ASPO Abstracts
Multi-Team Systems for Comprehensive Cancer Survivorship Care
Category: Survivorship & Health Outcomes/Comparative Effectiveness Research
Conference Year: 2019
Abstract Body:
Purpose of the study: Effective approaches to provide comprehensive, high quality care for cancer patients with multiple chronic conditions are needed. This study describes a multi-team system (MTS) encompassing oncology, primary care, and other specialties to care for vulnerable cancer survivors with multiple chronic conditions within an integrated county safety-net health system and factors that facilitate or impede MTS implementation. Methods: Qualitative study using direct observation of clinic practices and in-person interviews with system and clinic leaders, clinicians, and staff. Results: Care for vulnerable cancer survivors living with multiple chronic conditions was fragmented and siloed across provider teams despite an integrated health system with a common electronic health record system. The health system planned to implement a new model of care creating a MTS encompassing oncology (surgical and medical) and primary care (and its allied specialties) led by a nurse care coordinator. External moderators that facilitated emergence and implementation of this MTS included introduction of a new value-based payment system, facilitative and visionary leaders, motivated clinic teams, and collaboration with researchers. This system context was offset by barriers that included busy primary care practices with long wait times for new appointments, confusion between primary care and oncology clinicians over responsibility for cancer surveillance care, and lack of closed-loop communication systems. Conclusions: Even in integrated settings, organizing care for vulnerable cancer survivors with multiple chronic conditions is challenging. A multi-team system care coordination model may optimize the interface between oncology and primary care to facilitate co-management and comprehensive survivorship care.
Keywords: care coordination, multiple chronic conditions, survivorship, colorectal cancer, breast cancer