Download Patient Pathway Mapping Project

Border/East Hume Cancer Network
Patient Pathway Mapping Project
Colorectal and Upper Gastrointestinal tumour
streams:
colon, rectal and pancreatic cancers
July 2013
Colorectal & Upper GI PPM Report
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TABLE OF CONTENTS
1.
EXECUTIVE SUMMARY ............................................................................................................................... 6
2.
AIM AND OBJECTIVES ..............................................................................................................................10
3.
PROJECT SCOPE ........................................................................................................................................11
3.1 Border/East Hume Cancer Network .......................................................................................................11
3.2 Patient Pathways Mapping Project ........................................................................................................12
4.
METHODOLOGY .......................................................................................................................................14
4.1 Operationalising the Patient Management Framework.............................................................................14
4.2 Participation of health professionals ..........................................................................................................17
4.3 Participation of consumers .........................................................................................................................17
4.3.1 Ethics approval ....................................................................................................................................17
4.4 Retrospective review of medical records ...................................................................................................17
4.5 Patient flow data analysis ...........................................................................................................................18
4.6 Assessment of scope of clinical practice ....................................................................................................18
4.7 Presentation of results ...............................................................................................................................19
5.
RESULTS ....................................................................................................................................................20
5.1 Data collected .............................................................................................................................................21
5.1.1 Participation of health professionals...................................................................................................21
5.1.2 Participation of consumers..................................................................................................................21
5.1.3 Retrospective review of medical records ............................................................................................21
5.2 Patient flow data analysis ...........................................................................................................................21
5.3 Supportive care...........................................................................................................................................25
5.4 Multidisciplinary care .................................................................................................................................26
5.4.1 Profile of Border/East Hume MDTMs..................................................................................................26
5.4.2 Number of patients presented at the MDTMs ....................................................................................27
5.4.3 Membership of the MDTM ..................................................................................................................28
5.5 Assessment of scope of clinical practice ....................................................................................................29
5.6 Generic successes and gaps in the care pathway across all tumour streams ............................................36
5.7 Successes and gaps in the pathway for gastrointestinal cancer ................................................................45
6.
RECOMMENDATIONS ..............................................................................................................................48
6.1 Multidisciplinary Care .................................................................................................................................48
6.2 Care coordination .......................................................................................................................................49
6.3 Supportive care...........................................................................................................................................50
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6.4 Reducing Unwanted Variations in Care ......................................................................................................51
7.
DISCUSSION ..............................................................................................................................................52
8.
ACKNOWLEDGMENTS ..............................................................................................................................53
9.
REFERENCES .............................................................................................................................................54
10. APPENDICES .............................................................................................................................................55
Appendix 1: Patient Management Frameworks toolkit ...................................................................................55
Appendix 2: Supplementary Health Professional Interview Questions............................................................62
Appendix 3: Consumer Participant Questionnaire ...........................................................................................64
Appendix 4: Background to the Patient Pathways Mapping Project................................................................88
A4.1 Frameworks to guide cancer reform in Victoria ......................................................................................88
A4.1.1 Cancer Services Framework for Victoria ...........................................................................................88
A4.1.2 Victorian Cancer Action Plan 2008-2011...........................................................................................88
A4.2 The Victorian Integrated Cancer Services ................................................................................................90
A4.3 Establishment of tumour streams ............................................................................................................91
A4.4 Patient Management Frameworks...........................................................................................................91
A4.5 The four priority service improvement areas for statewide reform ........................................................93
A4.5.1 Multidisciplinary care ........................................................................................................................93
A4.5.2 Care coordination..............................................................................................................................95
A4.5.3 Supportive care .................................................................................................................................95
A4.5.4 Reducing variations in care ...............................................................................................................96
Appendix 5: Profile of the Hume Region ..........................................................................................................98
A5.1 Geographic coverage................................................................................................................................98
A5.1.1 Overview of the Hume cancer networks...........................................................................................98
A5.1.2 Sub regions within the Hume cancer networks ..............................................................................100
A5.2 Population .............................................................................................................................................100
A5.3 Cancer Profile .........................................................................................................................................103
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LIST OF TABLES
Table 1: Tumour types identified as priority areas for the Border/East Hume Cancer Network.................... 13
Table 2: Tumour types identified as priority areas for the West Hume Cancer Network............................... 13
Table 3: Incidence of Colorectal and Upper Gastrointestinal Cancer in the 5-year period 2004-2008 by LGA
for Hume region, Albury and Southern/Border NSW ..................................................................... 20
Table 4: Patient flow analysis for Colorectal and Upper GI Cancer................................................................. 23
Table 5: MDTMs in the Border/East Hume Cancer Network .......................................................................... 26
Table 6: Number of patients presented at the Border/East Hume Cancer Network MDTMs ........................ 27
Table 7: Border/East Hume Cancer Network Gastrointestinal membership .................................................. 28
Table 8: Border/East Hume Cancer Network scope of clinical practice checklist for colon and rectal cancer 30
Table 9: Border/East Hume Cancer Network scope of clinical practice checklist for pancreatic cancer ........ 33
Table 10: Generic successes and gaps in the care pathway across all tumour streams ................................. 36
Table 11: Successes and gaps for gastrointestinal cancer............................................................................... 45
Table 12: Recommendations for multidisciplinary care .................................................................................. 48
Table 13: Recommendations for care coordination ........................................................................................ 49
Table 14: Recommendations for supportive care ........................................................................................... 50
Table 15: Recommendations for reducing unwanted variations in care ........................................................ 51
Table 16: Victorian and NSW LGAs considered in this Patient Pathways Mapping Project ............................ 99
Table 17: Hume region, Albury and Southern/Border NSW population forecasts ...................................... 101
Table 18: Hume, Albury and Southern/Border NSW population change 2011 - 2021 ................................. 102
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LIST OF FIGURES
Figure 1: Schematic representations of the optimal treatment pathways for the Colorectal and Upper GI
tumour streams ............................................................................................................................... 15
Figure 2 : Supportive care referrals ................................................................................................................. 25
Figure 3: Systematic approach to quality in cancer services ........................................................................... 89
Figure 4: Map of the Victorian Integrated Cancer Services............................................................................. 90
Figure 5: The seven steps of the patient journey identified in the PMFs ....................................................... 92
Figure 6: Victoria’s model for multidisciplinary care....................................................................................... 94
Figure 7: Model for safety and quality in Victorian cancer services ............................................................... 97
Figure 8: Map of the Hume RICS West Hume and Border/East Hume Cancer Networks ............................... 98
Figure 9: Map of the Local Government Areas from Victoria and NSW that form part of the broader
population catchment for cancer services in the Hume region....................................................... 99
Figure 10: Primary Care Partnership divisions in the Hume region .............................................................. 100
Figure 11: Total cancer incidence by LGA, Hume region, Albury and Southern/Border NSW for the 5-year
period 2004-2008 .......................................................................................................................... 103
Figure 12: Average annual cancer incidence by sex and age group, Hume region and Albury for the 5-year
period 2004-2008 .......................................................................................................................... 104
Figure 13: Average annual cancer mortality by sex and age group, Hume region and Albury for the 5-year
period 2004-2008 .......................................................................................................................... 105
Figure 14: Average annual cancer incidence by sex and cancer type in the Hume region for the 5-year
period 2004-2008 .......................................................................................................................... 106
Figure 15: Total cancer incidence by sex and cancer type in Albury for the 5-year period 2004-2008 ....... 107
Figure 16: Average annual cancer mortality by sex and cancer type in the Hume region for the 5-year period
2004-2008 ..................................................................................................................................... 108
Figure 17: Total cancer mortality by sex and cancer type in Albury for the 5-year period 2004-2008 ....... 109
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1. EXECUTIVE SUMMARY
The Victorian Department of Health (DH) has a significant cancer reform agenda that aims to improve
planning and delivery of treatment and support to patients so that appropriate care is provided in a timely
manner as close to the patients home as possible.1 Two leading policy documents guiding Victoria’s cancer
reforms are the Cancer Services Framework and Victoria’s Cancer Action Plan (VCAP). The Cancer Services
Framework identified structures and processes that support optimal cancer care, including the
development of the Patient Management Frameworks (PMFs) in 2006 to guide the delivery of consistent
cancer care for a range of tumour streams.2
The PMFs were developed to provide a consistent statewide approach to care management across the ten
identified tumour streams and are intended to improve patient outcomes by focussing discussion on the
critical steps of the patient journey in order to identify priority areas for improvement. They aim to reduce
unwanted variation in care and describe optimal referral pathways for cancer care from diagnosis to endof-life care, inclusive of treatment and supportive care. This project aimed to identify the successes and
gaps in the implementation of the PMFs across all stages of the patient journey for each of the four priority
service improvement areas for statewide reform (multidisciplinary care, care coordination, supportive care,
reducing unwanted variation in practice).
Further information about the background to the conduct of this project, including a detailed description of
the Patient Management Frameworks and the process with which they were evaluated in this project is
provided in Appendix 4 and 5.
Project data were collected via a variety of mechanisms including consumer questionnaires and interviews,
health professional interviews, and data analysis. The successes and gaps in service provision were
identified from these data and are presented in Section 5 of this report. Based on these findings,
recommendations for cancer service improvement were developed and prioritised, as presented below.
Multidisciplinary Care
Number
Recommendation
1
Continue to promote and support opportunities for non-local
clinicians to link into the Albury/Wodonga MDTMs remotely (eg. for
the surgeons based in Wangaratta to attend the Gastrointestinal
MDTM via WebEx)
2
Best practice models of multidisciplinary care continue to be
promoted to local health professionals, specifically with respect to
encouraging all specialists treating colorectal and upper
gastrointestinal cancers in the Border/East Hume Cancer Network to
refer to, and attend, the Gastrointestinal MDTM
1
Clinical Networks: A framework for Victoria 2008 Department of Human Services
2
Patient management frameworks 2006 Department of Human Services
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3
Hume RICS continues to contribute to local and statewide initiatives to
improve multidisciplinary team meeting administration, including to
support the implementation of sustainable, standardised software
and to contribute to statewide minimum datasets

4
Evaluate and enhance GP involvement in multidisciplinary teams,
including participation in local MDTMs

Care coordination
Number
Recommendation
1
Health professionals and consumers should be well informed about
the range of different treatment and supportive care options,
particularly those available close to the patient’s home
2
Hume RICS continues to promote engagement with the community
health sector, and Home and Community Care (HACC) services,
particularly in relation to linking rural and remote patients with their
local support services where possible

3
Relevant federal and statewide strategies working towards improving
communication channels between all health professionals, including
GPs, should be promoted widely (such as the Human Services
Directory (HSD) and e-referral

4
Communication systems are improved to ensure that patient medical
information is available in a timely manner to all relevant clinicians,
including the GP

5
Transition of care (discharge planning) processes should be improved
to promote continuity of care, particularly between metropolitan and
regional/rural health services, private hospitals and primary health
services, and also between specialist cancer services, primary health
and palliative care

6
The potential barriers in accessing appropriate services should be
identified and strategies developed to address them

7
Protocols are developed and implemented to ensure that patients
being transferred from a metropolitan treatment centre back to the
Border/East Hume Cancer Network are referred to the relevant local
support nurse/Cancer Care Coordinator in a timely manner

8
Processes are established to promote the development of cancer care
management plans and palliative care pathways (as guided by the
Goulburn Valley Health End of Life project)

9
Review of lymphoedema models of care, including early intervention,
are supported

10
Resources are developed for GPs that support appropriate and timely
referral of people diagnosed with cancer to specialist cancer services
and community services as appropriate
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Supportive care
Number
Recommendation
1
Health services are supported to ensure that all newly diagnosed
cancer patients have access to supportive care screening (including
the utilisation of a screening tool developed specifically for patients
aged over 70 years) and that these results are documented in the
patient’s central medical record
2
Supportive care screening is implemented at designated follow up
intervals, including recurrence
3
The importance of supportive care discussion within a
multidisciplinary team meeting is promoted and that this discussion is
documented
4
Health services are supported to develop service models which
include prevention, early intervention, treatment and support for
cancer patients. Such services may include lymphoedema services,
speech therapy, dietetics, counselling, PEG feeding and home oxygen
5
Hume RICS continues to provide and promote practical support and
information for consumers (including the Hume RICS website, tailored
standardised information packs and professional development
sessions for specialist cancer staff) and continues to focus on
improving information and access to travel, accommodation and
financial supports

6
Options for access to pastoral care should be investigated and
promoted

7
Partnerships with palliative care services are enhanced and a health
promotion approach to palliative care is supported, including
advocating for the importance of early intervention
8
Transport, financial, and emotional support continue to be raised as
issues for rural communities in accessing oncology treatment

9
Continue to raise awareness of the specific supportive care needs of
priority population groups including Aboriginal and Torres Strait
Islander, adolescent and young adults, and culturally and linguistically
diverse communities

10
A model is developed to facilitate increased access to psychosocial
oncology support for public and private patients in community and
inpatient settings across both sides of the NSW/Victorian border

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Reducing Unwanted Variations in Care
Number
Recommendation
1
Medical oncology education for small rural health services and GPs
should be facilitated, including pain and side effect management for
cancer patients
2
Systems for timely access to allied health services and practical
supports are developed, particularly for patients in private hospitals
3
In consultation with the Hume Medicare Local, Hume RICS provides
GPs with access to oncology/specialist referral criteria and pathways,
as informed by the findings of the West Hume Cancer Network GP
project
4
Waiting times around access to theatres should be investigated to
better understand the implications and impacts
5
Earlier referral processes from metropolitan settings to rural radiation
services are in order to avoid delays experienced by patients in
accessing local radiotherapy services
6
Support the work undertaken by the Albury Wodonga Regional Cancer
Centre Consortium to advocate for improved access to public medical
oncology and radiotherapy
7
Further investigate the inequities in financial supports (including
subsidies for dietary supplements, HACC services, community/district
nursing) to identify the differences for public/private patients and
NSW/Victorian residents

8
An education needs analysis should be conducted in order to develop
and facilitate appropriate professional development for a broad range
of health professionals involved in the care of patients with cancer;
particularly as related to issues such as death and dying, treatmentrelated sexual issues, health literacy and self care

9
Support health services in exploring opportunities to implement
and/or further extend their use of CHARM to improve systems relating
to safety, quality and efficiency

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2. AIM AND OBJECTIVES
The aim of the Patient Pathway Mapping Project was to identify opportunities for ‘whole system’
improvement and development, for consistent and coordinated cancer care across the Hume Region.
The objectives of this project were to use the Patient Management Frameworks (PMFs) to guide planning
for service improvement activities by:



Identifying the differences between the actual patient pathway and the optimal patient pathway as
described by the Patient Management Frameworks, for each selected tumour stream
Identifying strengths, gaps and duplications in the actual pathway of patients for each tumour
stream
Providing recommendations to support improvements focusing on delivering optimal treatment
and support to patients, at each step of the care pathway
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3. PROJECT SCOPE
3.1 Border/East Hume Cancer Network
The Border/East Hume Cancer Network is a cross-border collaboration of public and private health services
and clinicians, as shown in Appendix 5. Patients who attend these services are drawn from a large regional
population of close to 250,000 from the Victorian Local Government Areas (LGA) of Wodonga, Indigo,
Towong, Wangaratta, Alpine, Mansfield and Benalla, and from the Murray region of southern NSW.
The principal public hospitals providing cancer services in the Border/East Hume Cancer Network are:


