Elements of an Ideal Transition and Transfer Plan

Before the visit
    Initial data collection: chart review and entry into computerized database
    Core team meeting: case presentations and development of initial patient care plan
Clinic visit
    Introduction of transition-program concepts
    History and physical examination
    Participation by and education of health care trainees
    Patient education
    Modification of patient care plan to include additional diagnostic studies
    Appropriate therapeutic intervention
    Referral to additional members of core team, specialists, and primary care providers
After the clinic visit
    Review of previously collected data, additional diagnostic studies, and reports from referrals
    Finalization of patient care plan and formulation/modification of long-term care plan
    Communication with other involved health care providers
    Communication with patient and family members
    Web-based educational system for cancer survivors
    Clinical research studies
    Education of health care professionals
    Development and maintenance of support groups for childhood cancer survivors and their families
    Development of protocols for the LTFU of childhood cancer survivors