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