Albury Wodonga Health (Albury and Wodonga campuses) – AWH
Northeast Health Wangaratta – NHW
The principal private (Ramsay Health) hospitals providing cancer services are:



Albury Wodonga Private Hospital – AWPH
Murray Valley Private Hospital – MVPH
Wangaratta Private – WP
Albury Wodonga Health (AWH) and Northeast Health Wangaratta (NHW) are publically funded services and
provide diagnostic, surgical, chemotherapy and allied health services (please note that for AWH
chemotherapy is only available at the Albury campus). Depending on the procedure/treatment regime,
privately insured or Department of Veteran’s Affairs (DVA) patients may elect to have surgery and/or
chemotherapy at one of the private hospitals listed above. Other smaller rural hospitals across the
Border/East Hume Cancer Network may provide inpatient or outpatient supportive care services to cancer
patients.
In the Border/East Hume Cancer Network, radiation oncology and medical oncology are supplied by private
providers. Radiotherapy is provided by Radiation Oncology Victoria (ROV) at the Murray Valley Radiation
Oncology Centre in Wodonga. ROV is a private provider of radiotherapy services across metropolitan
Melbourne and country Victoria. Border Medical Oncology (BMO) is a private practice that provides
medical oncology consultancy in Wodonga. A public medical oncology registrar and Oncology Nurse
Practitioner are also employed by Albury Wodonga Health and they work in partnership with the medical
oncologists at BMO.
The Border/East Hume Cancer Network has also attracted the services of many generalist private medical
practitioners, including surgeons, pathology and radiology agencies, an oncology pharmacist, psychologists
and allied health providers (including physiotherapists, dietitians, lymphoedema therapists, continence
nurses), who contribute substantially to cancer care.
With respect to supportive services in the Border/East Hume Cancer Network, the Cancer Institute NSW
provides funding for a 1.0FTE Cancer Care Coordinator, a 0.5FTE Multidisciplinary Team Meeting
Administrator and a 0.6FTE Oncology Social Worker. Hume RICS also provides funding for a 0.5FTE
Multidisciplinary Team Meeting Administrator in the Border/East Hume Cancer Network (to enable the
cross-border position to be employed on a full-time basis) and a 0.8FTE Cancer Resource Nurse. There are
Breast Care Nurses in Albury/Wodonga, Benalla and Alpine (funded by the McGrath Foundation) and in
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Wangaratta (funded by Northeast Health Wangaratta). The Leukaemia Foundation funds a Support
Coordinator for Albury/Wodonga and surrounds. A number of surgeons in private practice also employ
nurses to provide support to their patients.
Palliative care clinical teams are located at Albury Wodonga Health (Wodonga campus), Northeast Health
Wangaratta and Mercy Health Albury. There is a community-based consultancy service provided by the
NSW Murrumbidgee Local Health District and Ovens and King Community Health/Gateway Health in
Victoria, including dedicated Clinical Nurse Consultant positions. There are also community based palliative
care services provided by District Nurses/Home Nursing in rural areas such as Alpine, Corryong, Benalla,
Tallangatta and Mansfield. Visiting palliative care physicians attend from NSW (from Sacred Heart Hospital
in Sydney) and Victoria (from St Vincent’s Hospital Melbourne).
Stakeholders in the Border/East Hume Cancer Network have crafted a collaborative model of regionally
based health care to service all in the region who seek cancer care. This collaboration was led in the mid2000’s through the Border Cancer Collaboration who developed partnerships and processes to reduce the
impediments faced by those accessing cancer services caused by state and other jurisdictional boundaries.
There are also linkages to metropolitan services and clinicians in Melbourne and Sydney and rare/complex
cases are referred to these services as required. Whilst the Border/East Hume Cancer Network hosts a
number of local Multidisciplinary Team Meetings (described in further detail in Section 5.4), remote
linkages to metropolitan meetings are also available.
3.2 Patient Pathways Mapping Project
Patient pathways mapping in the Border/East and West Hume Cancer Networks were undertaken for the
tumour streams as shown in Table 1 and Table 2. The Border/East and West Hume Clinical Reference
Groups, as well as the respective Network committees (who act as advisory bodies to Hume RICS) were
consulted to identify the top priority tumour types in each network. These tumour types were then
allocated to their corresponding tumour streams, and mapped against the relevant PMFs (as presented in
Table 1 and Table 2).
It is important to note that the primary focus of this project was on the services provided within the
Border/East Hume Cancer Network. Whilst consideration was given to the experiences of patients required
to travel outside of the region for components of their care, this was not a main focus of the project and
detailed investigation of the services provided outside of the region (including at metropolitan sites) was
not conducted.
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Table 1: Tumour types identified as priority areas for the Border/East Hume Cancer Network
Tumour type
Tumour stream
PMF
Ovarian
Gynaecological
Ovarian
Melanoma
Skin
Melanoma
Larynx, pharynx and oral
Head & Neck
Larynx, pharynx and oral
Prostate
Genitourinary
Prostate
Testicular
Genitourinary
Testicular
Pancreatic
Upper Gastrointestinal
Pancreatic
Colon & Rectal
Colorectal
Colon & Rectal
Intermediate grade Non-Hodgkin
lymphoma
Haematological
Intermediate grade Non-Hodgkin
lymphoma
Non-small cell lung
Lung
Non-small cell lung
Cerebral metastases
Central Nervous System
Cerebral metastases
Malignant glioma
Central Nervous System
Malignant glioma
Table 2: Tumour types identified as priority areas for the West Hume Cancer Network
Tumour type
Tumour stream
PMF
Non-small cell lung
Lung
Non-small cell lung
Colon & Rectal
Colorectal
Colon & rectal
Breast
Breast
Breast
Prostate
Genitourinary
Prostate
Ovarian
Gynaecological
Ovarian
Melanoma
Skin
Melanoma
Larynx, pharynx and oral
Head & Neck
Larynx, pharynx and oral
Intermediate grade Non-Hodgkin
lymphoma
Haematological
Intermediate grade Non-Hodgkin
lymphoma
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4. METHODOLOGY
This project compared the actual patient treatment pathway with the optimal pathway as described in the
Patient Management Framework “Colorectal tumour stream: colon and rectal cancer” and “Upper
gastrointestinal tumour stream: pancreatic cancer”. Project data were collected via a variety of
mechanisms including consumer questionnaires and interviews, health professional interviews, and data
analysis.
4.1 Operationalising the Patient Management Framework
Schematic representations of the optimal treatment pathway for the colorectal and upper gastrointestinal
(GI) stream were developed by the Project Team, based on the information provided in the PMF and are
presented in Figure 1. These were used alongside the project data collection tools in order to identify the
key steps of the optimal treatment pathway, and consequently the gaps and successes of the actual patient
pathway.
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Figure 1: Schematic representations of the optimal treatment pathways for the Colorectal and Upper GI
tumour streams 3
3
Patient management frameworks Colorectal tumour stream: colon and rectal cancer; and Upper gastrointestinal tumour stream:
pancreatic cancer 2006 Department of Human Services
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4.2 Participation of health professionals
Individual semi-structured interviews were conducted with clinicians and other health professionals to
identify the successes and gaps in the implementation of the PMFs. The interview tool that was utilised for
this project was based on the Department of Health resource “Patient Management Frameworks – toolkit”
(attached as Appendix 1). It incorporated the key elements of multidisciplinary care, care coordination,
supportive care and variations in care, at each stage of the cancer journey from diagnosis, through to end
of life care. Supplementary health professional interview questions were also utilised (attached as
Appendix 2).
4.3 Participation of consumers
Consumer participation in the project was designed as an ‘opt in’ approach. Flyers were distributed to
numerous health service sites including general practitioners, regional hospitals and community health
centres. The recruitment strategy also included circulating invitations to regional cancer support groups
and the Hume RICS Community Participation Network, as well as advertising through local newspapers and
other media. Consumers were offered the opportunity to participate in an individual interview, complete a
questionnaire or participate in a small group forum. The questionnaire and interview questions that were
developed for this project (attached as Appendix 3) were informed by previously utilised patient surveys.4 5
4.3.1 Ethics approval
Ethics applications were submitted to the Albury Wodonga Health Human Research Ethics Committee
(HREC) and the Northeast Health Wangaratta HREC. The ethics submission to Albury Wodonga Health HREC
included project research approval for Albury Wodonga Health (both Albury and Wodonga hospital
campuses), Albury Wodonga Private Hospital, Murray Valley Private Hospital, Goulburn Valley Health and
Kilmore District Hospital. The submission to Northeast Health Wangaratta HREC included project research
approval for this site only. The purpose of the HREC submissions was to seek approval for Hume RICS to
advertise for the recruitment of potential participants (cancer patients) in hospital settings within the
Hume Region, and to conduct subsequent interviews, questionnaires and small group forums to collect
information about their cancer care experiences.
4.4 Retrospective review of medical records
Within the Victorian Admitted Episodes Dataset (VAED), ICD-10 diagnostic and procedural codes were used
to identify a sample of patients with a new cancer diagnosis that had undergone treatment. Patients were
selected from the datasets available for the 2009/10 and 2010/11 financial years. Up to 25 patients were
randomly selected for each nominated tumour stream from each of the four Hume sub-regions. The actual
number of patients reviewed was fewer for the low volume cancers according to the number of diagnoses
within the specific period.
4
5
National Survey of NHS Patients Questionnaire (1999-2000), Centre for Social Research, Picker Institute Europe
Victorian Cancer Patient Experience Survey Tool 2011, Victorian Department of Health
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A proforma was developed to record standardised information from the medical records, however as
described in more detail below, there were major limitations in utilising information extracted from
medical records. It should also be noted that the information retrieved from the medical records for the
purposes of this project differed to that collected as part of the Victorian Cancer Service Performance
Indicator reports.
It was intended that information extracted from the medical record would be collected regarding
presentation at MDTM, evidence of correspondence with General Practitioners, details of treatment and
supportive care referrals. However, it was often difficult to generate a thorough and accurate
representation of the patients entire care pathway based on the medical record review. This was due to
patient care often being delivered across multiple sites in the Border/East Hume Cancer Network, which
has a mix of public/private services, each with their own individual medical record. By examining the
medical record at the site where the patient had the bulk of their treatment (eg. chemotherapy), it was
often not possible to determine all of the relevant treatment and referrals initiated before they were
admitted for chemotherapy (eg. from the site where they had their surgery) etc. Ideally patients would
have been followed longitudinally through their care pathway across multiple health service sites, but this
was not possible in the absence of a linked dataset that enabled patients to be easily tracked through the
system.
Therefore, a decision was made to exclude the majority of the information obtained from the medical
record review due to concerns the data did not accurately represent the patient journey. However,
information obtained from the medical record review regarding supportive care referrals was felt to be
representative enough in order to be summarised for inclusion in this report, represented as Fitch’s tiered
approach to providing supportive care.
4.5 Patient flow data analysis
The VAED was again utilised to analyse patient flow of local residents to service providers both within and
external to Hume RICS during the 2009/10 and 2010/11 financial years.
The dataset was used to identify local residents of each of the four Hume sub-regions, then analysed to
determine the service site at which these patients had an inpatient episode of care. A further analysis was
completed to determine the type of care delivered by ICD-10 diagnostic and procedural codes for each of
the nominated tumour streams.
Unfortunately, as the Albury Wodonga Health- Albury Campus does not yet submit data in to the VAED,
analysis of this activity was unable to be undertaken. Inpatient activity delivered at this service site is
therefore not able to be determined and is not included in the analysis. It is anticipated that during 20132014 Albury campus will develop systems and procedures in order to be able to report their data to the
VAED.
4.6 Assessment of scope of clinical practice
The Patient Management Frameworks provide clear guidelines regarding the scope of clinical practice in
order to provide quality and safe practice. As described in the PMFs, scope of practice reflects both the
expertise and experience of the individual as well as the organisational capability for the provision of safe,
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high quality cancer services. The guidelines presented in the PMF were used to develop a checklist that was
completed for each of the health service sites within the Border/East Hume Cancer Network to determine
their ability to provide the recommended level of service and expertise.
4.7 Presentation of results
As described in Appendix 4, the focus of this Patient Pathways Mapping Project was to investigate the
success with which the PMFs have been implemented at each step of the patient pathway, across each of
the four key priority areas of:




