Models of Care Toolkit

Diagnostic pathways and rapid referral services

clipart of person with a click in the backgroundRapid referral pathways streamline the pre-diagnosis process and improve the speed with which patients get accurate diagnoses. This can improve patient outcomes by finding cancers earlier. Reducing repeated scans also helps to mitigate the emotional turmoil patients face before a definitive diagnosis.6,15-17

Primary care teams play a critical role in diagnosis but may lack necessary knowledge or information to ensure patients have timely access to care14. Resource availability, lack of awareness of diagnostic tests and when to refer patients can be compounding factors in accessing the right diagnostic services at the right time.

Education and supports are important components in the early diagnosis phase. This includes tailored strategies co-created with primary care providers to facilitate uptake of new guidelines and educational programs.

Although connected care models are shown to streamline the diagnosis process, the lack of patient access to primary care and the resulting reliance on walk-in clinics and emergency departments impact continuity of care and timely diagnosis.

Digital navigation tools can provide practical solutions

clipart of handholding a cellphonePatient navigators are often a limited resource. Digital navigation tools can accelerate the diagnosis process and help with symptom management by providing educational material, answering frequently asked questions and connecting patients and their caregivers to additional resources in the community.

Connected care approach

A connected care approach can support and enhance the organization of patient care through patient access to information and navigation, effective communication and cooperation across healthcare providers, as well as timely delivery of services19.

Key enablers to implementing innovative models of care in the early diagnosis phase include:

  • Engagement of both cancer and primary care teams
  • Leadership buy-in
  • Creation of multidisciplinary teams
  • Involvement of patients in planning and decision making
  • A robust evaluation and sustainability plan.

The principles of equity-by-design, including goal clarity, a focus on equity-mindedness and continual learning, serve as core tenets of any major model implementation, especially those involving multiple care providers.20

Defining characteristics of a diagnostic pathway map

A – Provides a tailored snapshot of a patient’s unique care pathway.

B – Organizes information by cancer type and phase along the cancer journey

C – Designed as a tool for use by healthcare providers, administrators and people new to the cancer system.

D – Evidence-based from local, national and international clinical practice guidelines.

E – Responsive to new and rapidly evolving treatment or technology evidence.

clipart of a winding road

Evaluating interventions

Planning for performance measurement and evaluation early in the implementation phase supports continuous quality improvement, monitoring and learning about what’s working and why (or why not).

Involve key stakeholders and community partners in evaluation planning and consider applying the CART Principles to ensure the approach is credible, actionable, responsible and transportable:

Image source: Goldilocks M&E project

If an intervention is designed to address the needs of First Nations, Inuit and Métis and/or underserved communities, the project team must work with members of these communities to determine appropriate measures to describe progress and learning about advancing equity in cancer care.

Equity-based outcome indicators are critical to measuring the impact and effectiveness of such initiatives. Learn more about equity-focused evaluation and performance measurement.

Denmark’s three-legged referral strategy provides a roadmap for primary care teams that is based on a patient’s symptoms. Recognizing each patient will present differently along the disease trajectory, the referral strategy provides a clear pathway for alarm symptoms, serious but not cancer-specific symptoms and vague and non-serious symptoms.

Patients with specific alarm symptoms represent approximately half of cases and have access to an urgent referral with a 2-week wait time for a specialist based on symptom criteria listed in pathway.

Patients with serious but unspecific symptoms represent approximately 20% of cases and have access to an urgent pathway. A family physician orders a standard battery of tests then either refers the patient to the specific urgent referral pathway or decides on further diagnostic testing.

Patients with vague and non-serious symptoms represent approximately 30% of patients. No-Yes-Clinics provide family physicians access to more detailed diagnostic investigations without referring the patient to a specialist.

Denmark model pathway

 

The three-legged referral model supports:

  • Reduced wait times
  • Enhanced collaboration between primary health care and cancer care
  • A shift to earlier stages at diagnosis in some cancers and an increase in one-year survival rates
  • Enhanced satisfaction with quality of care and wait times among patients and staff

 

The Accelerated Diagnostic Assessment Program (ADAP) at Kingston Health Sciences Centre in Ontario reduces wait-times for patients needing diagnostic workup after imaging results where cancer is suspected.

The ADAP coordinates care from referral to diagnosis and treatment. Typical ADAP patients are referred by emergency departments or primary care providers and do not meet the criteria for existing referral pathways that include potential breast, prostate, gynecologic and lung cancers.

By providing a clear pathway for primary care providers and emergency departments to refer patients with suspected cancers, the ADAP significantly shortens time for patients from referral to tissue biopsy compared to a control group and provides patients with timely access to treatment that surpasses provincial and national guidelines.

Dial-a-specialist provides virtual solutions for connected care

Primary care-led diagnostic processes and post-cancer treatment surveillance/wellness programs support person-centred care in a timely way. However, studies show that primary care providers often feel that they do not have sufficient time and expertise to provide cancer support for their patients.21

While not cancer specific, this virtual tool is a good place to start.

The Ontario eConsult program leverages a secure web-based tool allowing physicians and nurse practitioners timely access to specialist advice often eliminating the need for a referral. Primary care physicians can link to cancer specialists and receive a response within an average of two days.

