Filling a Gap in Posttransplant Care: The Transitional Transplant Clinic

Mary Flowers, MD

Member, Fred Hutchinson Cancer Research Center

Medical Director, LTFU Clinical Program

Seattle Cancer Care Alliance

The Long-Term Follow-Up (LTFU) Clinical Program at Seattle Cancer Care Alliance (SCCA) has expanded its scope of services to assist in the hands-on management of patients who develop complex conditions more than 100 days after their peripheral blood hematopoietic stem cell transplant procedure.

The Transitional Transplant Clinic (TTC) started in September 2012 and offers specialized posttransplant care from a dedicated team of SCCA physicians and nurses. The TTC takes pressure off the early posttransplant care teams and referring physicians by providing temporary care for patients with complex medical conditions until they are ready to return to the care of their local oncologists or primary care physicians. The TTC also opens up capacity at SCCA, ensuring that new patients get access to life-saving transplants without delay, and improving the continuity of care for patients with lingering complications.

How the LTFU Clinical Program Works

Most patients who have a bone marrow transplant at SCCA initially receive care in a dedicated posttransplant clinic for 2 to 3 months and then return to the care of their primary physician. Once patients are discharged from this early posttransplant service, they become LTFU patients. The LTFU clinical program provides telemedicine and onsite clinical consultation to its patients. If a patient develops a typical, mild transplant-related problem, or if the primary provider has a question, clinicians in the LTFU program consult with them over the phone to provide advice or, if needed, coordinate a return to SCCA for an evaluation or clinical care.

Today, the LTFU program has more than 5000 patients who were transplanted between 100 days and 42 years ago at either Fred Hutchinson Cancer Research Center or SCCA. This growing LTFU population attests to the expanding use and improved long-term outcomes of modern bone marrow transplant techniques used at SCCA.

Helping Primary Physicians

Even with safer and more effective transplants, some patients will develop severe posttransplant complications that prevent them from being discharged to their primary provider at the expected 100 days after transplant. Other patients who have already been discharged also sometimes experience new or recurrent posttransplant complications that are difficult for a primary provider to handle.

These are often recipients of allogeneic transplants with new or poorly controlled late acute or chronic graft-versus-host disease. Or, they might be patients with serious or recurrent infections, poor graft function, or other— perhaps multiple—medical conditions that require extensive ongoing management. These types of patients require prolonged and frequent clinic visits that are hard for a busy oncology clinic to handle. The TTC at SCCA provides this complex level of posttransplant care.

The LTFU Clinical Program continues to offer its full range of services. What’s new is that the TTC now fills the gap in continuity of care for the high-acuity patients with complex posttransplant-related problems beyond 2 to 4 months after transplantation.

According to Paul V. O’Donnell, MD, PhD, past medical director of SCCA’s Adult Transplant Service, the TTC provides an essential backup service to referring physicians. “A private oncologist in the community may see three patients every hour, so caring for one of these patients with chronic or complicated issues can be extremely difficult,” O’Donnell said. “The TTC will take care of these patients and help them transition back to the referring physician over a period of a few months.”

Ensuring Capacity for New Transplant Patients Until recently, transplant patients with late-developing chronic or serious problems typically received care at SCCA’s early posttransplant clinic or the hematological clinic, located at the University of Washington Medical Center and Seattle Children’s Hospital. But increasing demand for transplants has reduced the capacity of these core clinics to keep or readmit patients with chronic problems.

“If these patients with late acute problems stay too long in the allogeneic or the autologous posttransplant care clinics, the clinic volumes build and build,” O’Donnell said. “We need those inpatient clinics for about five new patients each week.” If our transplant team is overloaded with complex patients, it makes it difficult to take new patients,” he said. “The TTC was designed to help us maintain this capacity for new incoming patients.”

Providing Continuity of Expert Care

Another primary motivation for creating the TTC was to establish a seamless continuity of care from a dedicated, expert medical team. The acute posttransplant team’s monthly staff rotation hampered their ability to provide continuity of care to patients with lingering complications beyond 3 months after transplant. The TTC has solved this problem, which is another novel aspect of SCCA’s transplant program.

The TTC team consists of two attending physicians— Merav Bar, MD, assistant member, Fred Hutchinson Cancer Research Center, and Laura S. Connelly-Smith, MBBCh, DM, SCCA staff physician— along with one dedicated midlevel practitioner, one dedicated nurse, and one support staff. The TTC team’s goal is to improve or stabilize the patient’s posttransplant medical conditions and eventually transfer their primary medical care back to their referring physicians with periodic follow-up by the LTFU team.

To date, 50 patients have received care at the TTC, which is more than originally projected. Approximately half of these patients required hospital admissions. The average duration of medical care received by TTC patients is 3 months.

More information about SCCA’s LTFU care can be found at www.seattlecca.org/diseases/bmt-long-term-follow-up.cfm.