The Cardio-Oncology Shared-Care Model: Who Owns What After Treatment Ends
Oncology closes the treatment chapter, cardio-oncology carries the cardiac-risk chapter, primary care runs the day-to-day. A shared-care model that keeps every survivor on-cadence — with the hand-off artifacts each role actually needs.
The most common failure mode in survivorship follow-up is not a missing guideline. It is unclear ownership. Oncology closes the treatment chapter. Cardio-oncology carries the cardiac-risk chapter for years. Primary care runs the day-to-day. The shared-care model below is what keeps every survivor on-cadence — with the hand-off artifacts each role actually needs.
Ownership matrix
Oncology owns the treatment summary, cumulative-dose accounting, and the initial late-effect risk stratification. The hand-off is a written statement that names the exposures and the surveillance schedule they trigger.
Cardio-oncology owns the cardiac-surveillance cadence for any survivor with an anthracycline, HER2, chest-radiation, or ICI exposure. The hand-off is an echo cadence, a GLS baseline, and a set of escalation triggers.
Primary care owns the day-to-day: recognition of the reflex bundle, screening for distress and cognition, deprescribing, and the referral script that reopens the cardio-oncology visit when a signal appears.
Why this fails without an artifact
Verbal hand-offs decay. A written, patient-carried transition-of-care plan plus a FHIR R4 bundle keeps the ownership matrix intact across moves, insurance changes, and clinician turnover — which is the survivor's actual life.
The Life Spark artifacts each role uses
Oncology: the treatment-summary export (auto-populated from the survivor's tool entries and risk-stratified against COG-LTFU / NCCN).
Cardio-oncology: the surveillance-cascade view and the escalation-trigger list.
Primary care: the reflex bundle checklist and the referral-script generator.
Frequently asked questions
- What if there is no cardio-oncologist in the region?
- General cardiology with a written treatment-exposure summary can carry the surveillance cadence. The workspace surfaces a virtual-consult path for the escalation-trigger conversations.
- How does primary care get paid for this work?
- The reflex bundle, distress screen, cognitive screen, and care-plan review are billable under standard survivorship / chronic-care-management codes. The coding guide in the clinician workspace maps each artifact to the right code family.
- Where does the patient sit in this model?
- At the center, carrying the record. Every hand-off is consent-scoped and revocable. Nothing moves between clinicians without the survivor's explicit share.