Health Sciences North (ON)

  • Mark Hartman, Vice President, Northeast Cancer Centre, Health Sciences North, Sudbury, Ontario
  • Amanda Hey, Regional Primary Care Lead, Health Sciences North, Sudbury, Ontario
  • Carole Mayer, Regional Psychosocial Lead & Manager, Supportive Care Program and Supportive Care Oncology Research Unit, Northeast Cancer Centre, Health Sciences North, Sudbury, Ontario

Optimizing a Cancer Survivorship Care Model for North East Ontario

The forecast crisis of a booming population of older adult cancer survivors and the finite capacity of oncologists has been a stimulus to health system leaders across many jurisdictions, including Cancer Care Ontario and the Northeast Cancer Centre (NECC), to strategically prioritize the development of new Models of Care for cancer survivors.

The NECC Models of Care population for our EXTRA project was defined as women diagnosed with Stage 1-3 breast cancer, who have completed an active treatment window within the last twelve months, who are without evidence of breast cancer, and who may still be on adjuvant hormone therapy. The proposed intervention was discharge to primary care compared to remaining under oncologist care; and our project outcomes were stakeholder awareness, acceptance, and early signs of adoption of a primary care led Model of Care.

A review of the evidence revealed two good quality randomized control trials that supported a primary care model; but qualitative studies concluded that stakeholder attitudes and beliefs plus the heterogeneity of patient need may pose implementation challenges. With system uncertainty regarding an optimum model of care, the HSN EXTRA team chose four actionable attributes of a high-performing healthcare system (Effective, Integrated, Accessible and Responsive) to ensure the NECC selected a model that will deliver the right care, at the right place, at the right time, to the right patient. Stakeholder engagement was sought.

Primary care engagement provided the following recommendations:
Effective: Using various formats, disseminate survivorship care evidence-based best practice.
Integrated: Optimize regional EMR integration and leverage other cancer system IT platforms.
Accessible: Expedite re-access to the NECC in a simple, streamlined and timely process.
Responsive: Surface patient psychosocial oncology needs and access early and throughout care.

Oncologist and NECC health professional staff engagement incorporated psychological theoretical constructs to understand the behaviour change process of implementing new clinical guidelines. There has been endorsement of a clinical pathway that transforms the current Well Follow-up clinic established in 2010, staffed by a general practitioner in oncology, to a Transitions Clinic. After initial low uptake, in the past 6 months, all oncologists now discharge patients to the clinic. Concurrent development of specific transition clinic referral and discharge criteria and tools, tested with rapid improvement cycles at key steps that have historically had poor uptake by oncologists is underway (e.g. use of the treatment summary).

Patient focus groups were conducted throughout the North East region, and the heterogeneity of risk and circumstance are apparent; reinforcing the need to further develop a person-centred needs assessment to stratify care at key points in the pathway.

Our stakeholder engagement and resultant identification of need for improved functional integration and accessibility will serve to inform a future NECC colorectal cancer survivorship model. We will share our results on a recently created Cancer Care Ontario (CCO) Survivorship working group for primary care education, psychosocial oncology and review of inclusion criteria for the Ontario Breast Screening Program. We will inform the CCO Integrated Care project and the LHIN Health Links of our work on transition of patient care.

We see merit in discussions at a CCO level of the health system policy recommendations by Lavis(1); calling for 1) more research into models of care, 2) accreditation and incentives for primary care settings engaged in survivorship care and 3) a possible role of regional cancer programs becoming purchasers of community based survivorship supports. We will follow the outcomes and integrate learning from American Society of Clinical Oncology(2) February 2013 priorities for further action to achieve high quality cancer survivorship care.