Models of care toolkit

About this section

This section of the toolkit describes how innovative models of care can be used to enhance the coordination of care between cancer care and primary health care teams.

Coordination with primary careclipart of heart in the centre with puzzle pieces surrounding it

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 departments8,9
  • 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.

Using Patient Reported Outcomes in connected care models

clipart of a woman with a medical sheet

The use of patient reported outcome (PRO) tools ensures patients with cancer are regularly screened for physical and emotional symptoms.

In Alberta, an easy-to-read dashboard allows clinicians to track changes and trends in a patient’s symptoms from visit to visit and helps to connect patients with appropriate supports.

Data analysis helps guide staff by demonstrating that patients with certain cancers require more support with symptom management by multidisciplinary teams including primary health care. Alberta is also exploring the use of PROs to provide effective virtual cancer care for people living in rural and remote areas6.

Other provinces are shifting to collecting PROs electronically.  A new Dalhousie University initiative that is being implemented in New Brunswick and Nova Scotia focuses on electronic collection and reporting of PROs for patients receiving radiation treatment.

Scalable and spreadable models

Models of care with potential for scale and spread across jurisdictions were identified using evidence from a rapid synthesis by McMaster Health Forum and existing best practices.

  1. Lavis JN, Hammill AC. Care by sector. In Lavis JN (editor), Ontario’s health system: Key insights for engaged citizens, professionals and policymakers. Hamilton: McMaster Health Forum; 2016, p. 209-69.
  2. Tremblay D, Latreille J, Bilodeau K, et al. Improving the transition from oncology to primary care teams: A case for shared leadership. J Oncol Pract. 2016;12(11):1012-1019.
  3. Tremblay D, Prady C, Bilodeau K, et al. Optimizing clinical and organizational practice in cancer survivor transitions between specialized oncology and primary care teams: a realist evaluation of multiple case studies. BMC Health Serv Res. 2017;17(1).
  4. Meiklejohn JA, Mimery A, Martin JH, et al. The role of the GP in follow-up cancer care: a systematic literature review. J Cancer Surviv. 2016;10(6):990-1011.
  5. Kang J, Park EJ, Lee J. Cancer survivorship in primary care. Korean J Fam Med. 2019;40(6):353-361.
  6. Watson L, Qi S, Delure A, et al. Virtual cancer care during the COVID-19 pandemic in Alberta: Evidence from a mixed methods evaluation and key learnings. JCO Oncol Pract. 2021;17(9):e1354-e1361.
  7. Cancer Quality Council of Ontario. Programmatic Review on the Diagnostic Phase: Environmental Scan.; 2016.
  8. Gorin SS, Haggstrom D, Han PKJ, Fairfield KM, Krebs P, Clauser SB. Cancer care coordination: A systematic review and meta-analysis of over 30 years of empirical studies. Ann Behav Med. 2017;51(4):532-546.
  9. Mittmann N, Beglaryan H, Liu N, et al. Examination of health system resources and costs associated with transitioning cancer survivors to primary care: A propensity-score–matched cohort study. J Oncol Pract. 2018;14(11):e653-e664.
  10. Zhao Y, Brettle A, Qiu L. The effectiveness of shared care in cancer survivors-A systematic review. Int J Integr Care. 2018;18(4):2.
  11. Jensen, H. Implementation of cancer patient pathways and the association with more timely diagnosis and earlier detection of cancer among incident cancer patients in primary care. PhD dissertation. Aarhus University; 2015
  12. Møller H, Gildea C, Meechan D, Rubin G, Round T, Vedsted P. Use of the English urgent referral pathway for suspected cancer and mortality in patients with cancer: cohort study. BMJ. 2015;351:h5102
  13. Prades J, Espinàs JA, Font R, Argimon JM, Borràs JM. Implementing a Cancer Fast-track Programme between primary and specialised care in Catalonia (Spain): a mixed methods study. Br J Cancer. 2011;105(6):753-759.
  14. Canadian Partnership Against Cancer. Leading Practices to Create a Seamless Patient Experience for the Pre-Diagnosis Phase of Care: An Environmental Scan. 2018. Accessed November 22, 2021.
  15. Walsh J, Young JM, Harrison JD, et al. What is important in cancer care coordination? A qualitative investigation: What is important in care coordination? Eur J Cancer Care (Engl). 2011;20(2):220-227.
  16. Wong WF, LaVeist TA, Sharfstein JM. Achieving health equity by design. JAMA. 2015;313(14):1417-1418.
  17. Vedsted P, Olesen F. A differentiated approach to referrals from general practice to support early cancer diagnosis – the Danish three-legged strategy. Br J Cancer. 2015;112 Suppl 1(S1):S65-9.
  18. All.Can. Danish Cancer Patient Pathways: three-legged strategy for faster referral and diagnosis of cancer. Accessed November 24, 2021.
  19. Ontario Health (Cancer Care Ontario). Navigating the Diagnostic Phase of Cancer – Ontario’s Strategic Directions 2014-2018. Accessed November 23, 2021.
  20. Lewis RA, Neal RD, Hendry M, et al. Patients’ and healthcare professionals’ views of cancer follow-up: systematic review. Br J Gen Pract. 2009;59(564):e248-59.
  21. Cancer Council Victoria. Optimal Care Pathway for Aboriginal and Torres Strait Islander People with Cancer Draft for National Public Consultation.; 2017. Accessed November 22, 2021.
  22. Jefford M, Koczwara B, Emery J, Thornton-Benko E, Vardy JL. The important role of general practice in the care of cancer survivors. Aust J Gen Pract. 2020;49(5):288-292.
  23. Cancer Care Manitoba. Manitoba’s Moving Forward After Cancer program. Accessed November 24, 2021.
  24. Alberta Health Services. Home to Hospital to Home Transitions. Accessed November 24, 2021.
  25. Ontario Health (Cancer Care Ontario). Follow-Up Model of Care for Cancer Survivors. Accessed November 24, 2021.
  26. Canadian Partnership Against Cancer. 5,000+ paramedics in six provinces to provide palliative care in the home. Accessed November 24, 2021.
  27. Canadian Hospice Palliative Care Association. Innovative Models of Integrated Hospice Palliative Care, the Way Forward Initiative: An Integrated Palliative Approach to Care.; 2013. Accessed November 24, 2021.