A Rural ModelCANCER CARE REFERRAL PATHWAY

:

Team Members

• Sandra Turley Cancer Care Coordinator (CCC) Project Lead

•Melissa Cumming Director Cancer & Palliative Care

•Previous Members:

• Jennifer Carter Psycho-Oncology Counsellor

•Ruby Hooke Psycho-Oncology Counsellor

Background

•2008 Loss of visiting Medical Oncology Service to Broken Hill

•Patients referred directly from GP to metro centres

•Local cancer services not accessed

•Decreased referrals to CCC

•Poor coordination of care

Background ctd

•Fragmented care

• Increased presentations to ED

• Increased patient & carer stress

•Poor communication between service providers

•Patients lost in the system

What now?

• Improve integration of care

• Promote role CCC – first point of contact

• Improve communication between providers

• Maintain profile of Cancer Services in BH

• Identify barriers to referral

• Develop and implement Cancer Care Referral Pathway (CCRP)

Method

•Multi step approach undertaken over a 4 year period

•Step 1 (2009) – successful recipients Innovation Scholarship NAMO

•Scoping study – service mapping, consultations with stakeholders, focus groups, consumer interviews, health advisory board members, community support groups

Findings from Scoping Study

9 findings in total – most significant being:

•Loss of Specialist Oncology Services had a profound impact upon cancer care

•Lack of awareness of the role of the CCC

•Lack of knowledge of how to access CCC

•High turnover of medical staff and GPs in BH

•People affected by cancer were not aware of supports available

Next Step

• (2011)- Applied for funding to develop and implement recommendations outlined in scoping study - application declined

•(2012)– Successful Innovation Grant CINSW Develop Cancer Care Referral Pathway

Developing the Cancer Care Referral Pathway

•Collaboration/consultation with GPs and Practice Nurses designing both an electronic/paper version

•Liaison with GP IT providers embedding trial templates & accompanying referral criteria into practices including Maari Ma (Aboriginal Health Service) and Royal Flying Doctor Service (RFDS)

Development Ctd

•Development promotional material

•Designed & implemented TV commercial

•Feedback letter template

•Acknowledgement of referral

•Public Launch & implementation of pathway

The Pathway Look

•Simple & easy to use

•Located in one electronic folder

•Utilized existing referral letter templates

•Uploaded section B IPTAAS form

•Local pathology & radiology request forms

•External provider request forms

Referral Criteria (hard copy)Criteria Rationale

New Cancer Diagnosis or

Unclear diagnosis and treatment plan

• Ensure patient and carers aware of service to access education and support when needed

• Provide point of contact

• Provide continuity of care

• To access need for ongoing support

• Facilitate links with treating specialist via face to face consultation of via telemedicine

Travel outside of FWLHD to access treatment and specialist intervention

• Provide coordination of appointments and tests

• Facilitate communication between clinicians, patients and carers

• Provide continuity of care, referral to Metro CCC

• Assist with travel and accommodation

Referral Criteria (hard copy) ctdCriteria Rationale

Unpredicted change in condition or treatment plan

• Facilitate new treatment plan with MDT

• Educate patient and carer

• Facilitate communication between clinicians

Admission to ED or Hospital

• Provide support and continuity of care

• Facilitate communication between clinicians, patient and carers

• Assess need for community services

Poorly controlled / multiple comorbidities

• Ensure knowledge of services and responsibilities of care

• Facilitate communication between clinicians, patient and carers

Promotional Material

Play video

Remembering the Aim of the Pathway

•Promote CCC as first point of contact after cancer diagnosis

•Promote role across all sectors ensuring integrated care coordination

•Raise community awareness of role

•Ongoing engagement with community and health providers

Referrals prior to PathwaySource Number

Patient/ family referrals 13

Public Hospital 13

GP referrals 6

Oncology referrals 2

Surgeon referrals 3

Community services 1

IPTAAS 5

7 sources of referrals

Total number of referrals 43

Results post introduction of PathwaySource Number

GP 15

Maari Ma 6

Plastic Surgeon 7

Gastro Surgeon 5

RFDS 3

Gynaecologist 3

Haematologist 2

Self-referral/ Family 40

Oncology 10

Wards 27

RAH 10

Pre-admission 9

IPTAAS 3

Source Number

Leukaemia

Foundation

1

Flinders Medical 2

Emergency 2

Theatre 1

Outreach 1

Breast Screen 1

19 sources of referral

Total number of Referrals148

Outcomes

•Patients not ‘falling through gaps’ - being referred at diagnosis / more timely manner

•Care is integrated and coordinated between care providers (local and tertiary)

•CCC can ensure right care is provided in right place at right time

•Patients/carers feel supported in navigating cancer treatment system

Testimonial

•“…the cancer care coordinator …has given me a lot more confidence about the process, my feeling of being back in control of my body, explaining the recent scan results in terms I can understand and helped me to overcome problems with pain, medication and side effects”

(Heather-patient)

Sustainability

•Embedded referral pathway

•Ongoing collaboration/ education

•Backfill for CCC

•Advertising / printed resources continue

•Ownership of coordinated care (eg Maari Ma)

•Formal evaluation of CCRPP with UDRH

•New collaborative partnerships between sectors

Transferability

•Cancer Care Referral Pathway is transferable across small ‘like’ rural / remote communities

• Promotion of the role within the community is paramount to success

•Components of CCRPP (eg advertising / electronic referral pathways) transferable to larger settings

Contact Details

sandra.turley@health.nsw.gov.au

•Mobile: 0427064367

•Landline: 08 80801197

melissa.cumming@health.nsw.gov.au

•Mobile: 0429984457

•Landline: 08 80801452