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The post‐visit follow‐up begins immediately after the visit. A designated person should assemble all information from the visit. Ideally, a core team meeting will discuss the patient status and the consequences on future management. During this meeting, the various results and the impressions of the team members will be summarized in a systematic and written document intended for the general practitioner of the long‐term survivor. An automated mechanism should be in place to contact patients not arriving for the scheduled visit. Patients lost to follow‐up should be traced and, whenever possible, brought back into a healthcare system. Telehealth and telemedicine are increasingly used to provide healthcare for long‐term survivors, particularly for those living at a great distance from the LTFU clinic or for survivors who cannot afford attending regularly a long‐term follow‐up in the site. A designated chapter in this book is dedicated to telemedicine in the care of long‐term transplant survivors (Chapter 4).

Long‐term survivors are generally followed on an annual basis at the survivorship clinic. The recommendations derived from the LTFU visit need to be implemented, monitored and if necessary adjusted. This part of the management belongs to the role of the general practitioner. For instance, if the LTFU clinic recommends treatment of essential hypertension, diabetes or dyslipidemia, the fine‐tuning surveillance and adjustment have to be carried out regularly by the general practitioner. A clear allocation of the responsibilities and the roles in follow‐up is the key to an optimal healthcare of the long‐term survivor. A model for such role distribution is shown in Figure 3.3.

Figure 3.3 Role distribution of responsibilities between the LTFU clinic, the general practitioner responsible for the long‐term survivor and the long‐term survivor.