The Georgia Cancer Center for Excellence at Grady launched the Survivorship Clinic in partnership with Dr. Wilhelmina Prinssen, MD, FAAFP, Medical Director of the Asa Yancey Health Center. The clinic ensures that all cancer survivors, including high-risk patients, smoothly transition from specialized oncology care back to primary care.

Last March, The Georgia Cancer Center for Excellence at Grady launched the Survivorship Clinic, in partnership with Dr. Wilhelmina Prinssen, MD, FAAFP, Medical Director of the Asa Yancey Health Center. The Grady Survivorship Clinic leverages partnerships with primary care physicians to gain access to tools in the primary care environment while sharing Cancer Center information with the Grady Neighborhood Clinics. The site boasts a 100% initial participation rate, and Grady is working on expanding services and monitoring long-term compliance.

The clinic is modeled after the survivorship program at the University of Arizona Cancer Center, which aims to build a stronger relationship with community health centers and primary care providers in the surrounding areas. Alliance Co-Principal Investigator Sheryl Gabram, MD, MBA first learned of Arizona’s success story during the inaugural Alliance to Advance Patient-Centered Cancer Care Annual Meeting, and reached out to Alliance Co-Investigator Dr. Leila Akbarian to bring this model to Grady. Dr. Akbarian, who serves as Medical Director of The University of Arizona Cancer Center Supportive Care Clinic, advised Grady throughout the process of expanding their survivorship care model and identifying key staff.

The Grady Cancer Center found that the model in place at the Arizona Cancer Center was the natural evolution for their existing Nurse Practitioner-led survivorship effort and set out to identify a Primary Care Champion for Survivorship, a physician who could collaborate with the Cancer Center and strengthen the relationship with their primary care associates. Dr. Prinssen was the perfect fit: she is well integrated in the local community, has experience being a care champion leading HPV vaccination efforts, and has worked on the National Colorectal Cancer Roundtable (NCCRT) 80% by 2018 initiative, a shared pledge between 1,500 organizations to screen 80% of adults aged 50 and older for colorectal cancer by 2018.

In addition to Dr. Prinssen’s role, the Grady Survivorship Clinic selected a Registered Nurse to serve as Survivorship Coordinator, a health navigator who works with patients to complete survivorship care plans in accordance to Commission on Cancer (CoC) standards. A survivorship care plan is a comprehensive summary of a patient’s experience with cancer, a survivorship roadmap on what to expect after treatment. The plan includes a report of the initial diagnosis and treatment, follow-up care plans, recommended cancer surveillance tests, and detailed information on potential long-term effects of treatment. After reviewing the plan, the Survivorship Coordinator refers patients who need additional support to the Survivorship Champion for evaluation. Approximately 50% of patients who receive a care plan are referred to Dr. Prinssen. During these visits, patients can raise questions, air concerns, and have a chance to address any medical issues they may have. Once the evaluation has been completed the Survivorship Clinic facilitates a patient’s transition to primary care. Patients who do not have a primary care provider are referred to one of the neighborhood clinics within the Grady network.

The Survivorship Care Championship role allows the Georgia Cancer Center for Excellence at Grady to bring essential feedback from primary care back to the Cancer Center. This process ensures that all cancer survivors, including high-risk patients, smoothly transition from specialized oncology care back to primary care. The information collected during this transition is an essential part of long-term care for survivors, and helps prepare them for the road ahead. Patients referred to the Survivorship Clinic receive the tools they need to monitor their health, and can be prescribed additional medications or follow-up tests when needed. This process helps survivors gain a renewed sense of control over their condition.

Now that the clinic has been successfully established, there are plans in place to enhance programs based on patient feedback. Grady recently added colorectal cancer screening kits (FIT kits) to the clinic and posted detailed Neighborhood Clinics maps to help patients reach their primary care appointments on time. As for next steps, the survivorship clinic is working on expanding access to health and wellness resources through the hiring of an exercise coach who can assist patients with their exercise, diet, and fitness needs.