Transforming Cancer Follow-up

Transcription

1 Transforming Cancer Follow-up Mary Jo Thompson Macmillan TCFU Regional Programme Manager - NICaN Martha Magee Macmillan TCFU Project Manager WHSCT

2 Strategic context Principles for Change Integrated care - working together Promoting independence and personalisation of care Safeguarding the most vulnerable Ensuring sustainability of service provision Realising value for money Maximising the use of technology Incentivising innovation at a local level.

3 Transforming your Care Case for Change

4 Why introduce this change?

5 Background to TCFU programme Launched Nov 2010 Macmillan Cancer Support working in partnership with HSCB/PHA facilitated through NICaN Funding to support local bids Project structure established Prostate - regional approach Informed by people affected by cancer

6 Overview of the problem Issues with the current system Routine hospital follow up is not as effective as it could be Most recurrence is detected outside of follow up Many appointments add little value to either patient or doctor Framed around cancer as acute illness Current system is unsustainable Increase of 3% per annum of cancer survivors (currently 56,000 in NI) Already have major capacity issues Patients report unmet survivorship needs Focus is on detection of recurrence or late effects Other survivorship issues not addressed

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8 TCFU Programme Aims To introduce a new model of cancer follow up which will: Improve the quality of cancer patients after treatment experience Reduce inefficiencies in hospital follow up Enhance service coordination and integration

9 What model is proposed?

10 Prostate remote surveillance, use of IT PSA Tracking 30% minimum target on SDA pathways patients post breast cancer treatment

11 Breast Cancer Survival Age-Standardised relative survival for breast cancer by stage NI Cancer Registry

12 Regional target 30% new patients rising to 50% for Self directed aftercare UK (70-80%) Identifying suitable patients currently in review system Migration by early 2013

13 Breast: Two Work-strands Review mammography Equipping the patient to self manage Holistic assessment Information provision End of treatment summary record & care plan Identified point of access Survivorship services to support health & well being

14 LEAN Methodology: Value Stream Mapping Events (3) Northern Trust Breast Belfast Trust Breast & Prostate Preparation Engaging the team Map current state & identify issues Work through issues Map future state + actions Report & action plan

15 Review mammography workflow 3 Trusts 2 Trusts

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17 Equipping the patient to self manage 2 nd Work Strand Holistic Assessment / managing expectations Information provision End of treatment summary and care plan Point of access Health & Well Being Support Services

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19 Holistic Needs Assessment

20 New patients Minimum target 30% Trust New cases breast cancer / year Annual figure for 30% target Minimum Patients per month Numbers identified to date Northern Trust (Commenced Sept) Southern Trust (Commenced June) SET (Commenced June) Western Trust (Commenced May) Belfast Trust (Commenced Sept) patients patients patients patients patients

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22 Breast Pathway (Two Work Strands) Remote Surveillance/Review Mammography Achievements Within the Western Trust the remote surveillance/review mammography was already established by utilising the SECTRA/NIPACS since OCT 2011 Due to the geographical distance of the Trust there are mobile units who do screening at different locations for the symptomatic yearly review patients System not as labour intensive Centralised database where all the symptomatic patients are stored and new review appointments can be created Challenges Safety mechanisms not as good as the NBSS Workflow and failsafe manual records created to ensure governance

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24 Health and Well-Being Cancer Rehabilitation Rehabilitation is an essential component of the cancer journey and aims to optimise dignity and reduce the extent to which cancer effects the patients physical, psychological and economic functioning In collaboration with the oncology physiotherapist there will be a cancer rehab pilot programme to commence in Oct 12 Survivorship Patient engagement in healthcare via self-management is widely recognised as crucial to improved outcomes for people with long-term chronic conditions (DH, 2010) Collaborative work partnership with the voluntary sector, charities to scope the programmes that are already available for Health and Well-Being and signposting patients to these Working with the long-term conditions self-management co-ordinator (only one in N.I) to develop pilot programme for Self-management (based on stanford model) in Nov 12

25 How you can support this programme Signpost patients Survivorship services available Continue the self directed after conversation

26 8. 7. Carers Support Cancer Follow Up 5. Financial Benefits Health & Well-Being 4.

27 Transforming Cancer Follow-up Programme & Survivorship Aligned with on NHS Improvement Survivorship pathway (NCSI), Portal for patients and professionals Services that can improve psycho-social morbidity Promote healthy living

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29 Domains and sub domains Domains Sub domains 1. Clinical Support Services (a) Psychological (a) Physiotherapy / occupational therapy (a) Continence / stoma care (a) Diet and nutrition (a) Sexuality / body image (a) Lymphoedema 2. Education and Information (a) Self management programmes (a) Information days (a) Information Centres / officers 3. Physical Activity (a) Local authority, community or privately run exercise schemes (a) Trust Led Exercise programmes 4. Other support services (a) Reablement / social care (a) Finance and benefits (a) Vocational Rehabilitation (a) Complementary therapies (a) Voluntary sector / support groups

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31 Contents of website Statutory services Community services Voluntary services Sustainability Links with HSCB / PHA

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33 Search Mechanisms Postcode Health and Social Care Trust Area Name of provider Services that cover all of NI All services

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50 Website - Next steps Ratification from HSCB Testing period for providers of services GO LIVE early October Information Posters / leaflet All TCFU patient information Raise awareness & dissemination

51 Progress phases

52 Challenges and Achievements Reluctance to change Fear of patients being lost from the system Changing one part of system has ramifications to other parts Timescales Resources Public Relations messages People coming on board Patients involved based on their feedback Eagerness for collaborative working Maximising resources statutory, voluntary, community Macmillan supporting robust evaluation

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