multidisciplinary care
care coordination
supportive care
reducing unwanted variation in practice (quality monitoring and support)
Accordingly, the successes and gaps in the care pathway for Colorectal and Upper Gastrointestinal (Colon,
Rectal, Pancreatic) cancers in the Border/East Hume Cancer Network were described across these four
priority areas. There were also a number of successes and gaps identified that were relevant across all
tumour streams, and these have been presented separately to the tumour-specific successes and gaps. The
results have been presented in a tabular format and directly reference the steps in the patient pathway
listed in the PMF. Whilst there are seven steps of the patient pathway presented in the PMF, the focus of
this project centred primarily around the six stages from initial diagnosis and referral through to end of life
care.
Recommendations across the four priority areas were developed and circulated to the Hume RICS
Border/East Hume Clinical Reference Group for comment and classification as short-term or long-term
activities.
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5. RESULTS
This section presents the results of the Patient Pathways Mapping Project in the Border/East Hume Cancer
Network. Table 3 presents data specifically related to the incidence of colorectal and upper gastrointestinal
cancer in the five year period 2004-2008 for LGAs in the Victorian Hume region, as well as the NSW LGAs
that are part of the broader population catchment for cancer services provided in the Hume region.
Presented in this table are the data for Albury (which has been combined with Wodonga), as well as the
combined incidence data for the LGAs of Corowa, Greater Hume, Berrigan, Deniliquin, Murray, Conargo,
Jerilderie and Urana (collectively referred to in this report as Southern/Border NSW). Please note that
Victorian LGA incidence data was sourced from the Cancer Council Victoria and NSW LGA incidence data
was sourced from NSW Cancer Registry. Across Hume, Albury and Southern/Border NSW LGAs, there were
a total of 1521 cases of colorectal cancer and 697 cases of upper gastrointestinal (GI) cancer for the five
year period 2004-2008, which equates to approximately 304 and 139 cases per year, respectively.
Table 3: Incidence of Colorectal and Upper Gastrointestinal Cancer in the 5-year period 2004-2008 by LGA
for Hume region, Albury and Southern/Border NSW 6
LGA name
Colorectal Cases
Upper GI cases
Albury/Wodonga
283
137
Southern/Border NSW*
228
97
Indigo
90
23
Wangaratta
121
63
Alpine
49
42
Towong
33
5
Mansfield
27
14
Benalla
67
34
Greater Shepparton
242
111
Mitchell
115
57
Moira
133
63
Murrindindi
82
23
Strathbogie
51
28
1521
697
TOTAL for five-year period
* Combined figures for the LGAs of Corowa, Greater Hume, Berrigan, Deniliquin, Murray, Conargo, Jerilderie and Urana
With respect to pancreatic cancer specifically, across all Hume LGAs the Cancer Council Victoria has
reported an average annual incidence of 38 cases of pancreatic cancer across the most recent five year
6
Data obtained from Cancer Council Victoria and NSW Cancer Registry
Colorectal & Upper GI PPM Report
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period. The NSW Cancer Registry has reported a total of 28 cases of pancreatic cancer in the Albury LGA,
and a total of 35 cases in Southern/Border NSW for the five year period 2004-2008.
5.1 Data collected
Data for this project were collected from a variety of sources, including health professional interviews,
consumer questionnaires and interviews, medical record reviews, health service checklists and data
analysis.
5.1.1 Participation of health professionals
A total of 28 clinicians and health professionals were interviewed for the entire Patient Pathways Mapping
Project (across all 9 tumour streams for the Border/East Hume Cancer Network), including medical
oncologists, radiation oncologists, surgeons, physicians, general practitioners, registrars, oncology nurses,
Nurse Unit Managers, Nurse Practitioners, Cancer Care Coordinators, research nurses, palliative care
nurses, social workers, dietitians and other nurses who are involved in the care of cancer patients.
5.1.2 Participation of consumers
For the entire Patient Pathways Mapping Project (across all 9 tumour streams for the Border/East Hume
Cancer Network), a total of 43 consumers were interviewed (26 completed a written questionnaire, 5
participated in a small group forum and 12 consumers participated via a phone interview).
5.1.3 Retrospective review of medical records
A total of 61 medical records were reviewed for patients who had received treatment specifically for
colorectal cancers and a total of 51 medical records were reviewed for patients who had received
treatment specifically for upper GI cancers and in Upper and Central Hume.
5.2 Patient flow data analysis
Table 4 below illustrates the number of patients who contributed to hospital inpatient episodes of care for
residents of the Hume region in the 2009-10 and 2010-2011 financial years. This specifically relates to
residents of the Upper Hume sub region (Wodonga, Indigo and Towong LGAs) and Central Hume sub region
(Wangaratta, Alpine, Mansfield and Benalla LGAs) but does NOT include residents of NSW. The diagram
shows the number of patients who are residents of the Upper Hume and Lower Hume sub regions who
received components of their care both within the Hume region (Central Hume, Upper Hume, Goulburn
Valley and Lower Hume sub regions), and outside the Hume region (LMICS, NEMICS, SMICS, WCMICS,
BSWRICS*) and at other private hospitals across the state.
As described previously, unfortunately, as the Albury Wodonga Health- Albury Campus does not submit
data in to the VAED analysis of this activity was unable to be undertaken. Inpatient activity delivered at this
service site is therefore not able to be determined and is not included in the analysis. Additionally, due to
Colorectal & Upper GI PPM Report
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privacy reasons, where there is less than 5 patients, the exact number can not be listed and instead must
be represented as <5.
As shown in Table 4 there were 94 patients who were residents of Central Hume, who also received their
treatment within that sub-region. Other residents of Central Hume travelled to receive treatment for their
colorectal and upper gastrointestinal cancer at WCMICS and BSWRICS, and other private hospitals. Due to
the small numbers, it is not possible to report the reasons for their travel to these metropolitan locations.
However, it does highlight the fact that patients from Upper and Central Hume do travel outside the region
to receive components of their care. Further investigation is required to determine whether this travel
outside the region is necessary and appropriate, and if so, how patients can be supported to receive
seamless care coordination between health service sites.
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Table 4: Patient flow analysis for Colorectal and Upper GI Cancer
Colorectal:
Residency of patient
Treatment location
Central Hume
Upper Hume
Central Hume
81
<5
Upper Hume
19
44
Goulburn Valley
0
0
Lower Hume
0
0
LMICS
0
0
NEMICS
<5
0
Other Private
7
<5
SMICS
<5
0
WCMICS
10
5
BSWRICS
0
0
* Please note that this does not include residents of NSW or patients receiving treatment at AWH Albury
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Upper Gastrointestinal:
Residency of patient
Treatment location
Central Hume
Upper Hume
Central Hume
13
0
Upper Hume
5
8
Goulburn Valley
0
0
Lower Hume
0
0
LMICS
0
0
NEMICS
0
0
Other Private
5
0
SMICS
<5
0
WCMICS
0
0
BSWRICS
0
0
* Please note that this does not include residents of NSW or patients receiving treatment at AWH Albury
Note:
LMICS = Loddon Mallee Integrated Cancer Service
NEMICS = North East Metropolitan Integrated Cancer Service
SMICS = South Melbourne Integrated Cancer Service
WCMICS = Western and Central Melbourne Integrated Cancer Service
BSWRICS = Barwon South Western Regional Integrated Cancer Service
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5.3 Supportive care
The Victorian supportive care model adopts Fitch’s tiered approach to providing supportive care.7 For the
purpose of this discussion, this approach defines the ‘different levels of need’ within a population group. 8
For the purpose of this project, complexity has been identified by the number of referrals required to meet
the supportive care needs of each patient. These data were extracted from a retrospective review of
patient medical records. Utilising this definition referral patterns in the Border/East Hume Cancer Network
reflect Fitch’s Diagram.
Figure 2 : Supportive care referrals
General
needs
All patients
74.9%
Many patients
19.3%
Up to 2 referrals
2-5 referrals
5-7 referrals
Complex
needs
Some
patients
Few
Fitch's Diagram
7
8
5.8%
0%
>7 referrals
Results of Border/East Hume
Cancer Network PPM project
Achieving best practice cancer care, A guide for implementing multidisciplinary care 2007 Department of Human Services
Achieving best practice cancer care, A guide for implementing multidisciplinary care 2007 Department of Human Services
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5.4 Multidisciplinary care
5.4.1 Profile of Border/East Hume MDTMs
There are a number of regular MDTMs held locally in the Border/East Hume Cancer Network, as well as
linkages available to metropolitan MDTMs. Table 5 lists these MDTMs and the frequency with which they
were held during the 2009/2010, 2010/2011 and 2011/12 financial years.
Table 5: MDTMs in the Border/East Hume Cancer Network
MDTM Meeting
2009/2010
2010/2011
2011/2012
Gastrointestinal
Monday monthly
Monday fortnightly
Monday fortnightly
Urological
Thursday 4 weekly
Thursday 4 weekly
Thursday 4 weekly
Breast
Wednesday 4 weekly
Wednesday 4 weekly
Wednesday 4 weekly
Mentoring in the
Management of
Haematological Malignancies
(MMHM) -via teleconference
with Royal Melbourne
Hospital (RMH)
Thursday fortnightly
Thursday fortnightly
Thursday fortnightly
Wangaratta General Tumour
Stream
1st Thursday
month
1st Thursday of each
month
1st Thursday of each
month
Head and Neck clinic
Tuesday fortnightly
Tuesday fortnightly
Tuesday fortnightly
of
each
Border/East Hume Cancer Network formal linkages to metropolitan MDTMs*
Lung (RMH)
Friday weekly
Friday weekly
Friday weekly
Lung (Austin)
Thursday weekly
Thursday weekly
Thursday weekly
Royal Womens Hospital
Oncology and Dysplasia
Service
Tuesday weekly
* Hume RICS does not keep data relating to these MDTMs as they are administered by the metropolitan sites
A general multidisciplinary team intake meeting is also held weekly in Albury to present all new medical
oncology patients across all tumour streams.
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5.4.2 Number of patients presented at the MDTMs
Table 6 outlines the number of patients presented at these MDTMs during the same periods. The
Gastrointestinal MDTM is held fortnightly on a Monday in the Border/East Hume Cancer Network. In the
2011-12 financial year, 192 patients were discussed at this MDTM. Further analysis has begun to quantify
sub groups of this total number of patients according to tumour type etc, and will be reported to the
MDTM participants according to the reporting deliverables of the Hume region MDTM data scorecard
which is currently under development.
Table 6: Number of patients presented at the Border/East Hume Cancer Network MDTMs
MDTM Meeting
2009/2010
2010/2011
2011/2012
Gastrointestinal
121
191
192
Urology
84
105
104
Breast
125
126
126
90
80
127
Wangaratta
Stream
General
Tumour
Head and Neck*
84 (46 patients in attendance)
MMHM (via teleconference with
RMH)
77
55
74
Total
497
557
707
* Hume RICS commenced administration of the Head and Neck clinic from 20 September 2011
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5.4.3 Membership of the MDTM
The PMF describes the recommended membership of the multidisciplinary team to be involved in initial
treatment planning for a Gastrointestinal cancer. As shown in Table 7, the Border/East Hume Cancer
Network MDTM met the recommended membership during the project period, with the exception of a
social worker. A Cancer Care Coordinator attends this meeting and takes on much of the support role and
refers to the oncology social worker as required.
Table 7: Border/East Hume Cancer Network Gastrointestinal membership
PMF Recommended Membership
(in alphabetical order)
Border/East Hume Cancer Network
Gastrointestinal MDTM membership
Dietician
Yes
General Practitioner
Yes
Medical Oncologist
Yes
Nurse
Yes
Pathologists
Yes
Radiation Oncologist
Yes
Radiologist
Yes
Social Worker
No
Surgeon (colorectal surgeon for rectal cancer)
Yes
With access to:
Allied Health services (including dietician) where possible
Yes
Stomal Therapist prior to surgery
Yes
Palliative care service for patients with locally advanced cancers and
metastatic disease
Yes
Psycho-oncology services where appropriate
(psychologist/psychiatrist)
Yes
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5.5 Assessment of scope of clinical practice
As described previously, the Patient Management Frameworks provide clear guidelines regarding the scope
of clinical practice in order to provide quality and safe practice. As described in the PMFs, scope of practice
reflects both the expertise and experience of the individual as well as the organisational capability for the
provision of safe, high quality cancer services. The guidelines presented in the PMF were used to develop a
checklist that was completed for each of the principal health services within the Border/East Hume Cancer
Network to determine their ability to provide the recommended level of service and expertise.
There are several issues to note when considering the checklists below:


