Survivorship Connections: A Pilot Model of Post Treatment Shared Survivorship Care for Adolescent and Young Adult Cancer Patients (AYAs) in Victoria.
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The model will focus on a nurse led intervention aimed at increasing young people’s engagement with primary care to facilitate a shared care approach in cancer survivorship. A comprehensive review of the literature, current models of care and survivorship resources will be followed by a particular focus on:
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- Understanding current AYA/GP engagement and the follow-up management of patients by tumour stream across pilot institutions;
- Facilitating the establishment of healthcare relationships between the young person, their GP and the acute healthcare service;
- Developing end of treatment summaries and survivorship care plans (incorporating medical and psychosocial elements of care) which are based on principles of survivorship care planning;
- Improving communication, transfer of clinical information and delineating role responsibility through up-to-date technologies between the young person, treating teams and GPs (i.e. web based, videoconferencing, teleconferencing);
- Developing AYA specific survivorship information which is relevant to the Australian context;
- Development of guidance documents and an AYA survivorship toolkit including information about the role of the patient, the GP and the acute healthcare facility; templates for end of treatment summaries and care plans; recommendations for consistent communication, patient assessments and follow-up and where required rapid re-entry to healthcare facility;
- Evaluation of this model of survivorship care.
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