Models of care toolkit

About this section

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

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

People undergoing cancer treatment face other acute and routine health concerns. For people with a primary care provider, coordination between cancer specialists and primary care is important during both active cancer treatment and in the treatment of chronic and emerging conditions that are unrelated to a patient’s cancer treatment regimen. Patients without access to primary care face additional challenges.

Health systems that connect cancer and primary 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 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 care providers.2 There may also be instances where primary care providers are better suited to meet the needs of their patients with cancer, especially during pre-diagnosis and post-treatment.

Increasing the role of primary care teams

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

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

Connected care models benefits:

  • Enhanced coordination between primary care and cancer care reduces wait times, stress and anxiety associated with a cancer diagnosis6
  • Appropriate health care utilization in primary, acute and hospice care settings, emergency departments and intensive care units reduces unnecessary care such as trips to emergency departments7,8,
  • Access to specialist support helps primary care providers feel supported in the delivery of cancer-related services to patients9
  • Collaboration among all members of the health-care team yields greater patient and provider satisfaction with both the quality of care and treatment outcomes
  • Enhanced quality of care is achieved when cancer and primary care teams work together to make decisions relating to patient 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.

Supporting unattached patients in the cancer system

Coordinated care models work best if a person has a primary care provider to support transition into and out of the cancer system, but 20% of people across Canada are not attached to a primary care provider or team.10,11

Cancer system partners in many jurisdictions report that the shortage of primary care providers impacts their ability to deliver efficient, equitable cancer care. Some cancer leaders indicate discharge can be delayed for patients who do not have a primary care provider to coordinate their care.

Learn more about how provincial and territorial governments are expanding access to primary care services.

Using Patient Reported Outcomes in connected care models

clipart of a woman with a medical sheet

Patient reported outcome (PRO) tools help to ensure patients with cancer are regularly screened for physical and emotional symptoms. An easy-to-read dashboard in Alberta allows clinicians to track changes and trends in a patient’s symptoms from visit to visit and helps them connect patients with appropriate support.

Data analysis helps staff to better support patients by demonstrating which types of cancers require more symptom management by multidisciplinary teams including primary care.  Alberta is also exploring PROs to provide effective virtual cancer care for people living in rural and remote areas12.

Other provinces are shifting to collecting PROs electronically. Radiation Oncology Centres in Nova Scotia and New Brunswick are using an online tool called Noona to provide patients an opportunity to electronically report and record cancer-related symptoms as well as highlight information about their wellbeing. Symptoms are reviewed by the care team and a follow-up care plan is created with patients when they come into the clinic. This innovative approach to electronic patient-reported outcomes reporting will be expanded to other settings beyond radiation therapy centres in Nova Scotia.

Patients with a primary care provider benefit most from connected care models

Connected care models in the cancer system work best if patients have a primary care provider. In 2023, 20% of Canadians reported they did not have regular access to a family doctor or a nurse practitioner.10,11

The number of patients who are unattached to a primary care provider or team is expected to grow significantly in the coming years. Older doctors are retiring, and fewer family medicine residents are entering comprehensive primary care practice.13

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  19. 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.
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  23. 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.
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