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Evaluating the impact of a novel, shared model of care on the quality of long term cancer follow-up

ABSTRACT: Interventions: The intervention is a novel, shared model of care between cancer services and primary health care using an interactive e-care plan called Inca and telehealth using telemedicine technology. It is being implemented at 2 public and 2 private cancer services in the South Eastern Sydney Local Health District. The e-care plan program is integrated with GP clinical information systems and includes care plan templates for colorectal and breast cancer follow-up care developed from the published literature and agreed guidelines for survivorship care plans. The e-care plan program provides a collaborative space for clinicians and patients to agree on the goals, tasks, responsibilities and the scheduling and monitoring of care. Other functionalities include the sharing of pathology results, measures (e.g. BMI, blood pressure), a health summary and a progress notes section for the specialist, GP or patient to add a note. Documents can be uploaded and downloaded. It provides the basis for non-urgent communication between specialists, GPs, patients and other care team members (e.g. allied health providers) who can be added to the care team and given access. Inca automatically emails notifications to the care team when changes are made to the e-care plan or when upcoming tasks and appointments are due. Patients will be emailed reminders for appointments or tasks that are upcoming from Inca. The e-care plan is not integrated with cancer service clinical systems. Cancer services and patients access the e-care plan through an online portal. This is a non-randomised quasi-experimental trial. Patients at the St George Cancer Centre and the Prince of Wales Private will be allocated to the intervention. Patients at the Prince of Wales Nelune Comprehensive Cancer Centre and the S Primary outcome(s): The quality of communication and information shared to support patient follow-up will be assessed by comparing participant satisfaction and experiences with communication and information sharing within and between groups. Methods Questionnaires will be administered at baseline, 9 months plus 18 months post commencement of follow-up care for delayed intervention group: The Short Form Patient Satisfaction Questionnaire (access, interpersonal manner and communication subscales) (Marshall GN, 1994) and The Survivors Unmet Needs Survey (access and continuity of care subscale) (Campbell HS, 2011) GP Questionnaire - Satisfaction with communication (Jefford M, 2008). Specialist and care coordinator questionnaire (satisfaction with communication and information shared) Qualitative interviews with a sample of intervention participants (10 patients, 5-7 GPs and 3-5 specialists) by phone with a researcher at 9 months and 18 months post commencement of follow-up care for the delayed intervention group [9 months post commencement of follow-up care plus 18 months for the delayed intervention group];Access to and continuity of follow-up care will be assessed by comparing participant satisfaction and experiences with follow-up care within and between groups. Methods: Questionnaires will be administered at baseline, 9 months plus 18 months post commencement of follow-up care for delayed intervention group: Short Form Patient Satisfaction Questionnaire (Marshall GN, 1994) and The Survivors Unmet Needs Survey (access and continuity of care subscale) (Campbell HS, 2011) Qualitative interviews with a sample of intervention participants (10 patients, 5-7 GPs and 3-5 specialists) by phone with a researcher at 9 months and 18 months post commencement of follow-up care for the delayed intervention group [9 months post commencement of follow-up care plus 18 months for the delayed intervention group] Study Design: Purpose: Prevention; Allocation: Non-randomised trial

DISEASE(S): Cancer-bowel-anal,Cancer-bowel-small Bowel (duodenum And Ileum),Colorectal Cancer,Cancer-bowel-back Passage (rectum) Or Large Bowel (colon),Breast Cancer,Cancer-breast

PROVIDER: 23160 | ecrin-mdr-crc |

REPOSITORIES: ECRIN MDR

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Project description:Interventions: Patients at Footscray Hospital will receive a personalised care plan summary which has the following components including Cancer stage, Planned treatment, Planned follow-up visits and Cancer helpline resources. The care plan summary will be generated and provided to the patient during their second consultation with the oncology clinician. The consultation with the clinician will usually take approximately 30 minutes where they are provided the care plan and informed that they will be asked to complete a survey about how useful the care plan is in 6 months. The patient will be approached to complete the survey at a further consultation with the clinician. The care plan summary will be generated from a HREC approved colorectal registry which all colorectal cancer patients at Footscray Hospital are entered into. This study utilised a waiver of consent approach where the participants will be told about the study and a questionnaire which will be provided to them for completion after they have completed their first course of the treatment. No written consent will be obtained from the participants. The duration of the study is approximately 7 months. The plan is to roll this out to other centres and for other tumour streams if determined to be an effective communication tool. Primary outcome(s): The successful development of electronically generated care plan for Colorectal Cancer (CRC) patients. This outcome will be assessed by running a report from the database on how many patients receive the care plan from the oncologist. We can measure this by comparing with the total number of patients entered onto the database.[Patients will receive their personalised care plan at their second clinic visit];Patient feedback and level of satisfaction with the information provided on their care plan and at their initial oncology clinic visits. This will be assessed through a patient survey that patients will be asked to complete. The name of the survey developed for this study is Bowel Cancer Patient Information Survey’[At completion of patient’s treatment];To evaluate and analyse General Practitioner (GP) satisfaction of the care plan through an evaluation survey. The care plan will be uploaded to the hospital system and sent out electronically to GPs, The name of the survey developed for this study is ‘GP Care Plan Evaluation Survey’[The evaluation of GPs will take place as soon as possible after the GP has received the care plan.] Study Design: Purpose: Natural history;Duration: Longitudinal;Selection: Defined population;Timing: Prospective

Project description:Interventions: 1. Intervention name Shared model of cancer follow-up care between general practitioners and radiation oncologists, for patients with breast, prostate or colorectal cancer. 2. Why The rising incidence of cancer and increasing number of cancer survivors has resulted in the need to find alternative models of care for cancer follow-up care. The acceptability for follow-up care in general practice is growing, and acceptance increases with shared-care models where oncologists are still overseeing care. However, a major barrier to this model is the effective two-way exchange of information in real-time between oncologists and general practitioners. Improved communication technology plays an important role in the acceptability and feasibility of cancer shared follow-up care. 3. What The intervention is additional radiation oncology follow-up appointments for the patient with their general practitioner; whilst the radiation oncologist is informed in real-time via the hospital oncology information system (electronic record). Digital health technology (PROsaiq) will be used to transfer the review information from the general practitioner directly into the hospital system. The radiation oncologist will oversee the care by accessing the review information directly, and identify if the patient needs any further medical intervention or support. 4. Who provided The general practitioner will complete a two hour radiation oncology course online (eviQ). A 30-minute training session will be provided by a radiation oncologist directly to the general practitioner on how to access the clinical assessment link, and what to do during the follow-up review by a radiation oncologist (review sleep, weight, skin reactions, bladder/bowel, prostate blood leve Primary outcome(s): Assessment of patient-perceived acceptability and feasibility of the intervention using semi-structured interviews. One on one phone and audio-recorded. [Baseline before intervention; and 6-months post-enrolment (immediately after the second intervention appointment). ];Assessment of general practitioner-perceived acceptability and feasibility of the intervention using semi-structured interviews. One on one phone and audio-recorded. [Baseline before intervention; and 6-months post-enrolment (immediately after the second intervention appointment). ];Assessment of radiation oncologist-perceived acceptability and feasibility of the intervention using semi-structured interviews. One on one phone and audio-recorded. [Baseline before intervention; and 6-months post-enrolment (immediately after the second intervention appointment). ] Study Design: Purpose: Educational / counselling / training; Allocation: Non-randomised trial; Assignment: Single group

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Evaluating the impact of a novel, shared model of care on the quality of long term cancer follow-up

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