Introduction
The Barwon South West Survivorship Project was funded to develop a model of care transferable across tumour streams and regional and rural centres.
To extend the window of opportunity provided by nurse led intervention, and in recognition that treatment effects may arise years later, the project framework was to include primary care and community health to ensure long term holistic follow up.
Objectives
Individual nurse led consultations and survivorship care plans were utilised to raise health literacy and empower participants in their recovery and health outcomes. General Practitioners (GPs) were engaged as essential partners in surveillance and to prepare for timely shared care or discharge arrangements.
Method
Participants attended 2 individual nurse consultations focused on health assessment, goal setting, provision of a treatment summary, specific tumour related information and allied health and community referrals.
GPs and practice nurses were consulted to identify communication requirements and to correlate with primary practice processes and GP Chronic Disease Management Plans. Transition to allied health and community services was also achieved by aligning with the language, frameworks and services of rehabilitation, chronic health care and health prevention.
Results
The survivorship service achieved significant results in health literacy, was highly rated by project participants (N=99) in meeting survivorship issues, and by GPs, allied health providers and cancer specialists across three sites. Key approaches and tips for developing a transferable model across tumour streams and sites will be presented.
Conclusion
This project developed a service model with processes and strategies that were successfully transferred across three sites and nine tumour streams while engaging cancer, primary care and community services to ensure people completing cancer treatment receive long term health care opportunities.