Integrating primary care and cancer care in survivorship: A collaborative approach.

Abstract

103 Background: Primary care providers (PCPs) have an important role in the provision of survivorship care. While there is evidence to support the feasibility and safety of PCP-led survivorship care, there are gaps in knowledge about how to best integrate providers to support transitions, enhance quality of care, increase system efficiencies, and improve patient and provider satisfaction. Methods: A pan-Canadian study comprised of three projects has been initiated to address three key aspects of care integration, based on a previously described system performance framework. Functional integration will be studied through the evaluation of electronic survivorship care plans using a prospective cohort of breast and colorectal cancer patients with pre and post measures of knowledge, care coordination, and satisfaction. Vertical integration will be evaluated through a series of descriptive case studies to document structures and processes that are currently in place to support PCP re-referral to regional cancer centres. Clinical integration will be studied through the development and evaluation of an interspecialty survivorship training curriculum for oncology and family medicine trainees. Results: Functional integration: Development of an electronic platform for care plan outputs is complete. Two sites in Ontario (ON) and one in British Columbia (BC) have been selected to study the impact on 200 patients and their providers. Vertical integration: Using a study-specific interview guide, 48 semi-structured key informant interviews have been successfully conducted in ON; 15 interviews are planned for Manitoba (MB) and 15 for BC. Clinical Integration: a National Advisory Committee was established and needs assessments were performed with postgraduate program directors, cancer survivors, and trainees using online surveys and focus groups. A blended learning curriculum is being piloted in MB, ON, and BC in 2015. Conclusions: Integrating primary care and cancer care in survivorship requires a collaborative approach that begins in residency, supports PCPs with clear mechanisms for re-entry, and optimizes communication. This study will inform approaches to enhancing provider integration and survivorship care.

Integrating primary care providers in the care of cancer survivors: gaps in evidence and future opportunities

“…These include: oncology specialist models, multi-disciplinary clinics, treatment/disease site specific clinics, general survivorship clinics, consultative survivorship clinics, integrated survivorship clinics, community generalist models and shared care models (with and without transitions). Further, we found published literature describing cancer survivorship care within primary care settings and among primary care providers including examples of the following: shared care (40, 42), interventions comparing primary care survivorship delivery to a specialist arm (18, 33, 34), consultative or oncogeneralist model, (37, 39), designated primary care panel within primary care settings (37) and case management approach (31, 37). Finally, one example of a primary care physician-led survivorship clinic specializing in long-term follow-up was described (37).…”

“…A survivorship care plan (or any tool that serves as a vehicle for information sharing) should be developed by the oncology team and revisited during follow up to assure that “shared” care is optimally coordinated until it is deemed appropriate to transition to the PCP. Case managers may be able to assist in care coordination in such scenarios (31, 37). …”