Breast Cancer Follow Up Shared Care Project
Southern Health, in conjunction with SMICS has recently been successful in its application to establish a demonstration site as part of the National Breast and Ovarian Cancer Centre’s (NBOCC) national Shared Care Demonstration Project.
This exciting project aims to trial and evaluate approaches to the delivery of shared care between primary and specialist clinicians in the planned delivery of the follow-up of patients from three months after completion of hospital-based therapy for early breast cancer or ductal carcinoma in situ (DCIS).
For women with breast cancer, follow-up care provided by a general practitioner (GP) has been found to be a safe and effective alternative to specialist follow-up with no differences in survival outcomes, breast cancer recurrence or serious clinical events. It has the added benefit of:
- promoting a model of wellness away from the acute hospital environment
- providing care in an environment closer to home
- provision of holistic care by the GP who knows the patient and their history
- better coordination, communication and continuity of their care between specialists and GPs
Shared care has been successfully and safely implemented across a range of health settings at Southern Health including diabetes, paediatric oncology, orthopaedics and obstetrics
Principles of shared care:
The following Principles were developed in consultation with experts in the field and are based on key elements of a National Breast and Ovarian Cancer Centre literature review from 2008.
Patient Centred
The patient and their whole person care is the focus for all care providers
Coordination, communication and continuity of care
Care of the patient requires coordination through timely and effective communication, and clarification of the roles and responsibilities of the care providers.
Support for primary care providers
Primary care providers are supported in the delivery of shared follow-up care through early involvement, and through the provision of education, resources and protocols.
Support for specialist treatment team
Specialist care providers are supported in the delivery of shared folow-up care through the provision of resources and protocols which improve efficiency and support data collection.
Care is delivered according to best practice standards
Provision of care is in accordance with nationally agreed standards and is outcomes focused.
Follow - Up Purpose:
Purpose of follow-up care after treatment for early breast cancer includes
- early detection of local, regional or distant recurrence
- screening for a new primary breast cancer
- detection and management of psychosocial distress, anxiety or depression
- detection and management of treatment-related side effects
- reviewing and updating family history information
- observation of outcomes of therapy
- reviewing treatment, including new treatments that may be appropriate for the patient[1].
Follow-up guidelines:
NBOCC Follow-up care for women with early breast cancer - a guide for general practitioners (March 2010)
Information for health professionals
Shared care demonstration project