Principles of shared follow-up care for early breast cancer

• Person-centred care
  The individual and their whole person care is the focus for all care providers.Care is respectful and responsive to the individual’s needs, preferences, circumstances and values. The individual is supported to participate in shared decision making and self-management.
• Care is delivered according to best practice
  Provision of care is in accordance with nationally agreed standards and is outcome focused. Individual follow-up care includes identified pathways for timely access to specialist providers as required.
• Coordination of care
  Care coordination is enhanced through timely and effective communication, and clarification of the roles and responsibilities of the care providers. The collection and sharing of appropriate clinical data and information supports continuity of care and integration across treatment modalities, providers and health settings.
• Support for living well
  Individuals are supported to make positive lifestyle choices which promote health, reduce risk of disease and prevent distress. The individual’s supportive care needs (physical, psychological, social, cultural, informational and spiritual) are assessed with appropriate referrals and management to promote optimal health and quality of life.
• Support for primary care providers
  The role of primary care in the delivery of safe and effective follow-up care is supported. Primary care providers are supported in the delivery of shared follow-up and survivorship care through early involvement, and through the provision of education, resources, information for people affected by cancer and pathways for access to specialist advice.
• Support for specialist treatment team
  The role of specialist care providers in the delivery of safe and effective follow-up care is supported.Specialist care providers are supported in the delivery of shared follow-up and survivorship care through the provision of resources, information for people affected by cancer and pathways for communication with primary care providers.
• Care is informed and improved by data
  Improvements in shared care are data-driven.The collection and utilisation of key cancer data, including consumer experience and outcome data, supports the delivery of holistic patient care and continuous improvement in care.

Find out more about:

• Principles of shared follow-up care

Related resources:

• Principles of cancer survivorship
  Cancer Australia’s Principles of Cancer Survivorship aim to guide national approaches to reduce the impact of cancer and improve the health and wellbeing of people affected by cancer across the cancer care continuum.