Summary report about the Border Cancer Care Collaboration project which included care coordination as one of its focus areas

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

Fact sheet regarding the piloting of cancer care coordinator positions in Northern NSW during 2007-2008.

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

Fact sheet about policy for care coordination in Victoria

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.

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.

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

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)

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

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.

Summary factsheet of a progress survey of cancer nurse coordinators in NSW.

The Palliative Care Needs Assessment Guidelines and Needs Assessment Tool: Progressive Disease - Cancer (NAT: PD-C), both developed with funding from the Australian Government Department of Health & Ageing, are now available. The Guidelines, which were developed in 2006, provide a comprehensive review of the physical and psychosocial issues that may impact upon people with advanced cancer, their caregivers, families and health professionals. The NAT: PD-C was developed to complement the Guidelines. When used in both generalist and specialist settings by health care providers involved in the care of people with cancer, the NAT: PD-C can assist in matching the types and levels of need experienced by people with advanced cancer with the most appropriate people or services to address those needs.

The NAT: PD-C aims to distinguish between those who have: no problems and no need for services; minor problems (ie low need), which may be met by their primary health professional; moderate to high needs and potentially require a referral for full assessment by specialist services.

Systematic use of the Guidelines and NAT: PD-C had an impact on some patient outcomes

assisted busy clinicians to efficiently identify issues of concern, particularly in areas that are not routinely well addressed such as psychosocial issues; and did not create additional burden in terms of consultation length. The NAT: PD-C was also reliable, valid and clinically feasible when tested in a clinical setting with people with advanced cancer. If you would like any further information about the tool, please contact Ms Amy Waller at the Centre for Health Research & Psycho-oncology (CHeRP) on Ph: (02) 4913 8609 or by email: amy.waller@newcastle.edu.au; or Professor Afaf Girgis on Ph: (02) 4913 8600 or by email: afaf.girgis@newcastle.edu.au. A summary version of the Guidelines and the NAT: PD-C are both available at http://www.newcastle.edu.au/research-centre/cherp/professional-resources. A training resource for this tool is available on the Coordination of Care learning activities page.

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.

Patient navigation is an increasingly becoming an important part of cancer care to assist patients and their families to address potential barriers including social, psychological, financial, insurance, and cultural issues that may prevent them from receiving a timely diagnosis and access to quality cancer care.

This report reviews information on the types of patient navigation programs and services available. 

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.

Researchers at Memorial Sloan-Kettering Cancer Center have pioneered the use of computerized devices to help patients and their physicians decide among the major treatment choices for several cancers.

Online prediction tools include:

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