Given that radiation oncology is only provided by a private provider in the Border/East Hume
Cancer Network, Radiation Oncology Victoria (ROV) has been added to the table regarding
radiotherapy treatment as a separate service site
Whilst surgeons are not employed by the health services, they conduct surgeries as Visiting Medical
Officers at certain sites as identified in the checklists
In many cases, the private hospitals do not employ allied health providers, but are able to access services
for inpatients as required. However, this may be at an additional cost to the patient
This table shows that the health services in the Border/East Hume Cancer Network are generally well
equipped to deal with the majority of Gastrointestinal cancers, except complex cases which require referral
to specialist services in metropolitan sites.
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Table 8: Border/East Hume Cancer Network scope of clinical practice checklist for colon and rectal cancer
Checklist developed from the Patient Management Framework, Colorectal Tumour Stream: Colon and Rectal Cancer (pp 13 – 15)
LEGEND: AWH = Albury Wodonga Health, Albury & Wodonga Campuses, AWPH = Albury Wodonga Private Hospital, MVPH = Murray Valley Private Hospital, NHW = Northeast Health Wangaratta,
WP = Wangaratta Private, ROV = Radiation Oncology Victoria, BMO = Border Medical Oncology
Surgery
Description
AWH
AWPH
MVPH
NHW
WP
Yes
Yes
No
Yes
Yes
Surgeon (with credentials as specified above)
Yes
Yes
No
Yes
Yes
Anaesthetic services
Yes
Yes
No
Yes
Yes
Stomal therapist
Yes
Yes
No*
Yes
No*
Intensive care/ high dependency unit
Yes
Yes
No
Yes
Yes
24-hour medical staff availability
Yes
No**
No**
Yes
No**
24-hour operating room access
Yes
Yes
No
Yes
No
Diagnostic imaging facility
Yes
Yes
No*
Yes
No*
4A.2 Training and experience of surgeon
Surgeon (FRACS or equivalent) with adequate training and experience in colon or rectal surgery (as
appropriate) that enables institutional credentialing and agreed scope of practice within this area
4A.3 Hospital or treatment unit characteristics- Staff (surgery)
4A.3 Hospital or treatment unit characteristics – Facilities available (surgery)
* Not located on-site, however services are available from external private providers
** Patients would be transferred to a public health service in the case of a medical emergency
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Radiotherapy
Description
AWH
AWPH
MVPH
NHW
WP
ROV
4B.2 Training and experience of radiation oncologist
Radiation oncologists (FRANZCR or equivalent) with adequate training and experience that
enables institutional credentialing and agreed scope of practice within this area
Available through ROV
Yes
4B.3 Hospital or treatment unit characteristics – Staff (radiation)
Nurses
Yes
Yes
Yes
Yes
Yes
Yes
Radiation oncologist (with credentials as specified as above)
Available through ROV
Yes
Radiation oncology medical physicist
Available through ROV
Yes
Radiation therapist
Available through ROV
Yes
Dual modality LINACS
Available through ROV
Yes
CT planning facilities
Available through ROV
Yes
Treatment planning system
Available through ROV
Yes
CT simulation
Available through ROV
Yes
4B.3 Hospital or treatment unit characteristics – Facilities available (radiation)
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Drug therapy
Description
AWH
AWPH
MVPH
NHW
WP
Registrar +
consultant
Med Oncs
from BMO
Consultant
Med Oncs
from BMO
Consultant
Med Oncs
from BMO
Consultant
Med Oncs
from BMO
Consultant
Med Oncs
from BMO
Medical oncologist (with credentials as specified as above)
As above
As above
As above
As above
As above
Nurses with adequate training in chemotherapy administration, handling and disposal of cytotoxic waste
Yes
Yes
Yes
Yes
n/a*
If chemotherapy is prepared on site, a pharmacist with adequate training in chemotherapy medications,
including dosing calculations according to protocols, formulations and/or preparation, is required
Not applicable, as no local health services prepare
chemotherapy on site
n/a*
Some components of less complex therapies may be delivered in a setting where no medical oncologist is
locally available, by another medical practitioner with training and experience that enables credentialing
and agreed scope of practice within this area. This should be in accordance with a detailed treatment plan
or agreed protocol, and with communication as agreed with the medical oncologist or as clinically required
Yes
Yes
Yes
Yes
n/a*
The facility has a clearly defined path to emergency care and advice after hours
Yes
Yes
Yes
Yes
Yes
The facility is able to care for neutropenic patients
Yes
Yes
Yes
Yes
Yes
There is access to haematology testing
Yes
Yes
Yes
Yes
Yes
Cytotoxic drugs are prepared in a pharmacy with appropriate facilities
Not applicable, as no local health services prepare
chemotherapy on site
n/a*
Occupational health and safety guidelines are followed in relation to handling of cytotoxic drugs, including
preparation, waste procedures and spill kits
Yes
Yes
Yes
Yes
Yes
Guidelines and protocols, in the case of extravasation of drugs are available and understood
Yes
n/a**
Yes
Yes
n/a*
Intensive care/high dependency unit is available
Yes
Yes
No
Yes
Yes
Combined therapy with chemo/radiotherapy needs coordination, especially where facility is not co-located
Yes
n/a*
Yes
Yes
n/a*
4C.2 Training and experience of medical oncologist
Medical oncologist (FRACP or equivalent) with adequate training and experience that enables institutional
credentialing and agreed scope of practice within this area
4C.3 Hospital or treatment unit characteristics – Staff (drug therapy)
4C.3 Hospital or treatment unit characteristics – Facilities available (drug therapy)
* Not applicable as chemotherapy is not administered at this health service
** Not applicable as IV chemotherapy is not administered at this health service
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Table 9: Border/East Hume Cancer Network scope of clinical practice checklist for pancreatic cancer
Checklist developed from the Patient Management Framework, Upper Gastrointestinal Tumour Stream: Pancreatic Cancer (pp 12 – 14)
LEGEND: AWH = Albury Wodonga Health, Albury & Wodonga Campuses, AWPH = Albury Wodonga Private Hospital, MVPH = Murray Valley Private Hospital, NHW = Northeast Health Wangaratta,
WP = Wangaratta Private, ROV = Radiation Oncology Victoria, BMO = Border Medical Oncology
Surgery
Description
AWH
AWPH
MVPH
NHW
WP
Hepatopancreaticobiliary surgeon (FRACS or equivalent) with adequate training and experience in
pancreatic surgery that enables institutional credentialling and agreed scope of practice within this area
Yes
Yes
No
No
No
Surgeon (FRACS or equivalent) with adequate training and experience in palliative pancreatic surgery that
enables institutional credentialling and agreed scope of practice within this area
Yes
Yes
No
Yes
Yes
Surgeon (with credentials as specified above)
Yes
Yes
No
Yes
Yes
Anaesthetic services
Yes
Yes
No
Yes
Yes
Nurses experienced in oesophagogastric surgery
Yes
Yes
No
Yes
No
Intensive care unit for major surgery
Yes
No
No
Yes
No
High dependency unit for palliative surgery
Yes
Yes
No
Yes
Yes
Pathology services: frozen section reporting, margins reporting
Yes
No
No
Yes
No
Interventional radiology capable of managing development of biliary obstruction and complications of
surgery
Yes
Yes
No
Yes
No
4A.2 Training and experience of surgeon
4A.3 Hospital or treatment unit characteristics- Staff (surgery)
4A.3 Hospital or treatment unit characteristics – Facilities available (surgery)
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Radiotherapy
Description
AWH
AWPH
MVPH
NHW
WP
ROV
4B.2 Training and experience of radiation oncologist
Radiation oncologists (FRANZCR or equivalent) with adequate training and experience that
enables institutional credentialing and agreed scope of practice in the treatment of upper
gastrointestinal malignancy
Available through ROV
Yes
4B.3 Hospital or treatment unit characteristics – Staff (radiation)
Nurses
Yes
Radiation oncologist (with credentials as specified as above)
Available through ROV
Yes
Yes
Yes
Yes
Yes
Yes
Radiation oncology medical physicist
Available through ROV
Yes
Radiation therapist
Available through ROV
Yes
Dual modality LINACS
Available through ROV
Yes
CT planning facilities
Available through ROV
Yes
Treatment planning system
Available through ROV
Yes
4B.3 Hospital or treatment unit characteristics – Facilities available (radiation)
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Drug therapy
Description
AWH
AWPH
MVPH
NHW
WP
Registrar +
consultant
Med Oncs
from BMO
Consultant
Med Oncs
from BMO
Consultant
Med Oncs
from BMO
Consultant
Med Oncs
from BMO
Consultant
Med Oncs
from BMO
Medical oncologist (with credentials as specified as above)
As above
As above
As above
As above
As above
Nurses with adequate training in chemotherapy administration, handling and disposal of cytotoxic waste
Yes
Yes
Yes
Yes
n/a*
If chemotherapy is prepared on site, a pharmacist with adequate training in chemotherapy medications,
including dosing calculations according to protocols, formulations and/or preparation, is required
Not applicable, as no local health services prepare
chemotherapy on site
n/a*
Some components of less complex therapies may be delivered in a setting where no medical oncologist is
locally available, by another medical practitioner with training and experience that enables credentialing
and agreed scope of practice within this area. This should be in accordance with a detailed treatment plan
or agreed protocol, and with communication as agreed with the medical oncologist or as clinically required
Yes
Yes
Yes
Yes
n/a*
The facility has a clearly defined path to emergency care and advice after hours
Yes
Yes
Yes
Yes
Yes
The facility is able to care for neutropenic patients
Yes
Yes
Yes
Yes
Yes
There is access to haematology testing
Yes
Yes
Yes
Yes
Yes
Cytotoxic drugs are prepared in a pharmacy with appropriate facilities
Not applicable, as no local health services prepare
chemotherapy on site
n/a*
Occupational health and safety guidelines are followed in relation to handling of cytotoxic drugs, including
preparation, waste procedures and spill kits
Yes
Yes
Yes
Yes
Yes
Guidelines and protocols, in the case of extravasation of drugs are available and understood
Yes
n/a**
Yes
Yes
n/a*
Palliative care service is available and integrated into the treatment, because most patients with
pancreatic cancer will not be cured of their disease
Yes
Yes
Yes
Yes
Yes
4C.2 Training and experience of medical oncologist
Medical oncologist (FRACP or equivalent) with adequate training and experience that enables institutional
credentialing and agreed scope of practice within this area
4C.3 Hospital or treatment unit characteristics – Staff (drug therapy)
4C.3 Hospital or treatment unit characteristics – Facilities available (drug therapy)
* Not applicable as chemotherapy is not administered at this health service
** Not applicable as IV chemotherapy is not administered at this health service
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5.6 Generic successes and gaps in the care pathway across all tumour streams
Table 10 presents the successes and gaps that are relevant across all tumour streams with respect to
meeting the recommended care pathways described in the PMF. This table highlights issues across the
steps of the care pathway from diagnosis to end of life across the four priority areas of multidisciplinary
care, care coordination, reducing unwanted variations in care and supportive care. Please note that this
table has been repeated across all tumour stream reports and the tumour specific gaps and successes are
presented separately.
Table 10: Generic successes and gaps in the care pathway across all tumour streams
SUCCESSES
GAPS
Initial diagnosis and referral
The process for referring patients for discussion by the
local multidisciplinary team meetings (MDTM) has been
shown to be known and understood by the relevant health
professionals
Generally, there is agreement between the relevant health
professionals of which investigative tests are needed, and
who is responsible for ordering/undertaking them
On rare occasions referrals from GPs for suspected
cancers are directed to an oncologist, whereas it may
have been more appropriate for some referrals to be
initially directed to a surgeon, depending on the
tumour stream
Multiple providers of imaging and pathology services are
available, with low waiting times
With multiple providers of diagnostics and imaging
facilities, some clinicians stated that it can be difficult to
retrieve previous results leading to duplication of tests
for convenience
PET scanner at Albury hospital due to be operational by
late 2013
PET scanner currently only available in metropolitan
centres, which requires substantial travel for patients
and their carers
Patients are billed the costs of CT/MRI at Regional
Imaging if they are referred there by a GP or specialist.
ROV and BMO have a MOU with Regional Imaging that
their patients are bulk billed. This may impact on some
patients’ ability to have staging imaging as outpatients
There are clear referral pathways and protocols to
specialised support services
The specific needs of the Adolescent and Young Adult
(AYA) cancer patient may not always be considered
Patients have continuing access to a key worker – Cancer
Care Coordinator (CCC), Breast Care Nurse (BCN), and
other specialised support nurses who are able to link
patients with services, improving access to cancer
treatments and supports
Patients receive relevant detailed verbal information about
their disease, diagnostic procedures, treatment options,
treatment effectiveness, possible adverse effects and
Colorectal & Upper GI PPM Report
There are fewer written resources in languages other
than English for patients in low volume tumour streams,
Page 36 of 109
outcomes. Written information is offered at all services,
with a dedicated Cancer Council NSW Cancer Information
and Resource Centre available at Murray Valley Private
Hospital
and few non written general cancer resources available
There can be varying levels of financial support for
patients depending on whether they meet the criteria
for Department of Veteran’s Affairs (DVA), Home and
Community Care (HACC) etc
Feedback from several health professionals suggested
that there are many people from Aboriginal and Torres
Strait Islander communities with cancer who do not
access appropriate cancer services at all, or do not
access them within a suitable time frame. This often
leads to a delay in diagnosis and hence more advanced
disease at diagnosis
Determination of treatment
The Border/East Hume Cancer Network has wellestablished local MDTMs for gastrointestinal, head and
neck, breast, and urology tumour streams. A haematology
MDTM is held via a WebEx link to specialists at the Royal
Melbourne Hospital. A general tumour stream MDTM is
also held in Wangaratta
Not all local surgeons nominate their patients for
discussion at MDTMs
The MDT have developed protocols that are defined within
the Terms of Reference regarding when a patient’s care
plan will be discussed
Not all patients meeting the nomination guidelines in
the local MDTM Terms of Reference are presented for
discussion at these meetings
There has been a 29.7% increase in the number of patients
presented at local MDTMs from 2009-10 to 2011-12
Clinicians are also able to link into selected metropolitan
MDTMs for lung and gynaecological cancers
Local clinicians are not always notified when a patient
from the Border/East Hume Cancer Network is being
discussed at a metropolitan MDTM and reliability of the
links to these meetings (via Webex etc) is variable
depending on the facility holding the meeting
Supportive care needs are not always routinely
discussed at the clinical MDTMs due to time constraints
A supportive care meeting is held immediately after the
weekly medical oncology intake meeting for staff working
in the Albury/Wodonga region
The supportive care meeting is not currently structured
as a formal multidisciplinary meeting and is not
administered through CANMAP. Therefore, no formal
documentation is developed at this meeting, despite it
being a good forum for discussion of the supportive care
needs of patients and their families
GPs are routinely invited to attend local MDTMs (face-toface or teleconference)
GPs of each individual patient presented at MDTMs are
invited to participate but there is no standing GP
representative
Clinical trial involvement is considered by the
multidisciplinary team for eligible patients who undergo
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cancer treatment. Representatives from the Border
Medical Oncology Research Unit regularly attend local
MDTMs
A recommended treatment summary is recorded live
within the MDTM discussion which includes treatment
recommendations and has the capacity to record
supportive care recommendations (when discussed). This
is forwarded to the lead clinician, central medical record,
GP and medical and radiation oncology (as relevant). The
recommended treatment summary is able to be accessed
24/7 through the CANMAP database by relevant members
of the multidisciplinary team
Ongoing refinement to CANMAP is required to improve
utilisation and acceptability to nominating clinicians and
their administrative staff
Progression of care is generally well coordinated ensuring
the GP and MDT members are clear on their
responsibilities. The lead clinician responsible for
treatment coordination is clearly documented within the
recommended treatment summary for those patients
presented at MDTMs
Recommended treatment summaries generated at
metropolitan MDTMs are not routinely forwarded to
local medical records for patients receiving components
of their care in the Border/East Hume Cancer Network
Some nursing staff felt there can sometimes be
confusion about who is taking responsibility for the
ongoing management of patients who are not
presented at a MDTM
Registrars routinely participate in local MDTMs, and there
is a dedicated 1.0FTE MDTM Administrator (0.5FTE funded
by NSW and 0.5FTE funded by Victoria)
Written communication between metropolitan and
local health care services (MDTMs, discharge summaries
etc) is variable depending on the services involved.
Verbal communication may be better but is clinician
dependant. GPs may be particularly disadvantaged by
these limited formal written communication pathways
All patients presented at MDTMs provide verbal consent
for their case to be discussed
Health literacy and communication between patients
and health professionals has been identified as an issue
requiring further attention, specifically as related to
patients understanding and managing their own care
Treatment
Several patients reported that attempts are made at
medical and radiation oncology services to coordinate
patients and their needs (travel etc) when planning
investigations and treatments
Some rural patients reported that coordination of
investigations/treatments was not always done with
consideration to their travelling time etc
Theatre availability can be an issue and hospital bed
availability is a major issue
Patients being treated in the public hospitals (AWH and
NHW) are generally able to readily access outpatient and
supportive care services
Colorectal & Upper GI PPM Report
There is a financial inequity in accessing services for
private patients. Private patients do not have access to
the outpatient and supportive care services that public
patients can access through public hospital systems.
Cost may be a barrier to such patients accessing private
services such as private dietetics, physiotherapy etc
Page 38 of 109
Prior to the early 2000’s, there were no local medical
oncologists or radiation oncologists and only a visiting
service was available to local patients. Border Medical
Oncology now has four medical oncologists and Murray
Valley Radiation Oncology Centre has two radiation
oncologists
The Border/East Hume Cancer Network only has
private radiation oncology and medical oncology
services and the cost of local care can be prohibitive for
some patients
An outreach chemotherapy programme is currently being
developed in partnership with the Royal Children’s Hospital
to deliver chemotherapy to paediatric patients in Albury
Outreach chemotherapy protocols have been developed to
allow a small number of non-complex chemotherapy
treatments to be delivered in Deniliquin one day a week
Some day chemotherapy unit staff indicated they would
like the communication systems to be improved to
support the delivery of more timely information prior to
a patient’s first chemotherapy treatment
In addition to the two day oncology units in the regional
hub of Albury/Wodonga, a day oncology unit is available at
Northeast Health Wangaratta five days a week with highly
skilled staff, for the delivery of less complex outpatient
chemotherapy
Some patients reported not understanding why they
weren’t given the option to undertake their
chemotherapy treatment closer to home in Wangaratta,
instead of Albury/Wodonga which required additional
