Abstract

Purpose: Every person who experiences cancer requires continuous support as they transition between the different stages of their cancer journey.  Currently in Alberta, there are over 130,000 cancer survivors in the post-treatment phase of follow-up, surveillance and monitoring, and/or receiving adjuvant treatment.  It is expected this number will double in the next 10 years. These patients are at increased risk for reoccurrence, developing a second unrelated cancer, and other late and long-term effects of their diagnosis and treatment. CancerControl Alberta has a key leadership role in collaborating with all key stakeholders to determine a sustainable way forward to meet these needs, now and in the future.

Materials & Method: Transitional support is identified as essential to providing quality health care (AHS Patient First Strategy, 2015) and is defined as the coordination and continuity of health care as patients transfer between internal and external providers, and across sites/systems over time. Development of a “Transition of Care Model” to improve transitions for well patients post-treatment is underway through the Provincial Integrated Cancer Survivorship Project-PICSP (2014-2016). While currently underway, several key elements required to improve transitional care have emerged including:  general and tailored self management and decision support resources, and optimized processes for care coordination between CCA and Primary Care. 

Results: This presentation will outline progress to date and lessons learned, concentrating on three aspects of the transitions of care model: provincial follow up guidelines, patient education and self-management resources, and decision-support and care coordination improvements for healthcare providers.

Conclusion: To live well beyond the diagnosis and treatment of cancer, patients require an effective transition to ensure continuous care, self-empowerment and management of their symptoms, and clear steps for re-entry into the cancer system if needed.