The document describes the development of a Cancer Care Referral Pathway (CCRP) in a rural community. It was developed to address issues like fragmented care, poor coordination after a local oncology service closed. The CCRP aims to promote the Cancer Care Coordinator as the first point of contact and integrate care. It was developed through stakeholder consultations and implemented using electronic and paper referral templates. After implementing the CCRP, referrals increased from 43 to 148 from more sources, and outcomes include more timely care and patients feeling more supported. The CCRP has been embedded and its components could transfer to other rural communities.

2. CANCER CARE REFERRAL PATHWAY
A Rural Model
:

3. Team Members
• Sandra Turley Cancer Care Coordinator (CCC)
Project Lead
•Melissa Cumming Director Cancer & Palliative
Care
•Previous Members:
• Jennifer Carter Psycho-Oncology Counsellor
•Ruby Hooke Psycho-Oncology Counsellor

4. Background
•2008 Loss of visiting Medical Oncology Service
to Broken Hill
•Patients referred directly from GP to metro
centres
•Local cancer services not accessed
•Decreased referrals to CCC
•Poor coordination of care

5. Background ctd
•Fragmented care
•Increased presentations to ED
•Increased patient & carer stress
•Poor communication between service providers
•Patients lost in the system

6. What now?
• Improve integration of care
• Promote role CCC – first point of contact
• Improve communication between providers
• Maintain profile of Cancer Services in BH
• Identify barriers to referral
• Develop and implement Cancer Care Referral
Pathway (CCRP)

7. Method
•Multi step approach undertaken over a 4 year
period
•Step 1 (2009) – successful recipients Innovation
Scholarship NAMO
•Scoping study – service mapping, consultations
with stakeholders, focus groups, consumer
interviews, health advisory board members,
community support groups

8. Findings from Scoping Study
9 findings in total – most significant being:
•Loss of Specialist Oncology Services had a
profound impact upon cancer care
•Lack of awareness of the role of the CCC
•Lack of knowledge of how to access CCC
•High turnover of medical staff and GPs in BH
•People affected by cancer were not aware of
supports available

9. Next Step
• (2011)- Applied for funding to develop and
implement recommendations outlined in
scoping study - application declined
•(2012)– Successful Innovation Grant CINSW
Develop Cancer Care Referral Pathway

10. Developing the Cancer Care Referral Pathway
•Collaboration/consultation with GPs and
Practice Nurses designing both an
electronic/paper version
•Liaison with GP IT providers embedding trial
templates & accompanying referral criteria into
practices including Maari Ma (Aboriginal Health
Service) and Royal Flying Doctor Service (RFDS)

11. Development Ctd
•Development promotional material
•Designed & implemented TV commercial
•Feedback letter template
•Acknowledgement of referral
•Public Launch & implementation of pathway

12. The Pathway Look
•Simple & easy to use
•Located in one electronic folder
•Utilized existing referral letter templates
•Uploaded section B IPTAAS form
•Local pathology & radiology request forms
•External provider request forms

13. Referral Criteria (hard copy)
Criteria Rationale
New Cancer Diagnosis
or
Unclear diagnosis and
treatment plan
• Ensure patient and carers aware of service to
access education and support when needed
• Provide point of contact
• Provide continuity of care
• To access need for ongoing support
• Facilitate links with treating specialist via face to
face consultation of via telemedicine
Travel outside of FWLHD
to access treatment and
specialist intervention
• Provide coordination of appointments and tests
• Facilitate communication between clinicians,
patients and carers
• Provide continuity of care, referral to Metro CCC
• Assist with travel and accommodation

14. Referral Criteria (hard copy) ctd
Criteria Rationale
Unpredicted change in
condition or treatment
plan
• Facilitate new treatment plan with MDT
• Educate patient and carer
• Facilitate communication between clinicians
Admission to ED or
Hospital
• Provide support and continuity of care
• Facilitate communication between clinicians,
patient and carers
• Assess need for community services
Poorly controlled /
multiple comorbidities
• Ensure knowledge of services and
responsibilities of care
• Facilitate communication between clinicians,
patient and carers

15. Promotional Material

16. Play video

17. Remembering the Aim of the Pathway
•Promote CCC as first point of contact after
cancer diagnosis
•Promote role across all sectors ensuring
integrated care coordination
•Raise community awareness of role
•Ongoing engagement with community and
health providers

18. Referrals prior to Pathway
Source Number
Patient/ family referrals 13
Public Hospital 13
GP referrals 6
Oncology referrals 2
Surgeon referrals 3
Community services 1
IPTAAS 5
7 sources of referrals
Total number of
referrals 43

19. Results post introduction of Pathway
Source Number
GP 15
Maari Ma 6
Plastic Surgeon 7
Gastro Surgeon 5
RFDS 3
Gynaecologist 3
Haematologist 2
Self-referral/ Family 40
Oncology 10
Wards 27
RAH 10
Pre-admission 9
IPTAAS 3
Source Number
Leukaemia
1
Foundation
Flinders Medical 2
Emergency 2
Theatre 1
Outreach 1
Breast Screen 1
19 sources of referral
Total number of Referrals
148

20. Outcomes
•Patients not ‘falling through gaps’ - being
referred at diagnosis / more timely manner
•Care is integrated and coordinated between care
providers (local and tertiary)
•CCC can ensure right care is provided in right
place at right time
•Patients/carers feel supported in navigating
cancer treatment system

21. Testimonial
•“…the cancer care coordinator …has given me a
lot more confidence about the process, my
feeling of being back in control of my body,
explaining the recent scan results in terms I can
understand and helped me to overcome
problems with pain, medication and side
effects”
(Heather-patient)

22. Sustainability
•Embedded referral pathway
•Ongoing collaboration/ education
•Backfill for CCC
•Advertising / printed resources continue
•Ownership of coordinated care (eg Maari Ma)
•Formal evaluation of CCRPP with UDRH
•New collaborative partnerships between sectors

23. Transferability
•Cancer Care Referral Pathway is transferable
across small ‘like’ rural / remote communities
• Promotion of the role within the community is
paramount to success
•Components of CCRPP (eg advertising /
electronic referral pathways) transferable to
larger settings

24. Contact Details
sandra.turley@health.nsw.gov.au
•Mobile: 0427064367
•Landline: 08 80801197
melissa.cumming@health.nsw.gov.au
•Mobile: 0429984457
•Landline: 08 80801452