- Complete physical exam, including any labs, x-rays or other
tests that may be indicated
- Medical evaluation and referral to specialists as needed
- Assessment of nutrition status by dietitian
- Collaboration with other specialists
- Endocrinologist available in clinic monthly to see survivors
- Clinical social work assessment
- Therapeutic interventions with patients and families
- Referrals to community agencies to assist with patients'
emotional and educational needs
- Resources/education for emotional wellness
- Summary including diagnosis, treatment details, complications and late effects
- Individualized recommendations for follow up based on patient’s cancer history
- Recommendations for maintaining a healthy lifestyle
Transition of Care
The Survive & Thrive team assists survivors by assessing readiness to transition and barriers to transition. Preparation for transition begins when survivors are 15-16 years old. The team works with each survivor to develop a plan for transition of care once they are 21 years old. The treatment summary and recommendations for follow up are shared with the primary care provider.
The Survive and Thrive team, in collaboration with the University of Kansas Medical Center and the Midwest Cancer Alliance, has developed the Survivorship Transition Clinic. This clinic is designed to meet the ongoing health care needs of young adult survivors who have transitioned from Children’s Mercy. A nurse navigator works jointly with the Survive and Thrive Program and the Survivorship Transition Clinic. Survivors meet the nurse navigator before leaving the Survive and Thrive Program. The nurse navigator helps survivors navigate the new health care system and continues to meet their educational needs during visits in the Survivorship Transition Clinic. The Survivorship Transition Clinic is only one option for survivors leaving Children’s Mercy. Survivors have a choice of where to continue their follow-up care and the Survive and Thrive team will work to develop a plan that best meets each survivor’s needs.