Alberta Health

Services Cancer Centres

Living Well Beyond Cancer Improving Care Transitions, Post Cancer Treatment in Alberta

Transitions of Care Project Team, Amanda Jacques, mRT(T), MA, Jennifer Looyis, MPH1, Shelley Currie, MSW, RSW1, Linda Watson, RN, PhD, CON(C)1, Dellice Saxby, MSc, Mike Lang, MSc,

1Person-Centred Care Integration, Provincial Practices, Alberta Health Services – CancerControl

“We can’t do this alone. As more of our patients live longer with and after cancer, we need to find better ways to share what we know and what we are

learning with Primary Care, other health care providers, and with

patients and families.” - Oncologist

• There are currently over 130,000 cancer survivors receiving adjuvant treatment or who have moved into the post-treatment phase of follow-up, surveillance and monitoring. This number is expected to double in 10 years. • These patients have unique needs as they are at increased risk of re-occurrence, as well as increased risk for developing a second unrelated cancer. • Patients want trusted sources of information about their cancer, treatments and health concerns, quick access to help when they need it, and support to live as well as possible. • Supporting improved transitions between cancer specialists and primary care is central to ensuring cancer patients receive optimal follow-up care, self-management, and care coordination support. • Tumor Teams identified populations of patients who could be transitioned early, created provincial follow up guidelines for those populations, so that “End of Treatment” letters and patient resources could be created. • The objective of this work is to develop increased awareness of, and support effective uptake of targeted transition supports for well cancer patients after their cancer treatments are complete

We would like to acknowledge the involvement of GURU, C-MORE, Provincial Patient Education, Quality and Safety, ACPLF, and the Provincial Tumor Council and Teams in this work!

“I had completed treatment, returned to work, have felt completely lost, sad, out of sorts. Today was perfect in helping to deal with that. Awesome day! The topics and

types of presentations worked well.” - LYBL Participant / Cancer Survivor

“Our Primary Care Network wants to provide great care for our cancer patients. We need to know who is responsible for

what, what signs and symptoms to watch for, and how to manage concerns when

they arise. Help us understand what to do and we’ll do it.”

- Family Physician

Piloted in a Regional and Community

cancer centre

Building Capacities pilot run in diverse

Primary Care Networks

Biannual provincially

telehealthed patient

outreach event.

Patient Approaching End of Treatment

Patient participates in

“Living Your Best Life” event

Patient attends a “Transition Class” which prepares

patients for life after treatment

At last treatment visit, patient receives an “End of Treatment” letter, tumour

type specific Self–Management Resource, and a community based “Sources of Help” guide

Primary Care Physician receives “End of

Treatment” summary letter

“This is really a really practical and common sense approach. I think we

can do this in our clinics.” - Cancer Clinic Manager

“This class makes me feel more able to cope with the challenges of my

cancer experience.” - Cancer Patient

Full responsibility for follow up care is transitioned to Primary Care as per “End of Treatment”

letter

Established process for those patients who require re-entry

into the cancer system.

“Everyone at the cancer centre was so helpful when I was there for my treatments. When treatment was finished, I was relieved and excited to get back to ‘normal’, but scared and not sure what ‘normal’ was or how to

get there.” - Cancer Patient