Clinical Practice Guidelines for the Psychosocial Care of Adults with Cancer (National Breast Cancer Centre [NBCC] and National Cancer Control Initiative [NCCI], 2003)

Clinic-based protocols should be developed to ensure that:

•  All patients are able to identify a key health professional responsible for continuity of care.

•  Referral pathways for liaison psychiatry, psychologists, support groups, and relevant allied health professionals are established and known to the team.

From Cancer Patient to Cancer Survivor: Lost in Transition (IOM and NRC, 2006) Recommendation 2 Patients completing primary treatment should be provided with a comprehensive care summary and follow-up plan that is clearly and effectively explained. This “Survivorship Care Plan” should be written by the principal providers(s) who coordinated oncology treatment. This service should be reimbursed by third party payors of health care.
  Such a care plan would summarize critical information needed for the survivor’s long term care, including … information on the availability of psychosocial services in the community and on legal protections regarding employment and access to health insurance.


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