of a transitions program for treated stages ii and iii colorectal cancer (crc) patients, a post-implementation survey was mailed to transitioned patients with the primary outcome evaluated the patients’ perception of improved continuity of care and the main instrument used the patient continuity of care questionnaire. this was compared against a previously published pre-implementation historical control. the data presented comparing pre- and post-implementation patient cohorts reflect significantly improved patient-reported perceptions regarding the enhanced continuity and coordination of their follow-up and survivorship care after the province-wide introduction of a formal transitions process. this scp intervention has been sustained post implementation. using, as a starting-point, a standardized electronically scp, cancercare manitoba has successfully facilitated a jurisdiction-wide implementation of a scalable, reproducible, and adaptable transitions program. this intervention at the time of transition back to the community has enhanced crc survivor perception of continuity and coordination of follow-up care.