SURVIVORSHIP CARE PLAN TEMPLATE

A Survivorship Care Plan contains information about the survivor’s individual risks and care requirements, based on evidence-based recommendations, and can evolve over time with changing health and personal needs, as well as from new or updated guidelines. A personalised Survivorship Care Plan is an essential part of person-centred Survivorship Care, in particular to support self-management. Survivorship Care Plans delivered by a Survivorship Care clinic also increase general physicians’ knowledge of late effects and should contribute to earlier detection of health problems in primary care, thus resulting in both an increased well-being and a lower financial burden.34

For the Care intervention, the HCP prepares a preliminary Survivorship Care Plan before the clinic visit based on the risk factors identified in the Treatment Summary and Survivor Questionnaire, by consulting the evidence- and consensus-based recommendations included in the intervention. At the clinic visit, the preliminary Survivorship Care Plan is discussed and revised in a two-way sharing of information that is essential for the initiation of the survivor-HCP partnership. Then, the HCP executes the diagnostic tests as per the care plan and schedules those that cannot be done during the visit. Diagnostic test results are discussed during a follow-up communication, during which the Survivorship Care Plan is finalised. The final Survivorship Care Plan includes the Treatment Summary and personalised recommendations for lifestyle and surveillance. The survivor and other relevant HCPs will receive the Survivorship Care Plan by post and/or e-mail. Using their personalised Survivorship Care Plan as a guide, survivors can self-manage their own care, with the essential support of their HCPs.

During development of the Care intervention, a standardised format for the Survivorship Care Plan was agreed by first reviewing six care plan templates currently used in Survivorship Care (in Austria, Utrecht (the Netherlands), Lund (Sweden), Newcastle upon Tyne (United Kingdom) and Memphis (United States)), as well as the plan used in the Survivorship Passport (Italy). Following an extensive evaluation and consensus process that involved consultation with researchers, HCPs and survivor representatives, a final Survivorship Care Plan template was agreed in English and then translated to Dutch, Czech and Swedish. Minor modifications to the SurPass (in Italian) were implemented to align with the final Survivorship Care Plan template.

The Survivorship Care Plan template in English as well as the Survivorship Care Plan User Manual in English is provided below. Translations of the Survivorship Care Plan template in Czech, Dutch and Swedish are available upon request through info@pancare.eu.