Aim
To develop a sustainable model of shared care for breast cancer patients at Monash Health by:
• creating a shared care standard pathway
• initiating shared care from diagnosis
• improving communication between the specialist team, patient and GP
• employing GP support for patients close to home
• fostering patients transition towards wellness
• prioritising acute service resources towards patients with greatest need
Background
In 2013, 4075 Victorians were newly diagnosed with breast cancer. The five year relative survival rate for those with stage 1 and 2 cancers is 100% and 94% respectively resulting in increased numbers of health service follow-up visits placing pressure on limited acute sector resources. Research indicates that shared care for breast cancer follow up is a safe and effective alternative .
Initiative
Monash Health initiated a shared care pathway for breast oncology patients, informed by previous work undertaken in the 2010-11 Cancer Australia shared care demonstration project and supported by additional funding from Cancer Australia.
Patients enter the pathway at their post-surgical review and are encouraged to see their GP at the following intervals:
• post diagnosis
• post Multidisciplinary Team Meeting and treatment planning
• during active treatment as needed
• at end of active treatment
• the 6 month point between Monash Health annual reviews
• annually after 5 years when the majority of care is provided by the GP.
Monash Health gives patients and GPs a shared care follow up plan at the first annual review and patient education is carried out by breast care nurses. Patients are not discharged, and can rapidly access the health service as needed. A nurse led wellness clinic is planned to assist patients with un-met supportive care needs and to encourage a positive approach towards their health. In addition a GP active learning module is under development. To date there are 312 patients on the pathway.