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Patients with chronic graft versus host disease (cGVHD) experience a variety of health needs that result directly from the physical, functional, and psychosocial effects of the disease, are produced as side effects of immunosuppressive treatments, or derive from the late treatment effects of high-dose therapy and hematopoietic stem cell transplantation (HSCT). The achieving optimal outcomes for patients with cGVHD requires the coordinated efforts of an interdisciplinary team delivering a comprehensive range of clinical services in both community-based and specialty care settings. The services must be designed to promptly detect, effectively mitigate, and, where possible, prevent these sequelae. This chapter focuses on the principles of interdisciplinary practice in the care of patients with cGVHD. The chapter examines seven fundamental elements for successful interdisciplinary practice in cGVHD. These elements address (1) the composition, functioning, leadership, and coordination of the team, (2) the organizational service delivery model, (3) communication and collaboration, (4) eliminating barriers to access to needed services, (5) the development of standards of care, standard operating procedures, and evidence-based guidelines, (6) involvement of patient and family, and (7) coordination and continuity of care between specialty care centers and community. Case vignettes illustrate the application of the principles of interdisciplinary care and analyze the features of interdisciplinary team functioning that contribute to optimal clinical outcomes in HSCT survivors with cGVHD and the family members and communities who are caring for them.
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