The Paediatric Integrated Cancer Service receives recurrent funding from the Victorian Department of Health and Human Services to facilitate a Long Term Follow-up Program (LTFP) for children and adolescents who have completed their cancer therapy and are entering the survivorship phase of their care.
The LTFP has a strong patient focused approach with an emphasis on wellness and health promotion. The program has been developed based on the experiences of consumers, wide consultation with key stakeholders and service providers and is underpinned by evidence based care. The service model stratifies and triages patients based on diagnosis, treatment and complexity, facilitating shared care as close to home as possible.
The clinical service commenced in 2009 and has continued to grow and evolve. Since commencement, 974 individual patients have attended the program, with 2672 clinic attendances. Patients are seen with a multi-disciplinary approach and are provided with a treatment summary and an individualised roadmap of recommended future clinical follow up. In 2016, the program conducted 111 clinics across the Royal Children’s Hospital, Monash Children’s Hospital, The Alfred Hospital and the Peter MacCallum Cancer Centre.
The challenge faced by the LTFP is the transition of adolescents into appropriate follow-up services. As of 30th June 2016, 47% (N=484) patients over 17 years of age, have been successfully transferred to community, tertiary and adult health service providers.
This presentation will outline the key components of the Long Term Follow-up program model of care, including the risk stratification model, evolvement of the program, challenges faced and specific clinical outcomes seen.