Background
After completion of cancer-related treatments, patients in remission enter surveillance monitoring. Traditionally, patients are followed up by their medical specialist throughout the whole surveillance period. With an estimated 151 000 people diagnosed with cancer each year; this model of care may not be feasible.
A strategy implemented by Sydney Eastern Sydney Local Health District(SESLHD) is to incorporate shared care (GPCanShare) between the patient’s general practitioner (GP) and also their medical specialist. GPCanShare involves alternating visits between their local GP and medical specialist to ensure patients are followed up as per survivorship clinical guidelines.
Aim:
The establishment of GPCanShare aims to optimize care for cancer patients. This includes the ability to improve communication between the GPs and medical specialists, provide clinical and educational support to GPs and streamline urgent referrals back to the medical specialist if required.
Methods
Patients suitable for the shared care follow-up are flagged by the care coordinators or medical specialists. Verbal Consent is gained between the patient and their local GP. Care plans with scheduled follow-up dates and times are distributed to the patient and their local GP. Cancer diagnoses that have limited evidence-based surveillance guidelines are adapted to take into account the patient’s medical history, tumor grading, ECOG status, goals of care and any limitations with seeing GPs.
Results:
Since the commencement of this service, we have recruited 150 patients into GPCanShare. Overall, we have projected to save a total of 45 clinic hours at the cancer centre. Fact sheets have been developed for GPs to identify “red flag” symptoms that require urgent specialist assessment.
Conclusion
GPCanShare has allowed an alternative sustainable method for the follow up of cancer surveillance patients. An area of further focus may involve streamlining patient care between the different medical specialities like Radiation Oncologists, Medical Oncologist and Surgeons.