travel
Rural health services indicated their desire to be more
involved in the supportive care management of oncology
patients living in their areas
Some patients reported having to travel to
Albury/Wodonga for treatment that perhaps could have
been delivered from rural health services. i.e.; PICC line
and side effect management, etc
All new patients are counselled on their first appointment
prior to oncology treatment (medical and radiation) on
what to expect, referred to cancer care coordinators,
specialist nurses - there is a separate room for privacy for
this counselling to be undertaken
The Fight Cancer Foundation opened the Hilltop Patient
and Carers Accommodation Centre in 2013, which is colocated with the Albury Campus of Albury Wodonga
Health. Patient/carer accommodation is also available at
Willow Park Lodge located at Murray Valley Private
Hospital, in addition to a number of other local
independent accommodation providers
Many rural consumers raised transport as a limiting
factor in regards to accessing treatment sites in the
regional centre of Albury/Wodonga particularly for
frequent treatment regimes. Cost of private transport
and availability of community/public transport were
named as major concerns
Many rural consumers commented that the eligibility
criteria for the Victorian Patient Transport Assistance
Scheme (VPTAS) were very limiting. The criteria
currently require patients to travel 100 kilometres or
more one way, or to travel (on average) 500 kilometres
per week for five or more weeks in a row to be eligible
to receive a subsidy. Many patients from the Alpine
area do not meet these criteria as they live just within a
100km radius of Albury Wodonga
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Some clinicians commented that the private sector was
crucial in the provision of services that were previously
absent or severely limited in the region. Clinicians felt that
the shared care provided by the public and private sector
was very beneficial to helping achieve optimal patient care.
The vast majority of clinicians indicated that they had good
relationships with their peers and that appropriate crossreferrals are made according to local expertise
Some patients on low incomes reported that due to
their inability to meet the cost of consultations with
private specialist practices that they opted to have
treatment at a public treatment facility in Melbourne,
incurring additional costs for travel and accommodation
and high levels of stress. Some patients reported
difficulty negotiating bulk-billing or payment plan
options with local private services as they found it
“embarrassing” and “humiliating”
A successful bid was submitted for funding to build the
Albury Wodonga Regional Cancer Centre to house all
cancer treatment services and a dedicated wellness centre,
due to open in late 2015
There is a dedicated Oncology Nurse Practitioner (ONP)
position employed by Albury Wodonga Health. The ONP
routinely attends the Gastrointestinal, Breast, Urology,
Head and Neck and Haematology MDTMs, and the
supportive care meeting in Albury Wodonga
There can be difficulty accessing ongoing, specific
oncology training for specialist health care staff
(nursing, allied health)
Services in the Border/East Hume Cancer Network are
comprehensive enough to offer most patients a high
standard of care plus continuity and consistency with
clinicians that may not be available in larger metropolitan
areas
In NSW and Victoria, there are different arrangements
in place for the provision of chemotherapy drugs which
can affect the out of pocket expenses incurred by
patients for their chemotherapy medications
Patients attending the private chemotherapy unit at
Murray Valley Private Hospital (MVPH) do not usually incur
a cost for intravenous medications, as the out of pocket
expense is often paid for by the private health insurance
fund. Private patients may incur an out of pocket expense
for medications they receive on discharge
Some patients raised the issue of cost of chemotherapy
in the day oncology unit at Albury. Patients are required
to pay an out of pocket expense for medication (pretreatment medication, chemotherapy and supportive
medications for side effects). The out of pocket expense
is often significantly reduced when the patient reaches
their annual PBS threshold, however they may still be
subject to an out of pocket expense if the medication
they are receiving is not covered by the PBS. One
patient reported paying to have medication sent from a
Victorian metropolitan hospital pharmacy as they were
unable to afford to have prescriptions filled by the local
NSW-based community pharmacy. Another patient
reported not taking supportive medications as they
could not afford them
Patients attending the chemotherapy unit at Northeast
Health Wangaratta do not incur an out of pocket expense
for their chemotherapy, as any excess charge is absorbed
by the hospital
As with other sites, patients at Northeast Health
Wangaratta often incur an out of pocket expense for
their supportive medications to assist with the
management of side effects (anti-nausea medication)
and discharge medication. As described above, the out
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of pocket expense is often significantly reduced when
the patient reaches their annual PBS threshold
Public patients do not incur an out of pocket expense for
their attendance at the day chemotherapy unit at Albury
Wodonga Health or Northeast Health Wangaratta
Depending on the coverage provided by the patient’s
private health insurance fund, some patients receiving
treatment at the MVPH day chemotherapy unit may
incur an out of pocket expense for each visit
Formal supportive care screening with a validated
screening tool is now routinely offered to all patients at
their first visit to BMO, ROV, and chemotherapy units. This
is designed to facilitate early referrals to support services
Formal supportive care screening is not routinely
undertaken for patients receiving surgery alone
Processes have been developed to ensure that a copy of
the supportive care screening tool is distributed to the
relevant members of the treatment team, as well as to the
relevant central medical record
There are several public and private health services in
the Border/East Hume Cancer Network and it is not
always easy to identify which health services each
patient will attend for components of their treatment
and hence where to send a copy of the supportive care
screening tool
Patients and carers often reported a reluctance to initiate
contact with support services, but reported that they
benefited greatly when a CCC contacted them directly to
offer support
Access to CHARM for all clinical staff has been
incorporated into Albury Wodonga Regional Cancer Centre
planning
CHARM is currently available at AWH (Albury) and
MVPH (although the full functionality is not utilised),
but not available at Northeast Health Wangaratta. This
was reported to limit communication between medical
oncologists and the day oncology unit, with a current
reliance on faxed correspondence. As the faxed
medication charts are then transcribed at NHW, this can
be associated with a risk of human error
The vast majority of patients requiring radiotherapy are
able to undertake their radiation treatment at ROV in
Wodonga. However, if a highly specialised treatment is
required, referral pathways are in place to refer patients to
an appropriate metropolitan service with a radiation
oncologist
who
specialises
in
that
particular
treatment/tumour stream
ROV reported that radiation treatment can be delayed
beyond the recommended timeframes set out in the
PMFs due to poor post-surgical discharge processes
from some Melbourne health services, relying on the
local health service or the patient to arrange for
radiation treatment, and not taking into account the
time lapse before treatment can commence (eg.
planning time)
There is no system in place to routinely link to local
support services for patients who have the majority of
their treatment in metropolitan centres
Early referrals to palliative care are encouraged through
regular supportive care meetings
It was felt by palliative care staff that some health
professionals are unaware of the multiple roles that
palliative care can have throughout the cancer
trajectory, not just for end of life care. The palliative
care team can contribute to the ongoing management
of symptom control
There is no local medical model for the Hume region
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with regards to palliative care. The potential
appointment of a palliative care physician is being
considered, but the region is currently reliant on
metropolitan services visiting once a month
Feedback from health professionals identified a need
for culturally appropriate education for Aboriginal
Health Workers and community members regarding
cancer prevention and treatment
Follow up care
A supportive care meeting is held weekly in
Albury/Wodonga to identify the needs of the
patient/family. There is representation across nursing and
allied health to address the needs of patients and their
families/carers and referrals are made to health
professionals in Wangaratta and rural services as required
allowing for better coordination of care
There is difficulty accessing psycho-oncology services
(especially psychologists/psychiatrists) in the public
sector. There is a 0.6FTE Oncology Social Worker at
Albury Wodonga Health and a clinical psychologist with
oncology experience at Northeast Health Wangaratta,
but outpatients from rural areas may find it difficult to
access services. The cost of private psychology services
may be prohibitive for some patients
There are good communication links between CCC’s,
palliative care and the oncology team resulting in a large
proportion of cross referrals
The lead clinician (GP, specialist etc) is not always
clearly identified post treatment and this can lead to
patient confusion and inconsistent access to support
services
GP representatives reported that some GPs felt they are
not well informed about patients previous treatment or
medications when patients return for post- treatment
management
Specific local community supports for people with a cancer
diagnosis include breast cancer support groups, Look Good
Feel Better, Brave Hearts, Dragons Abreast, Mayflies, a
Gynaecology and Ovarian (GO) support group, a Prostate
Cancer Support Group and the Albury Wodonga Cancer
Foundation. There is also a Wellness Circle for women with
cancer
Local tumour specific community support groups are
limited to breast, prostate and ovarian cancers. Other
tumour streams rely on web or phone based support
Cancer patients have continuing access to a key worker in
the form of a Cancer Care Coordinator (CCC),Breast Care
Nurse (BCN), or Leukaemia Foundation Support
Coordinator
Health professionals and patients both reported
occasions where transfer of care was poorly
coordinated due to limited communication on discharge
from some metropolitan health services. Patients
reported feeling unsupported or unsure of what
services they needed and GPs reported they were not
informed of relevant treatment information
The Border/East Hume Cancer Network has several highly
skilled lymphoedema practitioners in public and private
settings
Local publically funded lymphoedema services currently
have a significant waiting time and access continues to
be raised as an issue
Referral to community nursing is very simple for NSW
patients but follows a much more complex system for
VIC patients due to the structure, pathway, and funding
bodies. This is one example of the cross-border
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differences in referral pathways and eligibility criteria
for a range of support services including allied health,
community and district nursing and HACC services
Patients often reported that Centrelink Forms are
confusing and difficult to manage particularly for
patients with low literacy levels. Access to Centrelink
can be difficult for patients living away from major
centres
Patients discharged from private hospitals can have
difficulty accessing publically funded support services at
home
It is unknown what supports are needed or available for
children and spouses of people with cancer in the
region
Determination of plans and treatment for recurrence
Treatment care planning for recurrence is often
undertaken by the MDT
GPs reported that they are sometimes not involved in
the coordination of follow up
Clear plans for follow up exist within local surgical and
oncological teams
When asked about follow up care plans, many patients
agreed that written information would have been of
more benefit than verbal information alone
There is difficulty accessing counselling, sexual health,
psycho-oncology, and family planning services in the
region
GPs commented that they would like to be better aware
of the service providers involved with their patients so
as to improve coordination of supportive care services
and not double up on referrals
End of life care
Mercy Health Albury has 10 inpatient hospice beds
There are some restrictions on access to palliative care
services across the NSW/Victorian border which can be
time consuming and frustrating for the
patient/family/carers. No dedicated “hospice” facility
within the Hume region (on the Victorian side of the
border). There are allocated beds across the region
within clinical hospitals for the management of end of
life care
Relevant services have been identified across the acute,
sub acute and community sector both locally and cross
border. Services are more readily available in the larger
sites with outreach services accommodating the needs of
patients living in rural areas. Feedback from clinician and
patient interviews acknowledges their utilisation
Palliative Care staff in metropolitan centres often refer
patients back to local palliative care services on discharge
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from a tertiary hospital
Palliative care staff reported feeling that many health
professionals are unaware of the multiple roles that the
palliative care team can have throughout the cancer
trajectory
It was noted that throughout the region there is no
clear known pathway to access to pastoral care services
- this is particularly pertinent with end of life care. There
is a lack of access to services to assist with spiritual
needs regardless of religious denomination – currently
there can occasionally be generalist and spiritual
support this may not always be the patients preference
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5.7 Specific successes and gaps in the care pathway for gastrointestinal cancer
Table 11 presents the successes and gaps particular to gastrointestinal cancer (colon, rectal, pancreatic)
that were identified in this project with respect to meeting the recommended care pathway described in
the PMF. This table highlights issues across the steps of the care pathway from diagnosis to end of life
across the four priority areas of multidisciplinary care, care coordination, reducing unwanted variations in
care and supportive care.
Table 11: Successes and gaps for gastrointestinal cancer
SUCCESSES
GAPS
Initial diagnosis and referral
Increasing the Gastrointestinal MDTM to fortnightly as
of July 2010 has enabled a greater number of patients
to be presented and enables greater education and
learning between specialists
Several specialists noted that one local surgeon is ‘not part
of the MDT and does not follow any pathway’ despite
attempts to engage them in the local MDTM process
Patients stated their diagnosis was given to them by a
surgeon and that they believed the surgeon took
sufficient time to explain their diagnosis. Some
clinicians stated that at the point of diagnosis, many
patients do not want a large amount of information
Most surgeons stated they don’t give information
booklets to patients at the point of diagnosis, however
take the time to explain the diagnosis and may draw
diagrams or utilise large diagram posters to aid the
discussion
Some surgeons have stated they will phone the patient
within a few days to ensure they understand their
diagnosis and to see if the patient has any further
questions
Not all patients are linked into a CCC. Comments from some
patients included:
‘I needed more understanding of what was happening and
someone to talk to’
‘I always felt lost and really did not know what was
happening’
‘I needed more information on what effects chemotherapy
and radiotherapy would have on me. Needed to talk to
someone who had undergone the treatments to give me
some idea of how I might feel and how to overcome the
side effects’
Determination of treatment
It was felt by some health professionals that the data
collection and outcomes entered in CANMAP from the local
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MDTMs were not as comprehensive as they should be.
Some health professionals also noted that other general
correspondence between members of the treatment and
supportive care teams could be improved
Some members of the MDTM team raised their concern
that there was not always a clear consensus made at the
end of the MDTM patient discussion in regards as to which
senior health professional would be following up and
completing referrals as required
Some health professionals felt that the current MDTM
model was quite medically based and that there was often
not a good representation from all involved in the care
coordination of the cancer patient, or opportunities for
these members of the supportive care team to provide
input into the MDTM discussion
Many patients stated that they did not have a written care
plan and felt they may have benefited from one.
‘My surgeon and oncologist were fantastic but I always
felt lost and really did not know what was happening’
Treatment
Endoscopic retrograde cholangiopancreatography
(ERCP) is available in Albury/Wodonga and Wangaratta
Many pancreatic cancer patients are no longer
transferred to Melbourne for treatment as the majority
of treatment can be provided locally. Clinicians felt that
there has been an improvement in local services for
the treatment of pancreatic cancers
Surgeons have generally stated a lack of time as a hindering
factor in nominating patients for clinical trials
General surgeons have noted that they “do what’s needed”
but this can lead to difficulties in having to manage many
aspects of the patient’s care when this could be managed
with shared care or with greater support for general
surgeons
Follow up care
Continence Nurse Advisors (CNA) are available and will
support rural patients at home if HACC eligible. Lack of
counselors trained in sexual problems. CNAs will
discuss continence issues and often discuss if the
patient is having erectile problems, but then refer
patient back to specialist (or to a local private sex
therapist).
There is not a standard process for referral to CNAs and it
depends on the specialist the patient is seeing.
Several local stomal therapists are available to support
patients
Some patients have stated they had poor initial stomal
support, in the absence of referral to a stomal therapist:
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‘Wish I knew back then what I know now’
‘Being an ostomate, support at first was sparse but did
improve later with the arrival of a competent stomal
therapist’
Determination of plans and treatment for recurrence
There are no specific successes or gaps for this tumour stream.
End of life care
There are no specific successes or gaps for this tumour stream.
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6. RECOMMENDATIONS
Recommendations for addressing the gaps that were identified in this project were developed and
presented under the four priority areas of multidisciplinary care, care coordination, supportive care and
reducing variations in care, and have been categorised as short or long-term according to their ease of
implementation.
It is the role of Hume RICS to work in partnership with the relevant health services, clinicians, other health
professionals and consumers to develop and/or support strategies to address these recommendations in
order to improve cancer service delivery.
6.1 Multidisciplinary Care
Table 12: Recommendations for multidisciplinary care
Number
Recommendation
1
Continue to promote and support opportunities for non-local
clinicians to link into the Albury/Wodonga MDTMs remotely (eg. for
the surgeons based in Wangaratta to attend the Gastrointestinal
MDTM via WebEx)
2
Best practice models of multidisciplinary care continue to be
promoted to local health professionals, specifically with respect to
encouraging all specialists treating colorectal and upper
gastrointestinal cancers in the Border/East Hume Cancer Network to
refer to, and attend, the Gastrointestinal MDTM
3
Hume RICS continues to contribute to local and statewide initiatives to
improve multidisciplinary team meeting administration, including to
support the implementation of sustainable, standardised software
and to contribute to statewide minimum datasets

