Delivering better care for older people with cancer

The intervention is a clinical model of care, which is supported by specific strategies to support its uptake into practice (these are called implementation strategies). We will use a implementation framework which helps to understand how to put research evidence into practice (in this case a model of care for older people with cancer into cancer services). Each cluster will include three cancer services. The cluster will start the trial at two time points spaced 3 months apart. The model of care will be implemented over a 18 month period. This will include a two-month initial training period. IMPLEMENTATION COMPONENT OF THE INTERVENTION Implementation of the Geriatric Oncology Model of Care will be guided by the integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework with two key elements being used to support uptake into real world practice, namely facilitation, and audit and feedback of performance against the clinical pathway. i) A Geriatric Oncology skilled facilitator in each cancer service (funded by the Medical Research Future Fund grant) will advocate for change, motivate others, and facilitate the adoption of the geriatric oncology model of care. The skilled facilitator will assist the multidisciplinary team to identify barriers and enablers, develop clinical pathways tailored to local context, improve knowledge using evidence-based approaches (e.g., teaching on-the-run (training based on actual clinical situations health professionals are tackling in near real time) or educational outreach methods (which uses an approach of defining a few key learning messages), support multidisciplinary team discussions, support older people with cancer to engage with the assessments and clinical care pathways, and support response to the iterative data on outcomes provided through audit and feedback (3 monthly). The facilitator will have solid understanding of geriatric assessment. They may require specific training to carry out their responsibilities (e.g., data entry or conducting the practical geriatric assessment). Any required training will be identified, and appropriate instructions will be provided. ii) Audit and feedback against clinical care pathway. Audit and feedback is a mechanism where data is collected from a range of approaches to capture how the model of care is tracking and this data is fed back to the involved clinical team who are delivering the care to reflect on and refine the model over time, hence supporting more successful adoption of the model. The audit data in this study will be a summary of clinical performance of geriatric oncology model of care every 3 months. It will include information on timeliness, adherence to steps in the pathway of care, results of the objectively measured professional practice and health care outcomes, and patient reported outcomes (PROMs) and experience (PREMs). CLINICAL COMPONENT OF THE INTERVENTION - The geriatric model of care The clinical model of care involves screening using the Geriatric 8 (G8) tool (which comprises of eight questions across various domains including age, nutrition, mobility, and self-rated health), conducted prior to or within two weeks of initial clinic assessment. Completion will be tailored to local context (e.g., by the skilled facilitator face-to-face or over the phone). When the G8 screen flags the need for further assessment the Practical Geriatric Assessment will be administered. Some components will be completed by patients or carers, and other components will be completed by the clinician or skilled facilitator. Clinicians from the multidisciplinary team will then determine the steps for further assessment and management according the recommendations of the Optimal Care Pathway for Older People with Cancer (Cancer Australia) prior to the cancer treatment decision being finalised. This clinical care pathway (CCP) will provide a point of care approach and include steps for further multidimensional geriatric assessment; exploration of the older persons preferences and values, and involvement of them in decision-making (including clinical trial participation); interdisciplinary referrals, support and management; and suggested longitudinal monitoring (geriatric issues, side effects of cancer treatment, unmet needs) with adaptation of care plan to meet emerging or ongoing needs. This model of care will be supported by provision of the OlderCan resources to the older person with cancer which are designed support older people with cancer to discuss their needs and what they value. This model of care will be implemented for an 18 month period, with newly eligible patients entering during the intervention phase receiving the model of care as part of standard practice. A medical record audit will be conducted to monitor adherence to the model of care. The qualitative sub-study is an evaluation component. The sub-study consists of semi-structured interviews with older people with cancer, carers, clinicians to explore experiences, acceptability and perceptions of the geriatric oncology model of care. Participant numbers are not predetermined and recruitment will continue until data saturation is achieved. Interviews will be conducted during the intervention period, with no fixed timepoints, following participants' exposure to or involvement with the geriatric screening/assessment model of care components. Timing of interviews will be determined pragmatically to ensure participants are able to reflect on their experiences..