2001a). That report provided the rationale and a strategic direction for redesigning the health care delivery system. It concluded that fundamental reform of health care is needed to ensure that all Americans receive care that is safe, effective, patient centered, timely, efficient, and equitable. Needed is a health care environment that fosters and rewards improvement by (1) creating an infrastructure to support evidence-based practice, (2) facilitating the use of information technology, (3) aligning payment incentives, and (4) preparing the workforce to better serve patients in a world of expanding knowledge and rapid change.

Barriers facing cancer survivors and their providers in achieving quality survivorship care include (1) a fragmented and poorly coordinated cancer care system; (2) the absence of a locus of responsibility for follow-up care; (3) poor mechanisms for communication; (4) a lack of guidance on the specific tests, examinations, and advice that make up survivorship care; (5) inadequate reimbursement from insurers for some aspects of care; and (6) limited experience on the best way to deliver care.

Recommendation 5: The Centers for Medicare and Medicaid Services (CMS), National Cancer Institute (NCI), Agency for Healthcare Research and Quality (AHRQ), the Department of Veterans Affairs (VA), and other qualified organizations should support demonstration programs to test models of coordinated, interdisciplinary survivorship care in diverse communities and across systems of care.

Several promising models for delivering survivorship care are emerging, including:

  1. A shared-care model in which specialists work collaboratively with primary care providers.

  2. A nurse-led model in which nurses take responsibility for cancer-related follow-up care with oversight from physicians.

  3. Specialized survivorship clinics in which multidisciplinary care is offered at one site.

There is limited evidence on which of these, or other delivery strategies, is feasible, cost-effective, or acceptable to survivors and clinicians (see Chapter 4). It is likely that different care models will be preferred and appropriate for different survivor groups and communities. Models for delivering survivorship care should address the fact that oncology specialists and primary care providers, facing an expanding population of cancer survivors, will become overburdened with follow-up care. The proposed demonstration programs could include assessments of methods to improve care with advanced information systems, such as electronic health records, virtual consultations, smart cards, and web-based approaches. CMS is the



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