Abstract
Survivorship Significance & Background: Access to primary care is essential for cancer survivors (CS), yet many lack a primary care provider (PCP). The PCP manages chronic conditions, offers preventive care, promotes healthy behaviors, and facilitates care coordination and communication with specialists. Coordinating to establish long-term survivorship care with a PCP is essential in the care of CS. Purpose: The Sylvester Survivorship and Supportive Care program ensures all patients have an established PCP. We aimed to implement a process that streamlined and increased referrals to PCPs for patients from the Sylvester Comprehensive Cancer Center (Sylvester) Survivorship Clinics through collaboration with the University of Miami Health System (UHealth) internal and family medicine clinics. Interventions: In collaboration with primary care leaders at UHealth, we assessed the need for primary care in our cancer patient population. Data from the electronic medical record (EMR) suggested that about 25% had no PCP. As a result, we identified PCPs within the health system who were interested in providing survivorship care and developed education and training in this area. A specific order referral was then created in the EMR to expedite scheduling appointments with PCPs. Additionally, we identified patients in the Sylvester Survivorship Wellness clinics without a PCP and referrals were placed. A Survivorship Care Plan (SCP) was created and delivered for each patient seen, alongside assessments of unmet needs and referrals. The SCP was shared via the EMR. Results: Out of 44 patients seen in the Survivorship clinic and referred to a Survivorship PCP from August 2023 to August 2024, 43 were contacted. Of these, 17 patients (39.5%) were successfully seen, while 15 (35%) could not be contacted. Additionally, 11 (25.5%) patients were not scheduled for various reasons, including refusal, cancellation, or left without being seen. Discussion: This initiative highlights the need to develop successful referral processes to improve cancer survivors' access to primary care. Future directions will address identified barriers to scheduling and enhancing follow-up to ensure optimal care continuity for this population. These challenges are a stark reminder of the complexities in the field of cancer survivorship care, but they also serve as opportunities for growth and improvement.