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A model of cancer survivorship care within a community health setting: The Good Life Cancer Survivorship program


Rebecca Mcintosh

Carrington Health, Box Hill, VIC, AU
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Lahiru Russell1, Rebecca McIntosh2, Carina Martin2, Janine Scott2, Wee Kheng Soo2,3,4, Bernadette Zappa3, Kerry Haynes1, Patricia M Livingston1 and Anna Ugalde1

1 Deakin University Geelong Victoria, Australia, School of Nursing and Midwifery, Faculty of Health

2 Carrington Health Box Hill Victoria, Australia

3 Eastern Health Box Hill Victoria, Australia

4 Eastern Health Clinical School, Monash University, Box Hill Victoria, Australia

Introduction:  Many people living with cancer do not receive adequate supportive care in oncology settings. Effective care coordination between oncology settings and community health could support survivors transition to allied health services and empower them to self-manage their health and wellbeing.

Description of practice change implemented: This study reports on the evaluation of a referral pathway from a hospital-based oncology service to a multidisciplinary community-based health service, Carrington Health.

Aim: The study aimed to understand patterns of service utilisation at Carrington Health, and health professionals’ perspectives on the implementation of a community-based model of survivorship care, the Good Life Cancer Survivorship (GLCS) program.

Targeted population: Survivors referred to GLCS were undergoing or had completed cancer treatment, and unable to participate in intensive ambulatory oncology rehabilitation.

Timeline: Carrington Health services utilisation was tracked over five months, and perspectives of health professionals referring to, and involved in the GLCS program were recorded using semi-structured interviews.

Highlights: The oncology service made 25 referrals. The most accessed services were physiotherapy with 18 appointments, followed by psychology (12) and dietitian services (11). Four themes emerged from the interviews: 1) Allied health services are relevant to people with cancer; 2) Education and information needs; 3) Communication gaps; 4) A one-stop multidisciplinary and holistic care model.

Sustainability: GLCS is a multidisciplinary cancer survivorship model integrated into an existing community-based chronic disease management program.

Transferability: Core components of GLCS could be implemented across other community health services to improve access to allied health services for all cancer survivors.

Conclusions: GLCS provides a model to support integrated allied healthcare services to help survivors transition from acute treatment to community-based care. Supporting ongoing awareness, education and understanding of services across both community and acute care settings will foster care coordination and strengthen referral pathways.

Discussions: Health professionals found the referral process acceptable and the program useful. A central point of contact for coordinating referrals and communicating information between acute and community health settings would help address communication gaps, reduce burden on clinicians and strengthen the model of care. Addressing specific communication and information needs of community allied health professionals will increase their confidence in discussing cancer specific needs with survivors. Discussing self-management and healthy lifestyle behaviour with survivors in the acute oncology setting will promote active discharge planning and aid transition of care.

Lessons learned: Accessing appropriate community-based allied health services will support survivors to develop self-management skills to manage their own health and improve their health outcomes and wellbeing in the survivorship phase.

Acknowledgments: The project was supported by the Victorian Government.

How to Cite: Mcintosh R. A model of cancer survivorship care within a community health setting: The Good Life Cancer Survivorship program. International Journal of Integrated Care. 2021;20(S1):130. DOI:
Published on 26 Feb 2021.


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