Transition of Care from St. Jude to Local Providers

Health care transition is the process of changing from one health care provider or clinical setting to another. As a St. Jude patient, you may have several types of transitions during your health care journey.

One of the most important health care transitions is the move from St. Jude to your community providers. This may take place with certain aspects of your care when you complete your treatment; or it may happen when your care team determines it is the best time for you.

The goal of transitioning care is to partner with you, to help you create a lifelong health care plan.

You and your primary St. Jude team

Your needs will change after you complete your treatments. Some tests and treatments can be stopped. Some conditions may require long-term care or monitoring that is best done by a local health care provider. Your St. Jude care team will help guide these decisions.

Your St. Jude primary team will continue to see you for several years after your diagnosis or transplant.

When you reach the 5-year post-diagnosis or transplant milestone, you will be eligible to begin the transition to the St. Jude After Completion of Therapy (ACT) clinic. You will be assigned a new primary oncologist, and the ACT team will become your primary clinic at St. Jude.

You will remain an active ACT patient until you reach one of these milestones, whichever comes last:

• 10 years after diagnosis
• Age 18
• High school graduation

Steps in the transition of care

Your local primary care provider

It is important for you to have a primary care provider. This might be a pediatrician, internist, or family practice provider. This person should see you every year for:

• Well-child or wellness visits
• Immunizations
  • Your child’s primary team will let you know when to resume vaccines.
• Any needs not related to your St. Jude treatment

Make an appointment to see your primary care provider within 3 months of completing your treatment. This should be your first step in the transition of care journey.

If you have had a transplant, your transplant team will let you know when to make this appointment.

Specialty care

Some patients are seen by specialists at St. Jude for complex medical problems during or after they finish treatment. Examples of specialists include neurology, endocrinology, nephrology, or cardiology. This care might include monitoring lab work or prescribing medications or medical equipment. In time, your visits to St. Jude will become less frequent and treatment for chronic conditions should move to a specialist or primary care provider in your community.

Once your medical team has decided the time is right, they will ask you to find a local provider and pharmacy. The goal is to transition ongoing specialty care and medicine within 3 years of completing St. Jude treatment or transplant.

Common questions about health care transition

Why should I see community providers?

Care that is closer to your home means less time away from school, work, and family life. It is also safer to have a provider nearby who can see you for urgent problems.

Who is the right provider for me to see?

Everyone’s situation is different. For example, you may still need to see a specialist like a cardiologist or a neurologist. Or your pediatrician or adult primary care provider might be the best person to manage your care. Your St. Jude primary team and specialists will direct you to the right kind of care provider in your community.

How will I find providers to see?

You may return to care with health care providers you already know, or you may need to find new providers.

We hope to empower you to manage your own care needs. Your primary care provider visits will be helpful in gaining specialist recommendations. Your insurance may also provide you with a list of approved health care providers. Your transition team can help you make a plan for finding health care closer to home.

Your St. Jude transition team might include:

• Social workers
• Care coordinators
• Members of the Transition Oncology Program (TOP)

How do I pay for the care I need?

We will help you understand your health insurance benefits and how to find other resources in your area.

Planning for your transition

Transition readiness

We want to know if there are barriers that might make the transition difficult for you.

Your St. Jude providers will discuss the transition with you. They will ask many questions to determine if you are ready. They will also find out how well you know your health history and your reasons for seeing new providers.

When adolescents and young adults prepare to transition to adult health care providers, we meet with them to discuss their ability to manage their own health care needs. For example, we may ask questions to learn if a young adult understands their diagnosis, their medications and how to take them, as well as when they need to see a health care provider.

Transfer to community providers

Before your first visit with your local provider, your St. Jude care team will give you and the provider a summary of your care at St. Jude and a description of your ongoing health needs. After your care moves to local providers, your St. Jude team will remain available to answer their questions.

Care at a St. Jude affiliate clinic

If you receive care at a St. Jude affiliate clinic, talk with your primary affiliate team about the timing for care transitions.

Emotions during the transition of care

It is normal to feel nervous or unsure with any big change. We are here to support you through these transitions. We want to help you feel more comfortable and confident in managing your care.

We encourage you to talk to all your St. Jude providers about how and when to transition your care in the best way possible.