Models of care toolkit

Coordination with primary care

People undergoing cancer treatment face other acute and routine health concerns. Coordination between cancer specialists and primary care is important during this time and supports primary health care providers in the treatment of chronic and emerging conditions that are unrelated to their patient’s cancer treatment regimen.

Health systems that connect cancer and primary health care can:

• Streamline diagnosis and initiation of treatment
• Address the physical, mental and social care needs that may affect treatment compliance
• Enhance support during post-treatment care
• Integrate community resources to ultimately improve patient outcomes

Family doctors and other primary health care providers such as nurses, social workers and dietitians are critical to the coordination of cancer care beginning with suspected diagnosis, through treatment, survivorship, palliative and end of life care.

For many in Canada, the cancer system has limited integration with primary and community care¹, which can create challenges for both patients and primary health care providers.² There may also be instances where primary health care providers are better suited to meet the needs of their patients with cancer, especially in the pre-diagnosis and post-treatment.

Increasing the role of primary health care teams

Many existing models of care that focus on diagnosis and post-treatment are plagued with poor information flow among care providers and diagnostic teams³, a lack of specialty training in how to provide effective and person-centred care⁴ and a lack of clarity about roles and responsibilities across providers. Post-treatment models are commonly oncology-led, constrained in capacity and limited in their approach to culturally appropriate, holistic care. With increasing cancer survivorship rates and limited access to specialist expertise it is critical that health-care system leaders find ways to increase the role of primary health care teams⁴.

In addition to helping patients manage cancer symptoms, primary health care providers enhance whole-person care by treating comorbidities and providing preventive services and psychosocial support.⁵ Involving a patient’s primary health care team in cancer diagnosis, treatment and survivorship also supports equitable care.

Connected care models benefits:

• Enhanced coordination between primary health care and cancer care can reduce wait times and reduce the stress and anxiety associated with a cancer diagnosis⁷
• Appropriate health care utilization in primary, acute and hospice care settings, emergency departments and intensive care units can reduce unnecessary care such as trips to emergency departments^8,9
• Access to specialist support provided through connected-care models helps primary health care providers feel supported in the delivery of cancer-related services to patients¹⁰
• Collaboration among all members of the health-care team yields greater patient and provider satisfaction with both the quality of care provided, and treatment outcomes
• Enhanced quality of care is achieved when cancer and primary health care teams work together to make decisions related to a patient’s care

There are limited data on which models best support connected care in First Nations, Inuit or Métis communities. Working with Indigenous communities to identify, develop and implement strategies that support a collaborative approach to the delivery of culturally appropriate and competent cancer care in their communities is a critical step.