Integrating Cancer and Primary Health Care

Integrated Care is one of those jargonistic terms that has arisen in attempt to
address issues with fragmented care. It is an underpinning concept of the 2011
National Health Reform Agreement and the 2013 National Primary Healthcare
Strategic Framework But just like patient-centred care, self-
management, holistic care, and a host of other similar terms, definitions and
applications of the concept can vary greatly. Simply put, integrated care is about
efficient delivery of patient-centred care.

Integrated care can occur across different levels or sectors of healthcare delivery,
such as between primary and acute care; referred to as vertical integration.
Horizontal integration could be something like a multidisciplinary approach, or
combining medical and surgical specialities. Other terms with similar meanings
are continuity of care and seamless care.

While the specific definitions of integrated care as used in the medical literature
vary, there seem to be a few common features:

  • Person-centred
    • The individual needs and preferences of the patient determine the
      shared agenda/vision/ goals of care for the healthcare team to achieve
  • Evidence based
    • Sits within conventional medicine
  • Coordinated, planned and proactive utilising a team approach
    • Achieving best outcomes requires a team structure to be defined
      • Defined team members
      • Designated leader/ coordinator
      • Shared agenda
      • Clear roles and responsibilities
      • Information sharing
    • Requires systems and structures to support collaboration

Most of the exploration of integrated care in the setting of cancer relates to
providing seamless cancer care. Examples include coordination of specialties for
prostate cancer, multidisciplinary clinics to provide holistic care, and early
involvement of palliative care. There appears to be very little literature exploring
integration of cancer care with primary health or other medical specialties to
consider broader health outcomes and chronic conditions. Chronic conditions
may not be viewed as an immediate priority for a person with cancer but are an
important aspect of optimising quality of life in the short and long
terms. Achieving best outcomes for patients who have a chronic condition in
addition to a cancer diagnosis relies upon patients effectively navigating our siloed
healthcare system.
One of the central assumptions of health policy and strategies to integrate care of
chronic conditions is that the primary health care provider is the gatekeeper for
connecting patients to appropriate health services. The success of strategies to
improve integration of cancer care with primary health care services therefore rely
on this assumption being true, otherwise significant gaps in service will exist.

Is the nature of fragmented care the same in the context of cancer as
for other chronic conditions?

I suspect there are elements of healthcare delivery that are unique to people with
cancer beyond those associated with their acute cancer treatment, such as
utilisation of primary healthcare services. These differences must be identified
and used to inform interventions and models of care that specifically address them
to avoid disparity and gaps in service. One avenue for exploring this could be to
establish a multi-perspective picture of core elements of team-based care.

  • How is the healthcare team defined?
    • Where do patient-selected alternative care providers fit in an evidence based, patient centred paradigm?
  • Who is best positioned to lead/ coordinate services?
    • How does cancer impact utilisation of PHC services?
      • does this change along the illness trajectory?
      • is it impacted by presence of pre-existing chronic conditions?
    • What is the capacity of cancer care coordinators to manage overall care?
    • What is the capacity of the patient/family to manage overall care?
  • Are goals of care clearly defined and consistently applied?
  • Are there clear expectations of team members?
    • Does the patient know who to get what from?
    • Are the values/ attitudes/beliefs toward support for self management consistent?
    • Are there formal agreements or informal MOUs between care providers?
  • Is information actively shared?
    • Therapeutic relationships
    • Interprofessional communication
    • Patient data
    • Medical records
    • Administration information
    • IT systems
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