4
Evaluate and enhance GP involvement in multidisciplinary teams,
including participation in local MDTMs

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
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6.2 Care coordination
Table 13: Recommendations for care coordination
Number
Recommendation
1
Health professionals and consumers should be well informed about
the range of different treatment and supportive care options,
particularly those available close to the patient’s home
2
Hume RICS continues to promote engagement with the community
health sector, and Home and Community Care (HACC) services,
particularly in relation to linking rural and remote patients with their
local support services where possible

3
Relevant federal and statewide strategies working towards improving
communication channels between all health professionals, including
GPs, should be promoted widely (such as the Human Services
Directory (HSD) and e-referral

4
Communication systems are improved to ensure that patient medical
information is available in a timely manner to all relevant clinicians,
including the GP

5
Transition of care (discharge planning) processes should be improved
to promote continuity of care, particularly between metropolitan and
regional/rural health services, private hospitals and primary health
services, and also between specialist cancer services, primary health
and palliative care

6
The potential barriers in accessing appropriate services should be
identified and strategies developed to address them

7
Protocols are developed and implemented to ensure that patients
being transferred from a metropolitan treatment centre back to the
Border/East Hume Cancer Network are referred to the relevant local
support nurse/Cancer Care Coordinator in a timely manner

8
Processes are established to promote the development of cancer care
management plans and palliative care pathways (as guided by the
Goulburn Valley Health End of Life project)

9
Review of lymphoedema models of care, including early intervention,
are supported

10
Resources are developed for GPs that support appropriate and timely
referral of people diagnosed with cancer to specialist cancer services
and community services as appropriate
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

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6.3 Supportive care
Table 14: Recommendations for supportive care
Number
Recommendation
1
Health services are supported to ensure that all newly diagnosed
cancer patients have access to supportive care screening (including
the utilisation of a screening tool developed specifically for patients
aged over 70 years) and that these results are documented in the
patient’s central medical record
2
Supportive care screening is implemented at designated follow up
intervals, including recurrence
3
The importance of supportive care discussion within a
multidisciplinary team meeting is promoted and that this discussion is
documented
4
Health services are supported to develop service models which
include prevention, early intervention, treatment and support for
cancer patients. Such services may include lymphoedema services,
speech therapy, dietetics, counselling, PEG feeding and home oxygen
5
Hume RICS continues to provide and promote practical support and
information for consumers (including the Hume RICS website, tailored
standardised information packs and professional development
sessions for specialist cancer staff) and continues to focus on
improving information and access to travel, accommodation and
financial supports

6
Options for access to pastoral care should be investigated and
promoted

7
Partnerships with palliative care services are enhanced and a health
promotion approach to palliative care is supported, including
advocating for the importance of early intervention
8
Transport, financial, and emotional support continue to be raised as
issues for rural communities in accessing oncology treatment

9
Continue to raise awareness of the specific supportive care needs of
priority population groups including Aboriginal and Torres Strait
Islander, adolescent and young adults, and culturally and linguistically
diverse communities

10
A model is developed to facilitate increased access to psychosocial
oncology support for public and private patients in community and
inpatient settings across both sides of the NSW/Victorian border

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Long-term





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6.4 Reducing Unwanted Variations in Care
Table 15: Recommendations for reducing unwanted variations in care
Number
Recommendation
1
Medical oncology education for small rural health services and GPs
should be facilitated, including pain and side effect management for
cancer patients
2
Systems for timely access to allied health services and practical
supports are developed, particularly for patients in private hospitals
3
In consultation with the Hume Medicare Local, Hume RICS provides
GPs with access to oncology/specialist referral criteria and pathways,
as informed by the findings of the West Hume Cancer Network GP
project
4
Waiting times around access to theatres should be investigated to
better understand the implications and impacts
5
Earlier referral processes from metropolitan settings to rural radiation
services are in order to avoid delays experienced by patients in
accessing local radiotherapy services
6
Support the work undertaken by the Albury Wodonga Regional Cancer
Centre Consortium to advocate for improved access to public medical
oncology and radiotherapy
7
Further investigate the inequities in financial supports (including
subsidies for dietary supplements, HACC services, community/district
nursing) to identify the differences for public/private patients and
NSW/Victorian residents

8
An education needs analysis should be conducted in order to develop
and facilitate appropriate professional development for a broad range
of health professionals involved in the care of patients with cancer;
particularly as related to issues such as death and dying, treatmentrelated sexual issues, health literacy and self care

9
Support health services in exploring opportunities to implement
and/or further extend their use of CHARM to improve systems relating
to safety, quality and efficiency

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





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7. DISCUSSION
The aim of this project was to identify opportunities for ‘whole system’ improvement and development,
for consistent and coordinated cancer care across the Hume Region. In accordance with the objectives, this
project identified the successes and gaps with respect to how well the actual patient pathway aligned with
the optimal patient pathway described by the PMF. Based on the findings of this project, key
recommendations were identified and classified as short-term or long-term priorities for Hume RICS to
incorporate in future cancer service improvement activities as directed by the Hume RICS Strategic Plan.
This project was able to collect broad data from a variety of sources, including interviews with clinicians,
health professionals and consumers, as well as from several local and statewide data sources. However,
several limitations of this project were identified, including the difficulty in obtaining an accurate and
thorough understanding of the patients’ journey from assessing medical records alone. This was
particularly noticeable in Albury/Wodonga where patients may receive treatment from a mix of public and
private services on either side of the border. This meant that a review of the medical record where the
patient received the bulk of their treatment may not accurately document the entire patient journey.
Improving the transfer of documentation between service sites is a priority area for service improvement. It
was also not possible within the scope of this project to review the medical records of patients receiving
components of their care at metropolitan sites. Future projects could investigate opportunities for review
of both regional and metropolitan health service sites to gain a thorough understanding of all treatment
and support provided.
Due to the limitations of the consumer recruitment strategy, it was sometimes difficult to recruit
consumers with a relatively recent diagnosis of some of the lower volume cancers. Future patient pathway
mapping projects could investigate recruiting consumers prospectively to document the entire patient
journey from diagnosis onwards.
Whilst there was positive engagement from the health professional community to participate, it was
sometimes difficult to obtain information about all the tumour types examined in this project. For example,
the majority of specialists in the Border/East Hume Cancer Network treat multiple tumour types and did
not have time to discuss the tumour-specific successes and gaps at length during their interviews with the
project team. However, it is acknowledged that many of the areas identified for improvement are general
across all tumour types (eg. improving communication processes etc).
A major limitation with respect to analysing data in the Border/East Hume Cancer Network was the
absence of Albury data in the VAED. This has been identified as a priority area for resolution as currently
the data available severely under-reports cancer service activity across the Border/East Hume Cancer
Network. It also limits the ability to determine patient flows both within and external to the Hume region. It
was also sometimes difficult to compare incidence and mortality data collected by the NSW Cancer Registry
and Cancer Council Victoria due to differing definitions and data fields collected.
In summary, this project has identified the gaps and successes with respect to the actual patient pathway in
the Border/East Hume Cancer Network as compared to the optimal patient pathway described by the PMF.
The findings of this project have enabled key recommendations to be developed and these should form the
basis of future cancer service improvement activities for Hume RICS, in partnership with health services
across the network.
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8. ACKNOWLEDGMENTS
The following Border/East Hume RICS current and former staff members are acknowledged for their
contributions to this project: Paula Fraser, Rebecca Myers, Kathy Vickers, Clare Dunin, Nick Brown, Robyn
Sharman, Liz Macpherson, Jenny O’Connor, Jenny Donnelly, Vanessa Sariman, Marg McKenzie, Alex
McKenna and Theresa Richards.
This project was conducted in partnership with the West Hume RICS team, and along with the staff of the
Directorate of Hume RICS, they are acknowledged for their contributions: Carole Mott, Christine Ryan,
Allison Hartney, Gemma Kenny, Rebecca McAllister, Megan Wright, Monica Harvey, Renee Scott and Clare
McCarthy.
The participation of the many consumers, clinicians, health professionals and staff members of our partner
health services in this project was pivotal and all participants are acknowledged and thanked for their
significant input to this project.
The Hume RICS Strategic Manager, Chris Packer, and Border/East Hume Clinical Director, Dr Craig Underhill
are acknowledged for providing strategic management to this project.
The Border/East Hume Clinical Reference Group and Cancer Network Committee provided overall guidance
regarding the objectives and scope of this project, as well as prioritising the recommendations for cancer
service improvement activity arising from this project.
The Hume RICS Executive are acknowledged for their support of this project across the Hume region.
Colorectal & Upper GI PPM Report
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9. REFERENCES
1,9
Clinical Networks: A framework for Victoria 2008 Department of Human Services
2,16,23,24 Patient management frameworks 2006 Department of Human Services
3
Patient management frameworks Colorectal tumour stream: colon and rectal cancer; and
Upper gastrointestinal tumour stream: pancreatic cancer 2006 Department of Human
Services
4
National Survey of NHS Patients Questionnaire (1999-2000), Centre for Social Research,
Picker Institute Europe
5
Victorian Cancer Patient Experience Survey Tool 2011, Victorian Department of Health
6,31,32
Data obtained from Cancer Council Victoria and NSW Cancer Registry
7,8,12,18
Achieving best practice cancer care, A guide for implementing multidisciplinary care 2007
Department of Human Services
10,14,15
A Cancer Services Framework for Victoria 2003 Department of Human Services
11
Victoria’s Cancer Action Plan 2008-2011, 2008 Department of Human Services
13,25
Clinical excellence in cancer care, a model for safety and quality in Victorian cancer services
2007 Department of Human Services
17
http://health.vic.gov.au/cancer/framework/pmfsnew.htm
19
Multidisciplinary Care Literature review June 2012 Department of Health
20
Multidisciplinary Team Meeting Toolkit 2006 Department of Human Services
21
Multidisciplinary team meetings in Victoria, Monitoring progress towards achieving best
practice cancer care 2010–11 Department of Health
22
Linking cancer care: A guide for implementing coordinated cancer care 2007 Department
of Human Services
26
PCP and ML regional and southern NSW boundaries 2011, Extract from
http://www.health.vic.gov.au/pcps/pcps_mls.htm
27
Service and Workforce Planning, Portfolio Services and Strategic Projects Division Feb 2009
Department of Human Services
28
Victoria in Future 2012: Population and household projections for Victoria and its regions
2011-2031, Department of Planning and Community Development
29
NSW Statistical Local Area Population Projections 2006 – 2036, NSW Department of
Planning
30
Data obtained from Victorian Department of Health and NSW Cancer Registry
33,35
Data obtained from Cancer Council Victoria
34,36
Data obtained from NSW Cancer Registry
Colorectal & Upper GI PPM Report
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10. APPENDICES
Appendix 1: Patient Management Frameworks toolkit
Patient Management Frameworks
Tools to assist in working with local tumour groups
The Patient Management Frameworks are a guide to the optimal care management of patients in each
tumour stream. They are intended to improve patient outcomes by facilitating consistent care based on
evidence and best practice across the state.
They can be used in a variety to ways:





Provide a uniform approach across the State and a common language for discussion about what is
required for optimal care for cancer patients
Can focus discussion on steps of the patient journey to identify where improvements can be made
Provide a benchmark to identify what needs to happen to improve care
Assist in identifying the priority areas that need to improve
Compare practice across an Integrated Cancer Service.
The tools in this package are designed to assist in these activities. You may wish to use them as they are or
to modify them to meet you specific needs.
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Patient Management Frameworks – A Guide to their use
Outlined below is a guide and some examples of what the Integrated Cancer Services may wish to consider when implementing the PMF’s. More specifically, the
types of questions the Local Collaborating Tumour Groups (LCTG’s) may wish to ask about the services/care they provide. The guide uses the priority outcomes for
the Integrated Cancer Services as a reference point, with the aim of maximising integration of the information. This is not an exhaustive checklist but rather a
starting point when implementing the PMF’s in your LCTG’s within your Integrated Cancer Service.
Steps of the patient pathway
At Community Level
Multidisciplinary Care
Initial diagnosis and referral
Is the process for referring patients for
discussion by the MDT known and
understood by the relevant healthcare
professionals?
Are members of the MDT clear about
where the particular care can be provided
within their tumour group?
Determination of treatment
Colorectal & Upper GI PPM Report
Multidisciplinary Care
Is there a MDT discussion/meeting that
Care Coordination
Is accurate, understandable information
available and accessible to the general
community about the signs and symptoms
(S&S) that need to be reported to a GP,
which may be suggestive of this tumour
type?
Are GPs aware of the S&S suggestive of
this type of tumour, as well as patients
that are at higher risk of the tumour due to
family/personal history?
Is there agreement between different HPs
(GPs, surgeons, oncologists) of what
investigative tests are needed, and who is
responsible for ordering/undertaking them
for this tumour group?
Are there clear referral pathways between
service providers within your tumour
group? Are there written protocols as
appropriate to ensure clear understanding
of processes and roles?
What is in place to support the processes
required? (eg common referral templates
inclusive of all information required)
Is there clear understanding of information
that the consumer needs at this stage?
Psychosocial and Supportive care
Are there clear screening processes in the
community regarding the patients risk of
anxiety and depression? Are you clear
within your tumour group what the
community capacity is, to contribute to
supportive care and who to refer to?
Variations in Care
Is there an awareness of where screening
is accessible to patients within your
tumour group?
Is there data to review these processes?
Do all patients receive relevant
information about their disease, diagnostic
procedures, treatment options, treatment
effectiveness, possible adverse effects, and
outcomes?
Are there clear referral pathways and
protocols to specialised supportive
services within your tumour group?
Are there clear referral processes in place
to ensure the patient receives the
necessary assessment by the appropriate
practitioner?
Care Coordination
Is consent of the patient sought prior to
Psychosocial and Supportive care
Is there an identified person to
Variations in Care
Are there agreed protocols and pathways
Page 56 of 109
takes place to prospectively plan the
patients care?
Are patients given full information on
advantages and risks and different options
recommended by the MDT for treatment,
with sufficient detail to allow them to play
an active part in decision making?
multidisciplinary discussion?
Has case conferencing and/or a MDT
meeting been conducted as appropriate to
ensure the care plan is coordinated and
then relayed to the patient?
Progression of care should be coordinated
ensuring the patient, GP and MDT
members are clear on their responsibilities
within the tumour group.
Are there mechanisms in place to ensure
this has been documented in the patient
record?
Are there mechanisms in place to ensure
continuity of care? (eg protocols/systems
of communication between service
providers – public/private, acute/GP – to
ensure relevant staff are informed of each
stage of the patients progress).
Does the patient have a care plan and
understand the planned treatment and
processes/sequence?
Is there access to a discharge summary
template and are the relevant team
members aware of the referral
mechanisms within your tumour group?
communicate the treatment and care plan
to the patient?
Is there adequate staff training within your
tumour group in identifying and
responding to supportive care needs?
for determining patient treatment within
your tumour group?
Is there an agreed process of involving
patients in decisions about their
treatment?
Do you ensure that
patients/carers/families are provided with
information in a variety of formats to meet
their needs? (eg written or verbal;
taped/written record of consultations;
facilitate the use of an interpreter if
necessary).
Is your workforce competent?
How do you know?
What data do you collect to measure this?
Are patients informed about sources of
social and practical help, such as support
groups and helplines?
Do patients have continuing access to a
key contact from the MDT?
Is there provision for patients to give
feedback on their experience of treatment,
facilities and services they receive?
Is the appropriate MDT in place to assist
his or her family through physical,
psychological, emotional and spiritual
needs? For many patients and families this
may include bereavement support
Is there timely re-assessment by
appropriate team members?
Are there clear communication strategies
in place between team members regarding
follow-up care?
Are there protocols in place to clearly
establish the plans and treatment for
recurrence in this tumour group?
Treatment
Has the MDT developed protocols on
when the patients care plan will be
discussed?
Does the MDT record include treatment
and care recommendations?
Follow-up Care
Does each patient have a written plan for
his or her treatment or follow-up, which
addresses the relevant issues for that
particular tumour group?
Determination of plans and
treatment for recurrence
Is treatment care planning for recurrence
undertaken by a MDT including the
patients GP?
Is patient decision-making considered
when planning coordinated
care/treatment for patients in this tumour
group?
End of Life Care
Are there relevant MDT members and
services in place that can assist the patient
in dealing with end of life/care issues?
Is the care that is coordinated considerate
to the needs and wishes of the patient and
family?
Are there clear communication channels
between the patient/families and care
providers?
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Are there appropriate end of life services
available to patients?
Are there agreed referral processes
between cancer and palliative care
services?
Patient Management Frameworks – worksheet
TUMOUR GROUP:
___________________________________
From the patient management framework, identify issues, gaps and inconsistencies, and then agree on priority initiatives.
KEY ASPECTS
TO ADDRESS
At
Community
Level
Initial
diagnosis
and referral
Determination Treatment
of treatment
Follow-up
care
Multidisciplinary
Care
Care
Coordination
Psychosocial
and Supportive
Care
Reducing
Variations in
Care
Agreed priority
initiative/s
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Determination End-of-life
of plans and
care
treatment for
recurrence
Identifying gaps in care coordination
Using the questions below, complete the columns in the table below:
1. Patient Perspective
Thinking from the patient perspective what information provision/ support needs to happen at this point at the interface between the health
professional and the patient to ensure continuity of care?
2. Health Professional perspective
In the role of a health professional, what information do you need to get at this stage and what do you need to pass on to others – How and to
whom?
3. Processes needed
What needs to happen behind the scene to ensure continuity between this stage and the next?
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Critical Point
Patient perspective
Health Professional Perspective
Processes
Patient perspective
Health Professional Perspective
Processes
Initial diagnosis and
referral
Determination of
treatment
Treatment
Critical Point
Follow up care
Determination of plan and
treatment for recurrence
End of life care
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Decision Making Grid
EFFORT
Difficult to do
IMPACT
Major
improvement
Minor
improvement
Build a realistic
strategy to get
there
Park it
Easy to do
DO IT
DO IT
Evaluate your strategies or initiatives to determine which ones you are going to pursue
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Appendix 2: Supplementary Health Professional Interview Questions

Please have a look at the Patient Management Framework (Patient
Pathway) as set out by the Victorian Department of Health.

