Evaluating the impact of a novel, shared model of care on the quality of long term cancer follow-up

The intervention is a novel, shared model of care between cancer services and primary health care using an interactive e-care plan called Inca and telehealth using telemedicine technology. It is being implemented at 2 public and 2 private cancer services in the South Eastern Sydney Local Health District. The e-care plan program is integrated with GP clinical information systems and includes care plan templates for colorectal and breast cancer follow-up care developed from the published literature and agreed guidelines for survivorship care plans. The e-care plan program provides a collaborative space for clinicians and patients to agree on the goals, tasks, responsibilities and the scheduling and monitoring of care. Other functionalities include the sharing of pathology results, measures (e.g. BMI, blood pressure), a health summary and a progress notes section for the specialist, GP or patient to add a note. Documents can be uploaded and downloaded. It provides the basis for non-urgent communication between specialists, GPs, patients and other care team members (e.g. allied health providers) who can be added to the care team and given access. Inca automatically emails notifications to the care team when changes are made to the e-care plan or when upcoming tasks and appointments are due. Patients will be emailed reminders for appointments or tasks that are upcoming from Inca. The e-care plan is not integrated with cancer service clinical systems. Cancer services and patients access the e-care plan through an online portal. This is a non-randomised quasi-experimental trial. Patients at the St George Cancer Centre and the Prince of Wales Private will be allocated to the intervention. Patients at the Prince of Wales Nelune Comprehensive Cancer Centre and the St George Private Hospital will be allocated to the comparison group that will receive a delayed intervention after 12 months. Brief training to access and use the e-care plan will be provided at baseline by a researcher to specialists, care coordinators and GPs in the intervention group. This will be face to face and take around 15 mins for GPs and 30 mins for specialists and care coordinators. Precedence Healthcare, the e-care plan software provider, will email patients information on how to access and use the e-care plan. Access to user manuals, videos and technical support will also be available to all participants on the Precedence Healthcare website. The intervention process: 1. Patient and GP enrolment 2. E-care plan connector installed remotely at general practices within two weeks of enrolment 3. Brief face to face training (15 mins) provided to the GP by the researcher at the time the software is installed or soon after 4. GP initiates e-care plan and gives e-care plan access to the specialist and care coordinator (at the time of training or first patient visit) 5. Brief face to face training (30 mins) provided to the specialist and care coordinator at the time of tailoring the care plan for the patient. Other care team members can be added (e.g. surgeon, radiation oncologist) 6. Patient visits GP, care plan agreed and shared care begins. Each task completed at an appointment is checked as completed within the e-care plan to assist with monitoring care 7. Patient receives an email with information on how to access and use the e-care plan as soon as the e-care plan is agreed 8. Care coordinator monitors the e-care plan routinely every one to two weeks to check that patients have attended appointments and tasks have been completed. The care coordinator follows-up with the clinician or patient as needed. (There is no mandatory requirement for the GP or specialist to check the care plan regularly). 9. Schedule of patient visits to GP and specialist continues as planned. The care plan can be reviewed and edited by the GP and specialist with the patient based on their needs, such as tailoring lifestyle goals, adding patient activities (e.g. make time each day to do something relaxing or enjoyable, join an exercise program) and changing the schedule of appointments between the specialist and GP. Other care team members or carers can also be added. 10. Web conference/phone calls and telemedicine available to support timely access to cancer centre when needed by the specialist, GP or patient