Shared follow-up and survivorship care

Shared follow-up and survivorship care

What changed?

• With increased pressures on the health system during the COVID-19 pandemic, some patients who were unable to visit their cancer service for their follow-up appointments or were concerned about visiting the cancer service, have reported having their follow-up care shared between their cancer specialists and their GP.¹
• Internationally, many post-treatment follow-up care appointments for cancer survivors were conducted using telehealth in specialist and primary care, and some non-urgent surveillance consultations were delayed in response to the pandemic or transferred between specialist and primary care.²

Impact of change

• Minimising unnecessary presentations to acute care facilities by transitioning patients to primary care for their follow-up and survivorship care and utilising telehealth, aimed to reduce the risk of survivors contracting COVID-19 infection while still providing continuity of follow-up care.²  Some GPs reported not being adequately prepared to provide follow-up care as clinical information exchange was limited.³
• The increased uptake of these alternative care models, such as shared follow-up care, increased the capacity of specialists to focus on patients requiring urgent care and relieved pressure on specialist and hospital-based services.² In particular, shared follow-up and survivorship care better leverages the skills and expertise of the specialist and primary care workforce to support the delivery of high quality, safe and sustainable follow-up and survivorship care.
• In conjunction with telehealth, shared online consultations allow engagement between the patient, the specialist primary care provider, allied health specialists, and/or family members in diverse locations.⁴
• The use of telehealth to support shared follow-up and survivorship care prompted some concerns regarding patient privacy, providing informed consent, and the increased risk of anxiety and distress among cancer survivors relating to the use of telehealth.²

How can high-value changes be embedded or enhanced?

The following strategies were identified in Australian and international literature and by leading Australian cancer experts and consumers. This list is provided to prompt considerations and future strategies to support high-value cancer care in the Recovery phases of the COVID-19 pandemic.

These strategies are listed at the system-, service-, practitioner-, and patient-levels and are intended to be used by a range of cancer control stakeholders across Australia to support high-value cancer care and improve outcomes for people with cancer.

System-level strategies

• Implementing national evidence-based and collaborative models of shared follow-up and survivorship care.¹
• Developing evidence-based consensus guidance for implementation of telemedicine in follow-up care addressing safety concerns, including surveillance practices requiring physical examination.³

Service-level strategies

• Adopting evidence-based, innovative models of care, including shared follow-up and survivorship care.
• Establishing and embedding processes and templates, to support shared follow-up care plans between multidisciplinary health professionals, and facilitation of rapid access to tertiary care settings for clinical issues requiring specialist consultation or advice.
• Establishing patient portals to allow remote communication, education, care coordination, systematising of follow-up appointments (including scheduling reminders for surveillance check-ups and investigations), and electronic collection of patient-reported outcomes. 

Practitioner-level strategies

• Empowering clinicians, care coordinators and allied health professionals, including Aboriginal and Torres Strait Islander Health Workers, to use telehealth to provide quality digitally-enabled survivorship care.^2,4
• Increasing access to education for health professionals on the evidence and benefits of alternative models of follow-up and survivorship care.
• Increasing access to guidance, resources, and education to support delivery of best practice, person-centred, evidence-based models of follow-up and survivorship care.
• Increasing access to standardised templates to support care coordination and agreement of alternative follow-up shared care arrangements.
• Facilitating utilisation of appropriate members of the specialist team (including specialist nurses) to support shared-care follow-up and survivorship care.⁵

Patient-level strategies

• Providing timely and accessible information to support patients to understand their follow-up and survivorship care plan and take an active role in managing their health. This includes clear and transparent communication from the initial consultation about the intended treatment pathway.
• Providing assurance to patients of rapid referral to the specialist team or back to the GP if required by any follow-up care providers.¹