CCS Transitions to Adult Care

Participants randomized to the ERP arm will receive the SRP, tailored patient education, and patient navigation mapped to the four components of patient navigation

A nurse navigator trained in patient navigation and motivational interviewing will contact CCS (childhood cancer survivor) randomized to the ERP arm and provide a brief introduction to the importance of survivorship care and schedule the patient for an appointment at an adult onco-primary care clinic. The nurse navigator will also schedule at an initial one-hour telehealth visit with the CCS for ~1 month after their last Pediatric ACE visit. During the initial telehealth visit, the navigator will provide tailored patient education and individualized navigation based on the baseline survey results for each adult CCS. The navigator will assess additional educational needs or barriers to determine whether additional visits are needed. Every CCS in the ERP arm will have at least one telehealth visit, but may have as many as five, as needed.

For the SRP, clinicians will send an electronic Care Everywhere referral to the adult onco-primary care program, via the ACE coordinator, an existing clinical staff member in onco-primary care. The coordinator will attempt to contact the adult participant 3 times by telephone or MyChart, which includes text messages. Once contact is made, the ACE coordinator will assess current insurance status and schedule a visit in one of the three onco-primary care clinics depending on patient preference, location, and insurance type

The proportion of participants in each arm who attend an onco-primary care visit.

Visit attendance will be assessed through clinic scheduling data.

The outcome will be analyzed as a binary proportion (attended vs. did not attend)

The proportion of participants in each arm who schedule an onco-primary care visit.

Visit scheduling will be assessed through clinic scheduling data.

The outcome will be analyzed as a binary proportion (scheduled vs. did not schedule)

Change in score on the the Transition Readiness Assessment for Youth scale.

The scale includes twenty readiness items rated as No (0), I want to learn (1), or Yes (2).

The items will be summed and the outcome will be analyzed as a scale variable ranging from 0 (lowest readiness) to 40 (highest readiness)

Assessed via the Healthcare Self-Efficacy Scale (3-item instrument).

The items are rated on a 3-point Likert-type scale: (1) not confident, (2) confident, (3) very confident.

The items will be averaged and the outcome will be anaylzed as scale variable ranging from 1 (least confident) to 3 (most confident).

The proportion of participants who complete a qualifying primary care visit, defined as: a visit with any primary care or a visit to an onco-primary care clinic.

Self-reported by participants and assessed through onco-primary care clinic scheduling data.

The outcome will be analyzed as a binary proportion (attended primary care vs. did not attend primary care).