Please consider the following questions (where applicable).
1. Could you please advise whether you think this is an accurate representation of
what occurs for the majority of your patients? (Is this the usual path that they
take?).
2. Are there any areas listed that you find are difficult to access and why?
3. At a point for referral along the patient pathway, i.e. initial diagnosis (General
Practitioner), where do the majority of your patient referrals come from?
4. What progression of disease do the majority of patients have when they attend
for their first appointment with you? I.e. post diagnostic work (breast
examination/mammogram/biopsy).
5. What level of support do you believe you have in your service delivery? (Do you
believe that you are well support professionally i.e. have access to services
than enable you to care for your patients along the patient pathway)?
6. In your current professional position, do you believe that are any gaps or
duplications in providing ‘optimal’ patient care? What are these are do you
know why they have occurred? I.e. preliminary workup by the patients General
Practitioner before being referred to specialist.
7. In what form to you complete referrals, as required, to other health
professionals or supportive care organizations (i.e. letters, phone calls, emails
etc).
8. What are your views on care coordination? Do you believe it is done well or
not?
9. Do you believe there are any areas that are of concern to you regarding the
patients’ treatment pathway? I.e. do you believe you have timely access to
investigation and treatment modalities? Are there any areas of diagnostic
treatment or testing that is impacting on the patient treatment?
10. Are all the patients that you see that have a diagnosis of cancer discussed at a
MDT meeting? Do you discuss with your patient’s multidisciplinary care and the
role of multidisciplinary teams meetings? At what stage are your patients
presented at a MDT meeting, i.e. pre or post surgical intervention?
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11. Do you have your own database or do you utilize a central database to house
patient information? Is this information shared with Health Information
Management (patient medical records) at all treating hospitals/health services?
12. In general, what information do you give to your patients regarding their
diagnosis, and at what point after investigations/diagnosis do you give patient’s
information?
13.Do you see private, public or a combination of both types of patients?
Generally, what percentage would you see for each?
14. What do you do if it is a complicated or rare tumor? Do you send tumor
markers off to other sites nationally or internationally?
15.Do you offer and give access to all eligible patients for clinical trials? How is this
determined? Do you receive regular information about clinical trials that people
are able to access?
16.Which hospitals in the metropolitan region so you have links to and refer to?
Why?
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Appendix 3: Consumer Participant Questionnaire
Participant Questionnaire - Patient Pathways Mapping
Hume Regional Integrated Cancer Service is undertaking a ‘service improvement’ project
entitled ‘Patient Pathway Mapping’. Your participation in this project will enable Hume
RICS to identify areas for improvement in patient access to cancer care services.
This questionnaire is based on The National Survey of NHS Patients Questionnaire (19992000) from the Centre for Social Research, Picker Institute Europe and the Victorian
Department of Health’s ‘Victorian Cancer Patient Experience Survey Tool’.
The questionnaire is structured into four parts:
1.
2.
3.
4.
About You
Finding out what was wrong with you
Treatment: Planning and Management, including Surgery
Treatment Journey, including Radiotherapy and Chemotherapy
The structure of the questionnaire means that a great deal of quantitative data will be
obtained. There are, where possible, areas in the questionnaire where participants can
make comments and share their opinion regarding how cancer services could be
improved.
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Part 1:
About You.
This section asks for some background information about you and your cancer treatment.
These questions help us get an idea of who is participating in the study.
1. Are you male or female?
Male
Female
2. What age bracket do you belong to?
18-30 years 30-40 years 40-50 years
50-60 years 60-70 years Over 70 years
3. What is your ethnic background?
Aboriginal
Torres Strait Australian
Other Describe: ____________________________________
4. What part of the Healthcare Sector do you belong to?
Public

Private

DVA

5. What is your postcode? _______________________________
6. What is your primary cancer diagnosis? __________________
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Part 2:
Finding out what was wrong with you.
When cancer is suspected, most people are referred to see a specialist doctor.
1. What was the outcome of your GP appointment?
Sent for tests
Referred to a Specialist Doctor
Referred to a Hospital
Review appointment with your GP
Nothing further
Other






Sometimes people will have several tests before a diagnosis of cancer is given.
2. Who gave you the result of the test that showed that you definitely had cancer?
GP ..........................................................................
Surgeon ..................................................................
Medical oncologist ..................................................
Radiation oncologist................................................
Haematologist .........................................................
Other (please specify) _______________________





3. Approximately how much time was spent explaining to you what
Less than 5 minutes
5 to 15 minutes
15 to 30 minutes
More than 30 minutes
Can’t remember
4. Did you feel the time taken was adequate?
Yes
No
was wrong?







5. When you were first told what was wrong, did you receive any written information?
Yes
No
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

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6. How useful did you find this written information?
Very useful
Useful
Not very useful
Can’t remember




7. When you were first told what was wrong, were treatment options explained to you?
Yes
No


8. Is there anything else you feel is important that you would like to add?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
_________________________________________________
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WHEN YOU WERE TOLD YOU HAD CANCER
The below questions relate to how you were told you had cancer.
WHEN YOU WERE TOLD YOU HAD CANCER
Yes,
definitely
Yes,
I
think
so
No,
I
don’t
think
so
No,
definitely
not
When my doctor told me that I had cancer:
a.
It was at a face-to-face appointment.
1
2
3
4
b.
I was told before the appointment that I could have a
friend or family member with me if I wanted to.
1
2
3
4
c.
I clearly understood the explanation my doctor had given
me.
1
2
3
4
Within a reasonable time of being told that I had cancer:
d.
I was given written information about cancer.
1
2
3
4
e.
I was given a sheet with suggestions about questions that
I might like to ask at my next appointment.
1
2
3
4
f.
I was told how I could get further information about cancer
e.g. websites, booklets, cancer helpline.
1
2
3
4
1
2
3
4
Overall, when I was diagnosed with cancer:
g.
I received good quality care.
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Part 3: Treatment: Planning and Management, including Surgery.
PLANNING CANCER TREATMENT / MANAGEMENT
The questions below ask about care given to you by a health professional when treatment (e.g.
surgery, radiotherapy, chemotherapy) was being planned. This means any professional involved in
your cancer care, for example, doctors, nurses, radiation therapists, social workers,
physiotherapists, psychologists etc.
PLANNING CANCER TREATMENT / MANAGEMENT
Yes,
definitely
Yes,
I think
so
No,
I don’t
think so
No,
definitely
not
The doctor(s) involved in planning my cancer treatment/ management:
a.
Gave me information about the advantages and disadvantages
of different treatment options.
1
2
3
4
b.
Gave me information on the possible short-term side effects of
treatment(s) (e.g. nausea, pain, fatigue).
1
2
3
4
c.
Gave me information on the possible long-term side effects of
treatment(s) (e.g. reduced fertility, lymphoedema).
1
2
3
4
d.
Asked my permission to discuss my case with other health
professionals (i.e. a multidisciplinary team).
1
2
3
4
When my cancer treatment was being planned a health professional:
e.
Asked me how much information I wanted.
1
2
3
4
f.
Encouraged me to be involved with planning my treatment
1
2
3
4
g.
Encouraged me to ask any questions about treatment.
1
2
3
4
h.
Gave me information about support services (e.g. the cancer
helpline, support groups or other services).
1
2
3
4
i.
Told me that counselling services were available if I wanted
them.
1
2
3
4
j.
Told me about additional services (e.g. nutritional advice,
occupational therapy, physiotherapy, support groups) that I
could access during my cancer care.
1
2
3
4
k.
Checked if I had concerns about practical issues such as
childcare, finances, or transport to and from the hospital.
1
2
3
4
l.
Made me feel comfortable to ask any questions I had.
1
2
3
4
m.
Checked that I understood the information provided to me.
1
2
3
4
1
2
3
4
Overall:
n.
The health professionals involved in my care helped me to
make a treatment decision that I was comfortable with.
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SURGERY
IF YOU HAVE HAD SURGERY, PLEASE ANSWER ALL QUESTIONS. IF YOU DID NOT HAVE SURGERY, GO
TO NEXT THE SECTION, PART FOUR: TREATMENT JOURNEY, INCLUDING RADIOTHERAPY AND
CHEMOTHERAPY.
Surgery to treat cancer usually involves an operation to remove some or all of the cancer.
This does not include biopsies. If you have had more than one surgery to treat cancer,
please think about the first surgical treatment that you had when answering the questions.
1. Did you have surgery to treat cancer?
Yes ............................................................................. 
No .............................................................................. 
2. Did you have surgical treatment in a:
Public hospital or public clinic...................................... 
Private hospital or private clinic ................................... 
Not sure ...................................................................... 
3. Where did you have your surgical treatment? (Please indicate name of
town/suburb or postcode of town/suburb where hospital is located)
Town/Suburb______________ OR Postcode_____________
Sometimes other treatments or tests need to be completed before a person is ready
to be booked in for surgery.
4. Once you were ready to be booked in for surgery, how long did you wait until you
actually had surgery?
3 days or less .............................................................. 
More than 3 days, but within a week ........................... 
More than a week, but within 2 weeks ......................... 
More than 2 weeks, but within 4 weeks ....................... 
More than a month ..................................................... 
If the length of time was more than a week, was this due to:
Personal decision to wait ....................................... 
Surgery waiting times............................................. 
5. Was the date of this hospital admission ever cancelled or postponed by
the hospital?
Yes, once

Yes, more than once

No, never

Not sure

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6. How far did you have to travel to get to the Hospital?
Less than 10 km
10-50 km
50-100 km
More than 100 km




7. During this admission did you feel you were given the opportunity to be involved in your care
and treatment?
Yes, all the time
Yes, some of the time
No, not really
Can’t remember




8. During this admission did you feel both yourself and your family were provided with adequate
information about you?
Too little information
Just enough information
Too much information
Not sure




9. Before you left Hospital, did staff enquire about your social and home situation?
Yes
No
Can’t remember



10. Before you left Hospital were you offered any home support?
Yes

No

Can’t remember

Type: ___________________________________________________
11. Before you left Hospital were you given written information about what you should or need to
do after discharge?
Yes
No
Can’t remember
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

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12. Before you left Hospital were you given a contact person if you had problems or were worried?
Yes
No
Can’t remember



13. Before you left Hospital were you given a clear plan of future treatment and Doctor
appointments?
Yes, and I completely understood what I was told
Yes, and I understood some of what I was told
Yes, but I did not understand what I was told
No, this was not explained to me
Can’t remember





14. Before you left Hospital were you given information about
social / financial benefits you could access?
Yes
No
Can’t remember



15. Did you feel your General Practitioner was provided with the appropriate information about
your hospital admission and treatment?
Yes
No
Can’t remember



16. Would you like to comment about anything else that was important to you or difficult for you
during this admission?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________
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SURGERY
IF YOU HAVE HAD SURGERY, PLEASE ANSWER ALL QUESTIONS. IF YOU DID NOT HAVE SURGERY, GO
TO THE NEXT SECTION , PART FOUR: TREATMENT JOURNEY, INCLUDING RADIOTHERAPY AND
CHEMOTHERAPY.
SURGERY
Yes,
definitely
Yes,
I think
so
No,
I don’t
think so
No,
definitely
not
Before having surgery for cancer I was given information
about:
a.
Why the surgery was necessary.
1
2
3
4
b.
How to prepare for surgery (e.g., if changes to other
medications were needed).
1
2
3
4
c.
How I would feel after surgery.
1
2
3
4
Throughout my surgery planning and follow up:
d.
I was given information about what I could do to manage
any physical side effects at home.
1
2
3
4
e.
I was able to ask any questions that I had.
1
2
3
4
f.
Any pain I had was well managed.
1
2
3
4
If you did not experience any pain, please check this
box.
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Part 4: Treatment Journey, including Radiotherapy and Chemotherapy.
THE FOLLOWING QUESTIONS RELATE TO POSSIBLE TREATMENTS YOU MAY HAVE HAD OTHER
THAN SURGERY.
Radiotherapy
Chemotherapy
Hormone
Therapy
Other
Less than 10 km




10-50 km




50-100 km




More than 100 km




Yes




No




Can't remember




Yes, and I completely understood
what I was told




Yes, and I understood some of what
I was told




Yes, but I did not understand what I
was told




No, this was not explained to me




Can’t remember




TREATMENT JOURNEY
a. How far did you have to travel for
your treatment?
b. Were you given information on
travel allowances you could
access?
c. Was the purpose of this treatment
explained to you prior to the first
appointment?
Colorectal & Upper GI PPM Report
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Radiotherapy
Chemotherapy
Hormone
Therapy
Other
Yes, I was given plenty of opportunity




Yes, but I was not given much time




No




Can’t remember




Yes, by the Doctors




Yes, by the Nurses




Yes, by the Doctors & Nurses




No




Can’t remember




Yes, and I completely understood what I was
told




Yes, and I understood some of what I was
told




Yes, but I did not understand what I was told




No, this was not explained to me




Can’t remember




TREATMENT JOURNEY CON'T
d. On arrival for your treatment were you
given the opportunity to ask questions?
e. On arrival for your treatment were you
asked about how you were feeling about
your condition and treatment?
f.
During your treatment were you given
further explanations about what to
expect?
Colorectal & Upper GI PPM Report
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Radiotherapy
Chemotherapy
Hormone
Therapy
Other
Yes, all of the time




