Connected care post-treatment

Connected care post-treatment

clipart of heart at centre with nurse, doctor, elderly patient walking with a walker and a handThe connected care model supports interdisciplinary coordination of post-treatment and follow-up survivorship care. This includes:

  • Prevention and surveillance for recurrent and new cancers
  • Management of long-term effects of cancer treatments, including increased risk of chronic conditions
  • Supports for social adjustments (e.g. managing impact of symptoms and physical burden of disease, distress and concerns related to returning to work)
  • Coordination between all providers22. Recognizing that cancer is a chronic disease that requires long-term support and management, the connected care model supports continuity of care for patients as they transition from active treatment back to their medical home with a primary health care provider. When post-treatment care is managed by primary health care providers, it is more seamless and offers patients holistic emotional and psychosocial supports.

From a cost and resource utilization perspective, well managed follow-up care delivered by primary health care providers is often more sustainable and cost effective.

Addressing connected-care barriers

Connected care models typically include a “transition” process where cancer care teams summarize for the primary health-care team, a patient’s cancer treatments and potential side effects that require monitoring (e.g. treatment summaries, survivorship care plans). When coupled with an appointment with a patient and their primary health care provider, this helps support an integrated and connected approach to survivorship.

Outcome indicators to evaluate the impact of connected care models in post-treatment include patient experience, health outcomes and/or clinical measures and cost and health care utilization.

Connected care models enhance person-centred care by empowering primary health care providers to play a larger role in survivorship. There are however key barriers for primary health care providers, including a lack of cancer-focused education and cancer-specific guidelines to support their provision of care. Insufficient support from specialists and inadequate reimbursement can also limit the ability of primary health care providers to play a larger role in survivorship care.

The approaches described below provide guidance on how to address these barriers. More consideration should be given to collaborating with patients and primary health care providers when implementing and evaluating possible approaches.

Moving Forward After Cancer Treatment is a program led by cancer centres that helps transfer main care patient care responsibilities from cancer teams to primary health care following cancer treatment.

Patients have a “transitional” appointment with their cancer team and receive a three-part plan that can then be supported by their primary health care provider. This includes:

  • A summary of treatments received and a schedule for follow-up appointments with the cancer team
  • Information about a person’s specific cancer, possible side effects and self-monitoring strategies
  • General cancer follow-up resources, including how to access psychosocial supports and a schedule of medical tests required as part of the monitoring process

Patients with cancer who do not have a regular primary care provider (unattached patients) are given priority access to a “Find a doctor program” and are only transitioned once they have adequate access to primary health care.


Survivorship education for health care professionals  

Moving Forward After Treatment has partnered with CancerCare Manitoba, Ontario Health and BC Cancer to launch a training program for medical students to support the provision of survivorship care. The Canadian Association of Nurses in Oncology developed the Adult Cancer Survivorship Manual, a learning resource that includes a survivorship module. 

Learn more about Manitoba’s Moving Forward After Cancer program23.

Alberta’s Living Well After Cancer – A Community Collaboration was launched by Alberta Health Services to improve transitions in care within the Home to Hospital to Home (H2H2H) initiative. The program includes three priorities that support the integration of cancer and primary care teams to provide seamless post-treatment follow-up care. This approach was created to help health-care providers and teams in acute, primary and community care settings operate as a singular entity, and work with patients and family members as equal partners. The goal is to put people and communities, and not diseases, at the centre of the system. Survivorship guidelines, knowledge products and self-management resources are available to support both primary health care providers and cancer survivors.

The Living Well After Cancer model supports:

  • Improved coordination by increasing knowledge, building capacity and sharing best practices in transition and cancer survivorship
  • Improved navigation through community supports that help patients overcome gaps and barriers and decrease their unmet needs after cancer

Learn more about Alberta’s Living Well After Cancer program24.

Ontario’s guideline for follow-up models of care for survivors gives health-care providers and administrators recommendations on implementing optimal follow-up care for all cancer survivors in Ontario. It clarifies the role of primary health care providers and specialist teams in care planning, surveillance and health promotion. This novel opportunity to support efficiency within the system includes a survivorship data cohort, which will help the province to understand the landscape and survivorship needs prior to resource commitment.

Recommendations focus on:

  • Follow-up care planning
  • Surveillance
  • Management and consequences of cancer
  • Health promotion and prevention

Learn more about Ontario’s Follow-up Models for Cancer Survivors Guideline program25.

British Columbia’s Survivorship Nurse Practitioner Program provides follow-up care for patients who are unattached to a family physician. Upon discharge, patients are connected with a nurse practitioner who helps navigate follow-up care and surveillance for late effects of treatment and recurrence.

Through a collaborative approach, the program provides patients and families with tools and connects them to resources to improve the quality and experience of post-treatment care. Receiving the necessary tools to participate in their recovery improves a patient’s transition from the cancer care team to primary care.

The model supports:

  • Reduced need for ongoing cancer specialist appointments, which increases clinic capacity to see urgent care patients and reduces wait times
  • Continuity of care for unattached patients
  • Builds capacity across the continuum to support all cancer patients

Learn more about British Columbia’s Survivorship Nurse Practitioner Program.

Coaching support for patients’ post-treatment

The Ottawa Regional Cancer Foundation, in collaboration with healthcare partners, pairs patients with a health care “cancer coach” who provides support, education, practical guidance and navigation to help the patient meet their health care goals. Patients can choose in-person or virtual coaching sessions which focus on supporting patients’ physical, emotional, informational and spiritual care.

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