The Association of Community Cancer Centers Cancer Program Guidelines have been established to assist cancer programs that want to develop and/or maintain a comprehensive interdisciplinary program that meets the needs of cancer patients and their families.

Other available survivorship resources including:

• Journey Forward: Computer-Based Tool Helps Survivors Move Forward After Cancer
• Delivering Effective and Meaningful Survivorship Care
• Survivorship Education for Quality Cancer Care: An Update
• ACCC Cancer Program Guidelines
• Comprehensive Survivorship Services:
  A Practical Guide for Community Cancer Centers

Report on a Victorian workshop held to explore approaches to care coordination.

Poster on the Victorian care coordination strategy presented at Cancer Nurses Society of Australia conference (2005)

This project is an initiative of Cancer Australia funded by the Australian Government.

The aim of this project is improve care coordination and supportive care for cancer patients over 70 years of age in the Hume region; to develop a system for routine screening of these patients for support needs.

Fact sheet about policy for care coordination in Victoria

Published in the March 2008 Cancer Forum, this is a report regarding the 1-day workshop convened by the Clinical Oncological Society of Australia (COSA) in 2007 aiming to define expected outcomes from cancer care coordination and methods for evaluating those outcomes and potential benefits. The goal was that participants would achieve a shared understanding of what can be achieved through coordination of cancer care.

A report regarding this workshop, Care Coordination Workshop, was published in Cancer Forum, Volume 32, Issue 1, March 2008.

In the All Other Documents section, these Improving Patient Outcome Guides relate to the management and coordination of care of cancer patients.

Tumour specific guides include:

• Improving Outcomes for People with Brain and Other CNS Tumours (2006)
• Improving Outcomes for People with Sarcoma (2006)
• Improving Outcomes for People with Skin Tumours including Melanoma (2006)
• Improving Outcomes in Breast Cancer (2002)
• Improving Outcomes in Children and Young People with Cancer (2005)
• Improving Outcomes in Colorectal Cancers (2004)
• Improving Outcomes in Haematological Cancers (2003)
• Improving Outcomes in Head and Neck Cancers (2004)
• Improving Outcomes in Urological Cancers (2002)
• Improving Supportive and Palliative Care for Adults with Cancer (2004)

Policy document about care coordination in Victoria with the purpose to identify strategic directions for cancer care coordination in Victoria and promote the development and implementation of activities and initiatives that facilitate the coordination of cancer care at one or more levels of the health and community care system.

Report about a health professional and consumer survey investigating whether care is coordinated for breast cancer patients.

A submission to Senate regarding the potential for reforming cancer services in Australia to better meet the needs of the individual patient, their carer and family.

The Cancer Nurses Society of Australia also submitted a document endorsing the joint submission, which can be viewed here.

Report on the Senate enquiry into the delivery of services for patients with cancer in Australia - includes a section on coordination of care.

The ASCO Cancer Treatment Plan and Summary is a brief record of a patients' cancer treatment. The forms provide a convenient way to store information about each patients' cancer, cancer treatment, and follow-up care and provide basic information about the patients' medical history for doctors caring for the patient in the future.

Oncologists can enter the dose of chemotherapy received, the specific drugs used, the number of cycles that were completed, surgeries done, and any additional treatment given (such as radiation therapy or hormone therapy) and health professionals seen (including allied health).

Survivorship Care plans are also available to document long term, follow up care needs.

A general template is available and specific plans are available for breast, colon, lung and lymphoma.

The first public national register of lymphoedema practitioners in Australia and New Zealand, the National Lymphoedema Practitioners Register (NLPR) has been developed by Australasian Lymphology Association (ALA) as a searchable database to facilitate easy,  confident, local referral for health professionals and lymphoedema consumers to lymphoedema practitioners who fulfill the accreditation and registration requirements of the ALA.

If you would like copies of the NLPR brochure to give to your clients, please email info@nlpr.asn.au

American Society of Clinical Oncology‘s (ASCO) Journal of Oncology Practice (JOP) is the authoritative resource on clinical and administrative management for practicing oncologists.

This article (March 2006, Vol. 2(2) p.95-96) explains the importance of and steps for developing a chemotherapy treatment plan.

Related templates and treatment plans are available: http://jop.ascopubs.org/cgi/reprint/4/1/31.

The Patient Management Frameworks are a clear description of the care pathway, identifying the critical points along that pathway and the optimal model of care required. They are intended to improve patient outcomes by facilitating consistent care based on evidence and best practice across the state. They set out the key requirements for the provision of optimal care which need to be considered at each step of the care pathway.

In contrast to clinical practice guidelines that guide appropriate practice and decision making, the patient management frameworks provide a guide to the patient journey to ensure patients with cancer and their families receive optimal care and support.

As a guide, the patient management frameworks are to be followed subject to the health professional's independent medical judgment and the patient's preference in each individual case. They are designed to provide information to assist in decision making and organisation of service delivery. The patient management frameworks are not rules and do not carry a sense of prescription. The patient management frameworks represent the what, rather than seeking to prescribe the how and have been developed in collaboration with a wide range of practitioners, consumers and carers.

Wherever possible, the patient management frameworks are based on current best practice, including clinical guidelines, care pathways, standards and research that exist to support optimal care at the critical points. In many cases, however, they are a statement of consensus regarding currently accepted approaches to treatment.

Pathways are included for the following cancer types:

• breast
• colorectal
• gynaecological/ovarian
• head and neck
• lung
• skin
• genitourinary/testicular
• upper GI
• oesophagastric
• central nervous system
• haematological
• lymphoma

A toolkit for users is also included.

Fact-sheet describing the National Cancer Institute‘s research program to trial a process of using a patient navigator to help patients and their carers navigate the cancer journey.

Providing guidance about the diagnosis/ evaluation/ risk assessment of cancer in Family Practice in the UK, this guideline offers advice on the referral of adults and children with suspected cancer to specialist services.

This PDQ cancer information summary provides comprehensive, peer-reviewed information for health professionals about patient transition from inpatient to outpatient.

Transitional care planning helps the patient’s cancer care continue without interruption through different phases of the cancer experience.

This site provides information, templates, tools, assessments and resources to assist with the coordination of care and support for the patient throughout their cancer journey.

Full and summary reports outlining competency standards for breast nurses including care coordination role. Includes literature review and stakeholder consultation.

Report outlining a model of careusing specialist breast nurses for women with breast cancer.

Cancer Australia has developed the Cancer Service Networks National Demonstration Program (CanNET) to link regional and metropolitan cancer services into comprehensive cancer networks.

There are seven CanNET projects, one in each state and the Northern Territory. Click the above link for further details and contact information.

CanNET will improve access to quality, clinically-effective cancer services throughout Australia, particularly for specific population groups that may currently have poorer cancer outcomes, including Aboriginal and Torres Strait Islander peoples and people living in rural and regional areas.

CanNET involves the Australian, state and territory governments working collaboratively with consumers of cancer services and primary, secondary and tertiary health professionals to improve outcomes through better coordination of existing services.

CanNET is also working on projects regarding specific areas of cancer care and access, including;

• Consumer involvement
• Primary care involvement
• Multidisciplinary care
• Quality improvement
• Workforce and professional development

COSA has identified the need to improve the coordination of cancer care as an important priority, and especially in the following areas:

• Outcome measurements
• Advocacy
• Facilitating networks