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Working in partnership, we will achieve world class cancer
- utcomes for the population we serve
Rationale
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Stratified follow-up: An update of the project to date Working in - - PowerPoint PPT Presentation
Stratified follow-up: An update of the project to date Working in - - PowerPoint PPT Presentation
Stratified follow-up: An update of the project to date Working in partnership, we will achieve world class cancer outcomes for the population we serve Rationale 2 RM Partners, West London Cancer Alliance Hosted by The Royal Marsden Hospital
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SLIDE 3
RM Partners, West London Cancer Alliance – Hosted by The Royal Marsden Hospital NHS Foundation Trust
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- Developing clinical service evaluation
- NHS Operational Planning Guidance mandated
- Building on existing FU models
RM Partners, West London Cancer Alliance – Hosted by The Royal Marsden Hospital NHS Foundation Trust
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Developing a baseline
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Review of:
- National guidance
- Regional Models
- Different tumour sites
- Local follow-up provision
RM Partners, West London Cancer Alliance – Hosted by The Royal Marsden Hospital NHS Foundation Trust
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RM Partners, West London Cancer Alliance – Hosted by The Royal Marsden Hospital NHS Foundation Trust
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Name of Trust Eligibility Criteria Clinical Management Protocols SOP Treatment Summary Remote Monitoring Support Worker Introduction to SSMFU letter Patient Information GP Information Patient Portal SFU Nurse led ✖ ✖ ✖ ✖ ✖ ✖ ✖ ✖ ✖ ✖ ✖ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✖ ✔ ✖ ✖ ✖ ✖ ✖ ✖ ✖ ✖ ✖ ✖ ✖ ✔ ✖ ✖ ✔ ✖ ✖ ✖ ✔ ✔ ✖ ✔ ✔ ? ✖ ✔ ✔ ? ✔ ✔ ✖ ✔ ✔ ? ✖ ✔ ✖ ✖ ? ✔ ✔ ✖ ✔ ✔ ? ✔ ✔ ✖ ✖ ? ✔ ✔ ✖ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✖ ✔ ✔ ✖ ✔ ✔ ✔ ✔ ? ✔ ✔ ✖ ✔
SLIDE 8
Model development
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- Proposed model developed via an iterative co-development process
- Ensuring robust systems for the management of surveillance are established
- Cancer Alliance-wide meeting to agree model
RM Partners, West London Cancer Alliance – Hosted by The Royal Marsden Hospital NHS Foundation Trust
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SFU: Breast Model Core components:
- Professional-led pathway for all breast cancer pathways
- Supported self-management pathway for Early Breast Cancer patients
- Embed needs assessment and care-planning for all patients at the end of treatment
- Ensure all patients and their GPs are provided with a Treatment Summary after completing treatment
- Process for clinician-patient review to determine and agree transition to supported self-management
pathway
- Provision of supported self-management and health and well-being information
- Surveillance protocol, with process for scheduling and monitoring investigations
- Process for patients to access support and advice
- Recall process for abnormal surveillance investigations and change in patient-reported symptoms
- Clinically-led review of patients 5 years after treatment to review adjuvant treatment regime and
discharge from secondary care-led follow-up
- Clinical appointment for patients requiring extended treatment regimes
- Process for discharge of patients to GP at 5 years
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SLIDE 11
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Conventional Model Current Model Proposed Model
MDT clinical review Clinical Review ▪ Needs assessment ▪ Care plan ▪ Treatment summary
Active treatment complete
Abnormal result Patient recalled <2 weeks MDT clinical review Extended therapy required
6- 12 weeks post treatment
Normal result Discharge to primary care for on-going monitoring OAFU Virtual MDT Abnormal result Patient recalled <2 weeks End of treatment appointment
Annually
Surveillance Normal result Patient OPA Professional- led pathway Support and advice
Indicative timeline
Breast follow-up
Completion of HNA, care plan and dissemination of treatment summary 5 years post treatment MDT Clinical review Extended therapy required Continue annual OPA Patient eligibility assessment Not eligible Continue annual FU OAFU appointment Discharge to Primary Care Dissemination of OAFU patient information completion of HNA, care plan and dissemination of treatment summary Patient concerns Helpline triage Patient re- access specialist service if required Patient tracking system Discharge to Primary Care Surveillance Supported self- management pathway Rehabilitation Provision of supported-self management and health and wellbeing information Surveillance protocol Follow up: ▪ Consultant led ▪ AHP/Nurse Specialist led Recall process Clinically-led review: discharge from surveillance Discharge to GP with information for on-going monitoring
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Conventional Model
- Traditional model – medically led
Current Model
- Incorporates Professional led and Open Access Follow-Up (OAFU) pathways
- OAFU introduced in 2014
Proposed Model
- Incorporates professional led and supported-self management (SSM)
pathways
- Working towards embedding HNAs and Treatment Summaries to address
unmet needs
- Exploring new delivery models for SSM information and patient facing
support worker roles
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Implementation
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- Focussed clinical and operational support dedicated to the project
- Senior management sponsorship across all organisations
- Core components agreed at Alliance level with ability to flex the model
depending on individual site requirements
- Exploring new ways of working: supported-self management workshop
- Development of Trust standard operating procedures and processes
- Examining barriers in completing Treatment Summaries, needs
assessments and care plans
- Standardising patient and GP documentations
- Standardising bone health management guidelines
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