Tips for delivering culturally appropriate care for First Nations, Inuit and Métis peoples

The Partnership is committed to reconciliation. Through our work and partnerships, we continue to support self-determined, Peoples-specific priorities for sustainable change across the cancer system that benefits all First Nations, Inuit and Métis peoples.

We work with partners to design and implement First Nations, Inuit and Métis-led models and identify ways to incorporate innovative models into Indigenous-led cancer care. Consider these tips for delivering culturally appropriate care:23

  • Co-develop care pathways and models of care with First Nations, Inuit and Métis partners and community health services.
  • Provide appropriate and accessible translation, interpretation and support services.
  • Recruit and retain First Nations, Inuit and Métis healthcare providers and navigators, and strengthen access to culturally appropriate care. Ensure all staff have the knowledge and skills to provide culturally appropriate care to First Nations, Inuit and Métis peoples.
  • Ensure culturally appropriate supports are available for First Nations, Inuit and Métis patients and families, including children. The Supportive Care Needs Assessment Tool for Indigenous People can help identify services.
  • Ensure appropriate supports are in place for those who must travel to complete diagnostic interventions.
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  7. Cancer Quality Council of Ontario. Programmatic Review on the Diagnostic Phase: Environmental Scan.; 2016.
  8. Gorin SS, Haggstrom D, Han PKJ, Fairfield KM, Krebs P, Clauser SB. Cancer care coordination: A systematic review and meta-analysis of over 30 years of empirical studies. Ann Behav Med. 2017;51(4):532-546.
  9. Mittmann N, Beglaryan H, Liu N, et al. Examination of health system resources and costs associated with transitioning cancer survivors to primary care: A propensity-score–matched cohort study. J Oncol Pract. 2018;14(11):e653-e664.
  10. Zhao Y, Brettle A, Qiu L. The effectiveness of shared care in cancer survivors-A systematic review. Int J Integr Care. 2018;18(4):2.
  11. Angus Reid Institute. (2023). Health Care Access Priorities. Angus Reid Institute. Accessed December 4 2023. Available: https://angusreid.org/cma-health-care-access-priorities-2023/
  12. Kiran, T. (2023). Our Care National Survey. Our Care. Accessed October 13 2023. Available: https://data.ourcare.ca/all-questions.
  13. Watson L, Qi S, Delure A, et al. Virtual cancer care during the COVID-19 pandemic in Alberta: Evidence from a mixed methods evaluation and key learnings. JCO Oncol Pract. 2021;17(9):e1354-e1361.
  14. Canadian Residency Matching Service. 2023 CaRMS Matching Results. Accessed December 12 2023. Available: https://www.cfpc.ca/en/education-professional-development/2023-carms-match-results.
  15. Canadian Institute for Health Information. Commonwealth Fund survey, 2020. Accessed October 13, 2023. Available: https://www.cihi.ca/en/commonwealth-fund-survey-2020.
  16. Jensen, H. Implementation of cancer patient pathways and the association with more timely diagnosis and earlier detection of cancer among incident cancer patients in primary care. PhD dissertation. Aarhus University; 2015
  17. Møller H, Gildea C, Meechan D, Rubin G, Round T, Vedsted P. Use of the English urgent referral pathway for suspected cancer and mortality in patients with cancer: cohort study. BMJ. 2015;351:h5102
  18. Prades J, Espinàs JA, Font R, Argimon JM, Borràs JM. Implementing a Cancer Fast-track Programme between primary and specialised care in Catalonia (Spain): a mixed methods study. Br J Cancer. 2011;105(6):753-759.
  19. Canadian Partnership Against Cancer. Leading Practices to Create a Seamless Patient Experience for the Pre-Diagnosis Phase of Care: An Environmental Scan. 2018. Accessed November 22, 2021. https://canimpact.utoronto.ca/wp-content/uploads/2018/04/Leading-Practices-to-Create-a-Seamless-Patient-Experience-for-the-Pre-Diagnosis-Phase-of-Care-CPAC-2018.pdf
  20. Walsh J, Young JM, Harrison JD, et al. What is important in cancer care coordination? A qualitative investigation: What is important in care coordination? Eur J Cancer Care (Engl). 2011;20(2):220-227.
  21. Wong WF, LaVeist TA, Sharfstein JM. Achieving health equity by design. JAMA. 2015;313(14):1417-1418.
  22. Lewis RA, Neal RD, Hendry M, et al. Patients’ and healthcare professionals’ views of cancer follow-up: systematic review. Br J Gen Pract. 2009;59(564):e248-59.
  23. Cancer Council Victoria. Optimal Care Pathway for Aboriginal and Torres Strait Islander People with Cancer Draft for National Public Consultation.; 2017. Accessed November 22, 2021. https://apo.org.au/sites/default/files/resource-files/2017-09/apo-nid108366.pdf
  24. Jefford M, Koczwara B, Emery J, Thornton-Benko E, Vardy JL. The important role of general practice in the care of cancer survivors. Aust J Gen Pract. 2020;49(5):288-292.
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