A nurse-enabled, shared-care model between primary and acute care for prostate cancer survivors (the MOSES-Survivorship study)

This intervention (entitled: MOSES-Survivorship) has been developed through a co-design process with end-users (men with prostate cancer, general practitioners, practice nurses, cancer specialists, and cancer nurses). MOSES-Survivorship strategically uses prostate cancer specialist nurses (PCSN's) - an existing workforce embedded in the health system - to implement a shared, follow-up care model between acute cancer care centres and general practices for people diagnosed with prostate cancer. PCSN's are trained and supported to (1) engage all stakeholders (patients, families, general practitioners, specialists, and allied health) to take an active role in cancer survivorship care in a shared, follow-up care model; (2) ensure timely information exchange and negotiation of shared-responsibilities through multidisciplinary case conferencing (Medical Benefits Schedule MBS - Item 750); and (3) ensure general practitioners and practice nurses have access to a survivorship care plan and a range of evidenced-based tools and resources. The intervention explicitly provides shared-care (interchanging specialist and general practice appointments during follow-up cancer care for men with prostate cancer) and enhanced care (overlaying general practice appointments with specialist appointments during follow-up care), depending on the clinical needs of the men with prostate cancer who are randomised to the intervention. During active surveillance (Group 1), at completion of curative intent treatment for localised prostate cancer defined as end of surgery or radiation therapy, whichever was delivered last (Group 2), or presenting with metastatic prostate cancer (Group 3), patients will be enrolled in the study, and randomised. For the intervention: 1 x 30-60 minute face-to-face or telehealth Prostate Cancer Specialist Nurse consult with the participant 8+/-2 weeks post-enrolment to: 1) provide treatment summary; 2) provide survivorship patient education including a written survivorship booklet on “Living Well After Cancer” published by Cancer Council Australia; 3) co-develop a draft Survivorship Care Plan (SCP) including SMART goals (using motivational interviewing and self-efficacy techniques); and 4) provide a draft post-treatment shared-care follow-up appointment schedule. A draft SCP (including the treatment summary) will be provided to the participant via email or post and their nominated GP via GP clinic preferred communication system. Adherence to the nurse-led clinic and its components will be monitored using a nurse-led clinic checklist. 1 x 20–30-minute video/telephone case-conference between the Prostate Cancer Specialist Nurse and GP (+/- GP practice nurse) within 4 weeks of Specialist Cancer Nurse consult to finalise the SCP and negotiate the GP’s role in facilitating SCP SMART goals as well as seek agreement on the shared-care follow-up appointment schedule. Adherence to the GP case conference and its components will be monitored using a GP case conference checklist. Up to 11 (depending on how far post-enrolment the patient is when they enter the study) alternating 6-monthly face to face or telehealth (as per clinician) patient appointments with cancer specialist or GP for 5 years will occur (for shared-care arrangements) or up to 11 additional 6-monthly face-to-face or telehealth (as per clinician) patient appointments with the GP in addition to the cancer specialist for 5 years will occur (for enhanced-care arrangements). At 5 years the patient will be discharged to the care of the GP. Appointment durations for the cancer specialist or the GP will vary depending on patient needs (approximately 10 to 30 minutes each). More specifically: 5 x GP appointments at <12- (initial), 18-, 30-, 42- and 54- months post-enrolment for review of SCP, general health, screening/management of comorbidities, psychosocial health cancer treatment toxicities, cancer-related symptoms, chronic disease management planning, allied health referrals and physical examinations (if required/agreed). The GP appointments duration will vary depending on participant need. Additional appointments with the GP can be scheduled if clinically indicated. The GP will have direct telephone access to the Prostate Cancer Specialist Nurse in case of concerns or escalation for acute care review. Adherence to the minimum GP appointment schedule will be monitored using MBS data. 6 x cancer specialist appointments at 12-, 18-, 24-, 36-, 48- and 60-months post-enrolment for review, physical examination, and imaging. The cancer specialist appointments duration will vary depending on participant need. Additional appointments with the cancer specialists can be scheduled if clinically indicated. Adherence to the minimum specialist appointment schedule will be monitored by checking medical records and hospital appointment scheduling data.