Care Coordination Toolkit

Resources for payers at every step of the transplant process

Diagnosis

Evaluation

Transplant

Follow-up care

Survivorship

Diagnosis

During this phase, your member receives a diagnosis of a disease that can be treated by a transplant. It's important the patient understands their coverage and benefits, gets all their questions answered, and understands next steps.

Resources for your member

Questions to ask about diagnosis: Agency for Healthcare Research and Quality: Questions To Ask Your Doctor
Learn about newly diagnosed disease: Diseases treated by transplant
Understand Social Security benefits: Social Security Disability Evaluation
Tools to help understand disease challenges: NCCS Cancer Survival Toolbox
Plan benefits booklet for coverage information

Resources for your providers (Primary Care)

Cancer treatment plan: ASCO Cancer Treatment and Survivorship Care Plans
Learn about the value of care coordination: American College of Physicians High Value Care Coordination Project
Learn about transplant terms and diseases treated by transplant: ASTCT Transplant Terminology
Understand the guidelines for referral to transplant: Be The Match Transplant Referral Timing Guidelines

Evaluation

During this phase, the patient is evaluated by a hematologist/oncologist and is referred to a transplant center to determine candidacy for treatment options. It’s important that the patient understands their benefits and expected out of pocket costs, in-network centers, and pharmacy coverage.

Resources for your member

Questions to ask about treatment: Agency for Healthcare Research and Quality: Questions To Ask Your Doctor
Learn about transplant terms and diseases treated by transplant: ASTCT Transplant Terminology
Get help navigating the transplant journey: Be The Match Patient Support Center
Financial considerations for transplant: Paying for transplant
Transplant coverage: Insurance coverage
Learn what to expect before, during, and after transplant: Be The Match: Patients and Families
Learn more about transplant: Blood and Marrow Transplant Information Network
Find a clinical trial: Jason Carter Clinical Trials Program
Tools to help understand disease challenges: NCCS Cancer Survival Toolbox
Support for caregivers: Caregivers and transplant
Caregiver resources: CancerCare Caregiving

Resources for your providers (Hematology/Oncology)

Complete patient’s diagnosis information: ASCO Cancer Treatment and Survivorship Care Plans
Create a treatment care plan: Providers tools for planning patient's care NCCS
Understand the guidelines for referral to transplant: Be The Match Transplant Referral Timing Guidelines
Learn about the value of care coordination: American College of Physicians High Value Care Coordination Project
Learn when stem cell transplant is indicated: ASTCT Policy Statements

Transplant

During this phase, the patient receives their transplant and post-transplant care while still in the hospital. The patient will be working with their transplant team and learn what to expect after transplant – it’s important that the patient and caregiver receive adequate support during this time and are prepared for a transition in care as they leave the transplant center.

Resources for your member

What to expect on the day of transplant: Transplant Day
Resources for caregivers: Support for Caregivers; Caregiver Resources
Talk to a transplant survivor or a family caregiver: Be The Match Peer Connect Program; BMT infonet: Talk to a Survivor or Family Caregiver; nbmtLINK Peer Support On Call Program

Resources for your providers (Transplant Team)

Customizable templates to create treatment, care, and survivorship plans: Providers tools for planning patient's care NCCS
Resource that encourages dialogue between cancer patients and survivors and their health care team: NCCS Tools for Care Providers

Follow up care

During this phase, the patient transitions from their transplant center to their community hematologist/oncologist. It's important to know what to look for after transplant and ensure the patient is receiving appropriate care from every provider involved in their care.

Resources for your member

Review checkup guidelines, set reminders, and check for signs of GVHD: Download Transplant Guide App
Review recommendations for care: Be The Match After Transplant Guidelines for Patients

Resources for your providers (Transplant team, Primary Care Physician, Hematologist/Oncologist)

Access the latest HCT research, view recommended post-transplant tests/procedures, check for signs of GVHD: Download Transplant Guide App
Access tools and resources to help screen, prevent, and address complications that can arise after HCT: Be The Match Post-Transplant Care
Understand guidelines and recommendations for care after transplant: Be The Match Post-Transplant Care Recommendations
Understand early complications after transplant: Early complications of HCT

Survivorship

During this phase, the patient and their family adjust to life after transplant. It's important to ensure members of the patient's care team, including primary care, oncology, understand how to screen and prevent any complications that can arise after transplant.

Resources for your member

Learn about what to expect after transplant: Be The Match: Life After Transplant
Receive support and counseling: Be The Match: Group Support; Be The Match: Counseling
Connect with peers: Be The Match Peer Connect Program; BMT infonet: Talk to a Survivor or Family Caregiver; nbmtLINK Peer Support On Call Program

For pediatric transplant patients and their healthcare providers:

Understand factors for transitioning from pediatric to adult care: ACP Pediatric to Adult Care Transitions Toolkit

Resources for your providers (Transplant team, Primary Care Physician, Hematologist/Oncologist)

Customizable templates to create treatment, care, and survivorship plans: Providers tools for planning patient's care NCCS
Tools and resources to help screen, prevent, and address complications that can arise after HCT: Be The Match Post-Transplant Care

About Care Coordination

Care coordination is the focus on organizing patient health care from multiple providers and can lead to improved health outcomes by addressing inefficiencies, waste, and potential errors. Well-coordinated care is especially important in hematopoietic cell transplantation (HCT), which is a resource-intensive and medically complicated procedure. This toolkit was created to provide resources for payers, their members, and providers in their networks at each stage of the transplant process.

The Care Coordination Toolkit was developed as a collaboration between the Advisory Group on Barriers to Transplant (AGBT) and NMDP/Be The Match. Special thanks to AGBT members Nandita Khera and Pat Martin for their work developing the toolkit.

Learn more about care coordination and HCT