the johns hopkins primary care for cancer survivor clinic: lessons learned in our first 4 years

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. 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. between 2015 and 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. 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. models of survivorship care embedded in primary care can provide meaningful, patient-centered care for cancer survivors.