BACKGROUND:International and local guidelines regarding advanced breast cancer (ABC) management recommend coordinated care, discussion in multi-disciplinary meetings (MDM), breast care nurse (BCN) involvement and supportive care screening (SCS). There was concern among clinicians at 3, university affiliated, Melbourne Australian hospitals that these were not routinely performed for all patients at our hospitals. A service improvement grant was used to design a Model of Care (MOC) aiming to address these deficiencies.METHODS:A 6 month retrospective audit of all new ABC patients was conducted at each institution. We reviewed timing and details of diagnosis, MDM discussions, BCN involvement, SCS and communication with general practitioners (GP). Surveys and interviews of GP, patients and oncology clinicians were conducted. A best practice MOC was developed, piloted for 3 months and evaluated.RESULTS:The new MOC resulted in an increased proportion of patients discussed in MDM (from 33% to 88%), reviewed by a BCN (from 30% to 80%), and improved provision (from 61% to 90%) and timing (median 20 down to 16 days) of communication with PCP. 50% of patients interviewed in both the baseline and subsequent evaluation surveys did not feel their care was well coordinated between specialists and GP.CONCLUSION:A best practice MOC for patients with newly diagnosed ABC is possible to implement across a number of institutions with improvements in supportive care. Further improvements can be made in coordination of care between PCP and specialists.