Improving Interorganizational Coordination Between Primary Care and Oncology: Adapting a Chronic Care Management Model for Patients With Cancer

Abstract

The objective of this study was to explore the implementation of a payment and delivery system innovation to improve coordination and communication between primary care and oncology. We employed a qualitative case study approach, conducting interviews ( n = 18), and reviewing archival materials. Chronic care coordinators and the cancer center social worker acted as boundary spanners. The chronic care coordinator role built on medical home infrastructure, applying the chronic care model to cancer care. Coordination from primary care to oncology became more routinized, with information sharing prompted by specific events. These new boundary spanner roles enabled greater coordination around uncertain and interdependent tasks. Recommendations for scaling up include the following: establish systematic approaches to learning from implementation, leverage existing capacity for scalability, and attend to the content and purpose of information sharing.

Methods and Effectiveness of Communication Between Hospital Allied Health and Primary Care Practitioners: a Systematic Narrative Review

“…None of the included studies speci cally investigated the methods of communication or evaluated the effectiveness of communication between hospital allied health professionals and primary care practitioners. Twelve of the 24 studies, however, described programs or processes that indirectly addressed components of communication between hospital allied health professionals and primary care practitioners [5,8,[36][37][38][39][40][41][42][43][44][45]. Narrative synthesis of each study included exploration of these 12 interventions within the context of their relationship to some guiding theoretical models of care, namely the chronic care model [46], the collaborative care model [47] and the integrated care model [48].…”

“…Chronic care management has evolved to incorporate a collaborative care model, which includes the active engagement of hospital and primary care providers in the shared care of patients beyond usual discharge summaries [47]. All 12 of the interventions identi ed in the literature [5,8,[36][37][38][39][40][41][42][43][44][45] included features consistent with a collaborative model of care in their initiatives to improve hospital discharge planning and continuity of care, even though they did not all reference a theoretical basis. A collaborative care model may have formed the theoretical framework for the 'Accountable Care in Transitions Program' [5] described by Hawes et al (2017), however was not speci cally named.…”

“…A wellcoordinated, multidisciplinary team approach was used within the outpatient transition setting to support patients in the community after hospital discharge, facilitated by direct communication between social workers acting as care managers in both the hospital and in the primary care setting [5]. Social workers too, were described as 'boundary spanners' to facilitate communication between a medical cancer centre and primary care in an intervention described by Flieger et al in 2019 [37]. In this study, the payment and delivery system innovation adapted an identi ed chronic care management model to become a more collaborative model of care.…”

“…In this study, the payment and delivery system innovation adapted an identi ed chronic care management model to become a more collaborative model of care. The reform prompted the routine sharing of information between the hospital social workers and the primary care chronic care coordinators, allowing improved care coordination and communication across healthcare settings [37].…”

“…Multidisciplinary care plans were important components of the 12 interventions aiming to improve communication processes between hospitals and primary care [5,8,[36][37][38][39][40][41][42][43][44][45]. The remaining 12 studies [49][50][51][52][53][54][55][56][57][58][59][60] assumed or suggested that multidisciplinary care plans were a means of facilitating healthcare communication, as outlined in Table 4.…”