Key Tactics for Implementation of Shared Care Models
Current scoping, rapid reviews and systematic reviews were identified that summarized key tactics for implementation of shared care models (i.e. specific actions or strategies). A rapid synthesis of the evidence (32 systematic reviews, 17 primary studies) by the McMaster Health Forum was conducted to review the evidence on the features of shared care models that enhance coordination between primary care and cancer care and the contribution of these models to quadruple aim of enhancing patient experience with health outcomes, manageable costs and positive provider experience (67). Other reviews have identified shared care as a viable model for post-treatment survivorship care given that significant differences in recurrence rates, mental health outcomes, quality of life outcomes between shared care and usual care were not found; with markedly reduced costs (i.e. reduction in urgent care services) (67). Four main implementation challenges identified were: 1) role clarity regarding designated accountability for follow-up surveillance of recurrence; 2) secondary cancers and provision of preventive services; 2) insufficient knowledge and confidence in survivorship care for PCPs; 3) survivors’ confidence in PCPs follow-up care abilities (67).
It is evident from the literature and experience of organizations that have implemented these models of care that shared care requires careful planning and implementation. We narratively summarized the key tactics that need to be taken into consideration in the implementation of shared care from reviews (68-71) and as reported in grey literature reports of the organizations who have operationalized this care model (72, 73). The implementation tactics were as follows:
Primary Care Providers (PCPs) (also called Primary Care Physicians (PCPs)) require specific training to ensure their confidence and capability in delivering quality post-treatment follow-up survivorship care.
Training of PCPs in survivorship care includes acquisition of knowledge regarding health risks, long-term complications, late effect risks depending on cancer type and treatment exposure.
Chan and colleagues in a systematic review identified 21 educational programs targeting PCPs with positive benefits on knowledge and confidence but the effect on health outcomes was less certain (74).
The American Society of Clinical Oncology has identified core curriculum (75) to equip providers to deliver comprehensive cancer care including:
Surveillance for recurrence and second malignancies
Long-term and late effects/comorbidities of treatments
Health promotion and disease prevention
Psychosocial well-being
Needs of special populations (different survivor groups, adolescents and AYA, older adults).
PCPs must be fully apprised of appropriate surveillance based on follow-up guidelines as specified for each cancer type and based on treatment exposures with special attention to FU for survivor populations on newer treatments with unique treatment sequalae (e.g. immunotherapy).
Providing PCPs with clear and concise guidance on recommended surveillance and follow-up care either in a FU guideline document and as a treatment summary in a SCP personalized to the treatment and cancer experience of the individual.
Systems are in place to ensure rapid re-entry to cancer care should recurrence be expected or patient exhibits signs of evidence of relapse.
Disease pathways of care that facilitate discussion with patients early in treatment to prepare them and normalize the transition to these alternate models of care.
Clear roles and responsibilities specified for each provider to ensure clarity in shared care delivery model (i.e. surveillance).
Policy and funding for shared care may be needed to include appropriate billing for survivorship care within primary care provider practices.
Mechanisms for communication and coordination and rapid re-entry to oncology specialist led-care model and roles of oncologist versus PCPs.
Survivorship care plans that include treatment summaries and specify surveillance for follow-up and other health risks can act as a communication tool for PCPs and for survivors to adhere to follow-up surveillance and screening tests.
Clear processes for handoffs and communication between oncologists to PCPs.
Timely access and referral to multidisciplinary specialists may still be needed to address specific long-term health consequences (i.e. fertility, sexual health, mental health) and rehabilitation programs for those with functional impairment; and for management of late effects (i.e. cardiomyopathy).