Cancer shared care

Cancer Shared Care

Cancer shared care involves the joint participation of GPs, specialists and allied health professionals in the planned delivery of follow-up and survivorship care for patients. These providers work together in agreed referral and care pathways to support patients to live as well as possible for as long as possible, both during and after active cancer treatment.

Patient-centred coordinated care, strengthening the relationship between general practice and oncology teams, and providing care as close to home as possible for the patient has the potential to improve their cancer treatment and care experience, while optimising the outcomes of people living with cancer, cancer survivors and their carers. This approach can be seen in the image below:

Cancer Shared Care diagram

Cancer Shared Care Project focus

The Cancer Shared Care project was implemented by Murray PHN between 2021-23, in collaboration with Gippsland PHN and Western Victoria PHN, and aimed to increase access to cancer shared care in regional Victoria.

It is known that GP-led follow up and shared care models offer promise of more holistic, coordinated and accessible care and may be appropriate for many survivors [RACGP].

Project strategies

The main focus of the project was to support practitioners in Gannawarra Shire and the City of Wangaratta LGAs (the highest prevalence of preventable cancer conditions within the Murray PHN region) to:

  1. Create and maintain sustainable relationships between care providers in acute and primary care settings, to enhance collaboration in the development and delivery of cancer shared care
  2. Build the capacity of local acute and community workforces to support those living with cancer and their carers through education, training and resource development (modes of care)
  3. Identify, develop, implement and embed shared care models for cancer survivorship in the Murray PHN region.

Project outcomes

A patient centred-care protocol has been co-designed with specialist, acute and primary healthcare providers from Gannawarra Shire and the City of Wangaratta, based on identified needs and experiences of patients living with cancer and their carers.

Main project highlights:

  • General practice hub – model has general practices as primary local hub using a multidisciplinary ‘whole of general practice’ approach where GPs, nurse practitioners, practice nurses and administration staff work collaboratively to coordinate care, assess and manage patients’ unmet needs
  • Internal general practice coordinated care – model includes integrated care management with nurse-led and GP-led care coordination
  • Medical neighbourhood approach to care – specialist and acute providers work collaboratively with general practices in share care arrangements through case conferences and information handover
  • Self-directed and stepped shared care management approach, aligned with the cancer care journey:
    • Stage 1: Patient onboarding
    • Stage 2: Shared care management
      • Diagnosis and treatment planning
      • During and at the end of treatment (if not having ongoing treatment)
    • Stage 3: Follow-up and end-of-life care
      • Transitioning from active treatment to follow-up care
      • When care is uncurable
      • Navigating ongoing treatment end-of-life care
  • Holistic assessment of patients’ unmet needs is embedded throughout the protocol to ensure timely referrals, after hours care support and that clinical deterioration monitoring is performed
  • Supplementary resources – protocol also includes a directory of referral pathways, MBS rebates for cancer management, and access to supplementary training and education for capacity and capability building of providers.

Resources

For more information

Contact Vitor Rocha, Palliative Care Lead e: vrocha@murrayphn.org.au

Last Update: May 23rd, 2024

Murray PHN acknowledges its catchment crosses over many unceded First Nations Countries, following the Dhelkunya Yaluk (Healing River).

We pay our respects and give thanks to the Ancestors, Elders and Young people for their nurturing, protection and caregiving of these sacred lands and waterways, acknowledging their continuing cultural, spiritual and educational practices.

We are grateful for the sharing of Country and the renewal that Country gives us. We acknowledge and express our sorrow that this sharing has come at a personal, spiritual and cultural cost to the wellbeing of First Nations peoples. We commit to addressing the injustices of colonisation across our catchment, and to listening to the wisdom of First Nations communities who hold the knowledge to enable healing. We extend that respect to all Aboriginal and Torres Strait Islander peoples.