Yes, some of the time




No




Can’t remember




Yes, major side effects/complications




Yes, minor side effects/complications




No




Can’t remember




Yes, very well




Yes, but things could have been
better




No




Can’t remember




TREATMENT JOURNEY CON'T
g. During your treatment did you have
adequate privacy?
h. During your treatment did you
experience any complications or
side effects?
i.
Did you feel these complications or
side effects were managed well?
Colorectal & Upper GI PPM Report
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Radiotherapy
Chemotherapy
Hormone
Therapy
Other
Yes, by the Doctors




Yes, by the Nurses




Yes, by the Doctors & Nurses




No




Can’t remember








No




Can’t remember




Yes




No




Can’t remember




TREATMENT JOURNEY CON'T
j.
During this treatment were you
offered any social or psychological
supports?
k. Prior to leaving were you given a
contact person should you become
concerned?
Yes: Who
________________________________
________________________________
________________________________
l.
Prior to leaving were you given the
opportunity to ask questions about
any of your concerns?
Colorectal & Upper GI PPM Report
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Radiotherapy
Chemotherapy
Hormone
Therapy
Other
Daily




Weekly




Fortnightly




Monthly




Other:
____________________________




Yes, once




Yes, more than once




No, never




Not sure




TREATMENT JOURNEY CON'T
m. How frequent were your
treatments planned for?
n. Have any of your treatments been
postponed or cancelled?
Colorectal & Upper GI PPM Report
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Radiotherapy
Chemotherapy
Hormone
Therapy
Other
Yes, all of the time




Yes, some of the time




No




Can’t remember




Yes, all of the time




Yes, some of the time




No




Can’t remember




Weekly or more often




Every couple of weeks




Monthly




Infrequently




Not at all




Can’t remember




TREATMENT JOURNEY CON'T
o. During subsequent treatments were
you given the opportunity to ask
questions?
p. During subsequent treatments did
you feel socially and psychologically
supported?
q. During your treatment phase how
often did your General Practitioner
review you?
Colorectal & Upper GI PPM Report
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Radiotherapy
Chemotherapy
Hormone
Therapy
Other
Yes, all of the time




Yes, some of the time




No




Can’t remember




Actual treatment and side effects




My illness and prognosis




My physical well being




My social situation




My family and significant others




My financial situation




Coping with cancer




Other _______________________________




TREATMENT JOURNEY CON'T
r.
During your treatment did you feel your
General Practitioner had been kept informed
about you?
s. What have been your main concerns been
about during your treatment?
t. Is there anything you feel you needed during your treatments that you did not get?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
u. Would you like to comment about anything else that is important to you about your treatment
journey?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Colorectal & Upper GI PPM Report
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RADIOTHERAPY
IF YOU HAVE HAD OR ARE CURRENTLY HAVING RADIOTHERAPY, PLEASE ANSWER ALL QUESTIONS.
IF YOU DID NOT HAVE OR ARE NOT CURRENTLY HAVING RADIOTHERAPY, GO TO THE NEXT
QUESTION, CHEMOTHERAPY.
Radiotherapy is the use of radiation to destroy cancer cells in the body, to slow the growth
of cancer, or to reduce the symptoms of cancer. External radiotherapy is given using a
machine that directs radiation onto the body. Internal radiotherapy (brachytherapy)
involves temporarily putting thin tubes, seeds or rods containing radioactive material inside
the body.
24. Did you have radiotherapy treatment for cancer?
Yes ........................................................................... 
No ............................................................................ 
25. Did you have radiotherapy treatment in a:
Public hospital ........................................................... 
Private hospital ......................................................... 
Not sure .................................................................... 
26. Where did you have your radiotherapy? (please indicate name of town/suburb or
postcode of town/suburb where hospital is located)
Town/Suburb_____________ OR Postcode____________________
27. Did you have to arrange different accommodation while receiving radiotherapy? For
example, this might have been at the home of a friend or relative or in a hotel or
hostel
Yes ........................................................................ 
No .......................................................................... 
Sometimes other treatments or tests need to be completed before a person is ready
to start radiotherapy.
28. Once you were ready to start radiotherapy,
until having your first radiotherapy treatment?
how
long
did
you
wait
3 days or less .............................................................. 
More than 3 days, but within a week ........................... 
More than a week, but within 2 weeks ......................... 
More than 2 weeks, but within 4 weeks ....................... 
More than a month ..................................................... 
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If the length of time was more than a week, was this due to:
Personal decision to wait ............................................ 
Radiotherapy treatment waiting times ......................... 
RADIOTHERAPY
IF YOU HAVE HAD OR ARE CURRENTLY HAVING RADIOTHERAPY, PLEASE ANSWER ALL QUESTIONS.
IF YOU DID NOT HAVE OR ARE NOT CURRENTLY HAVING RADIOTHERAPY, GO TO THE NEXT
QUESTION, chemotherapy.
RADIOTHERAPY
Yes,
definitely
Yes,
I think
so
No,
I don’t
think so
No,
definitely
not
Before starting radiotherapy for the first time I was given information about:
a.
b.
Why the radiotherapy was necessary.
How to prepare for radiotherapy (e.g., if changes to
other medications were needed).
1
2
3
4
1
2
3
4
c.
What having radiotherapy would feel like.
1
2
3
4
d.
How I would feel after radiotherapy.
1
2
3
4
1
2
3
4
Throughout my radiotherapy treatment and follow-up:
e.
I was given information about what I could do to
manage any physical side effects at home.
f.
I was able to ask any questions that I had.
1
2
3
4
g.
Any pain I had was well managed
1
2
3
4
If you did not experience any pain, please check this
box.
Colorectal & Upper GI PPM Report
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CHEMOTHERAPY
IF YOU HAVE HAD OR ARE CURRENTLY HAVING CHEMOTHERAPY, PLEASE ANSWER ALL QUESTIONS.
IF YOU DID NOT HAVE OR ARE NOT CURRENTLY HAVING CHEMOTHERAPY, GO TO THE NEXT SECTION,
FINISHING CANCER TREATMENT.
Chemotherapy is the use of drugs, which aim to destroy cancer cells in the body, or to stop them
from multiplying and spreading. It can be given through a drip that goes into a needle in your vein,
through an injection, as a tablet that you swallow, or as cream that’s put on surface of the skin.
29. Did you have chemotherapy treatment for cancer?
Yes ........................................................................ 
No .......................................................................... 
30. Did you have chemotherapy treatment in a:
A public hospital..................................................... 
A private hospital ................................................... 
Somewhere else ....................................................  please specify
Not sure ................................................................. 
31. Where did you have your chemotherapy? (please indicate the name of
the town/suburb or the postcode of the place where you had
chemotherapy?)
Town/Suburb____________ OR Postcode________________
32. Did you have to arrange different accommodation while receiving chemotherapy? For
example, this might have been at the home of a friend or relative or in a hotel or
hostel
Yes ........................................................................ 
No .......................................................................... 
Colorectal & Upper GI PPM Report
Page 83 of 109
Sometimes other treatments or tests need to be completed before a person is ready
to start chemotherapy treatment.
33. Once you were ready to be booked in for chemotherapy, how long did you
until your first chemotherapy treatment?
wait
3 days or less .............................................................. 
More than 3 days, but within a week ........................... 
More than a week, but within 2 weeks ......................... 
More than 2 weeks, but within 4 weeks ....................... 
More than a month ..................................................... 
If the length of time was more than a week, was this due to:
Personal decision to wait ....................................... 
Chemotherapy treatment waiting times .................. 
34. If you have not finished treatment, are you currently having:
Chemotherapy ........................................................... 
Radiotherapy ............................................................. 
Hormone therapy ....................................................... 
Other (please specify) _________________________
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CHEMOTHERAPY
IF YOU HAVE HAD OR ARE CURRENTLY HAVING CHEMOTHERAPY, PLEASE ANSWER ALL QUESTIONS.
IF YOU DID NOT HAVE OR ARE NOT CURRENTLY HAVING CHEMOTHERAPY, GO TO THE NEXT SECTION
- FINISHING CANCER TREATMENT.
CHEMOTHERAPY
Yes,
definitely
Yes,
I think
so
No,
I don’t
think
so
No,
definitely
not
Before starting chemotherapy for the first time I was given information about:
a.
b.
c.
Why the chemotherapy was necessary.
How to prepare for chemotherapy (e.g., if changes to
other medications were needed).
How I would feel after chemotherapy.
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
Throughout my chemotherapy treatment and follow up:
d.
I was given information about what I could do to
manage any physical side effects at home.
e.
I was able to ask any questions that I had.
1
2
3
4
f.
Any pain I had was well managed.
1
2
3
4
1
2
3
4
If you did not experience any pain, please check
this
box.
g.
Any nausea I had was well managed.
If you did not experience any nausea, please
check this box.
Colorectal & Upper GI PPM Report
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FINISHING CANCER TREATMENT
IF YOU HAVE FINISHED TREATMENT, PLEASE ANSWER ALL QUESTIONS BELOW . IF YOU HAVE NOT
YET FINISHED TREATMENT, PLEASE GO TO THE NEXT SECTION - CONTINUITY OF CARE.
FINISHING CANCER TREATMENT
Yes,
definitely
Yes,
I think so
No,
I don’t
think so
No,
definitely
not
1
2
3
4
Towards the end of cancer treatment I was given:
a.
A written plan that included information about my
cancer treatments and recommended follow-up.
Towards the end of cancer treatment I was given information about:
b.
Which follow up tests I might need.
1
2
3
4
c.
When I would need to have follow-up tests.
1
2
3
4
d.
The purpose for taking each of my medications.
1
2
3
4
e.
How to take each of my medications, including how
much I
1
2
3
4
should take and when.
f.
How to manage any ongoing symptoms or side
effects.
1
2
3
4
g.
Which new symptoms might mean that cancer has
come back.
1
2
3
4
h.
What I could do to stay as healthy as possible in
the future (e.g. information about exercise, diet,
stopping smoking).
1
2
3
4
i.
How people commonly feel emotionally after
finishing treatment.
1
2
3
4
j.
Where I could get extra support if I needed it.
1
2
3
4
1
2
3
4
Overall, toward the end of cancer treatment:
k.
I knew where I could get help for any problems
related to cancer that might come up over the next
few months.


Colorectal & Upper GI PPM Report

Page 86 of 109

CONTINUITY OF CARE
THE QUESTIONS BELOW RELATE TO YOUR CONTINUITY OF CARE. IT HELPS US IDENTIFY IF YOUR
CARE WAS COORDINATED.
CONTINUITY OF CARE
Yes,
definitely
Yes,
I think
so
No,
I don’t
think so
No,
definitely
not
From when I was diagnosed until now:
a.
There has been a health professional that I could
contact if I had any questions about my care.
1
2
3
4
b.
My GP has been kept well informed about my cancer
care.
1
2
3
4
c.
The health professionals involved in my care appeared
well informed about my cancer care.
1
2
3
4
If more than one treatment centre was involved in your care, please answer the following question:
The treatment centres involved in my care:
d.
e.
Were well informed about the care I received from
other hospitals or health services.
Co-ordinated my appointments to suit my needs.
1
2
3
4
1
2
3
4
THANKYOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE.
Colorectal & Upper GI PPM Report
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Appendix 4: Background to the Patient Pathways Mapping Project
A4.1 Frameworks to guide cancer reform in Victoria
The need for improved delivery of cancer services along with improved outcomes for patients and their
families has been identified as a priority for both State and Federal governments. The Victorian Department
of Health has a significant cancer reform agenda that aims to improve planning and delivery of treatment
and support to patients so that appropriate care is provided in a timely manner as close to the patients
home as possible.9
Two leading policy documents guiding Victoria’s cancer reforms are the Cancer Services Framework and
Victoria’s Cancer Action Plan (VCAP).
A4.1.1 Cancer Services Framework for Victoria
In 2002, the Department of Health (formerly the Department of Human Services) commissioned the
development of a Cancer Services Framework for Victoria.10
The principles upon which the Cancer Services Framework has been based include:



multidisciplinary cancer care to ensure effective and efficient patient management
maximal geographic access for patients and their carers/families
high quality and safe cancer services.
The Cancer Services Framework identified structures and processes that support optimal cancer care. These
include the development of the Integrated Cancer Services (ICS) to drive change at the local level, and the
development of the Patient Management Frameworks to guide the delivery of consistent cancer care for a
range of tumour streams. The Cancer Services Framework also targets four priority service improvement
areas for reform as:




multidisciplinary care
care coordination
supportive care
reducing unwanted variation in practice (quality monitoring and support)
A4.1.2 Victorian Cancer Action Plan 2008-2011
Released in December 2008, Victoria's Cancer Action Plan has been developed to provide policy leadership
and common goals for Government, health services, research institutes, peak bodies, health professionals
and consumer organisations working in the cancer control arena in Victoria. VCAP has measurable targets
across four key action areas including prevention, research, treatment and support. 11
9
Clinical Networks: A framework for Victoria 2008 Department of Human Services
A Cancer Services Framework for Victoria 2003 Department of Human Services
11
Victoria’s Cancer Action Plan 2008-2011, 2008 Department of Human Services
10
Colorectal & Upper GI PPM Report
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The relationship between the various structures and components of the cancer reform to drive service
improvement is depicted in Figure 3.
Figure 3: Systematic approach to quality in cancer services12
12
Achieving best practice cancer care, A guide for implementing multidisciplinary care 2007 Department of Human Services
Colorectal & Upper GI PPM Report
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A4.2 The Victorian Integrated Cancer Services
The Cancer Services Framework proposal of the formation of a service system led to the establishment of
the Integrated Cancer Services (ICS) in 2004, which includes three metropolitan and five regional ICS based
on specified geographic populations and one state wide paediatric service. The role of the Integrated
Cancer Services is to build partnerships; improve cancer care; and plan cancer services across a geographic
area based on access, appropriateness and effectiveness.13
Figure 4: Map of the Victorian Integrated Cancer Services
Each ICS is comprised of clusters of hospitals and associated health services that deliver services for people
with all type of cancers within a geographic area. The philosophy of an ICS is that hospitals and primary and
community health services develop integrated care and defined referral pathways for the populations they
serve. This promotes more effective local coordination of care for cancer patients, and a more rational,
evidence-based approach to cancer service planning and delivery, and provides a platform through which
improvements in cancer service delivery and patient care can be implemented.14
13
Clinical excellence in cancer care, a model for safety and quality in Victorian cancer services 2007 Department of Human Services
14
A Cancer Services Framework for Victoria 2003 Department of Human Services
Colorectal & Upper GI PPM Report
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A4.3 Establishment of tumour streams
The Cancer Services Framework for Victoria has recommended that organ or system specific tumour
streams be adopted to reduce variation in care.15 Tumour streams were developed as a means to drive
service improvement and ensure consistency across Victoria. As ten types of tumours account for more
than 90 per cent of the total incidence of cancer in Victoria, the recommended tumour streams were
therefore classified as:
1)
2)
3)
4)
5)
6)
7)
8)
9)
Genito-urinary cancers, including cancers of the prostate, bladder, kidney, and testis
Colorectal cancer
Breast cancer
Lung cancer
Skin cancers, notably melanoma
Haematological malignancies, encompassing lymphomas, leukaemia, and myeloma
Gynaecological cancers
Head and neck cancers
Upper gastro-intestinal cancers, encompassing cancers of the oesophagus, stomach, pancreas, and
hepato-biliary system
10) Central nervous system cancers
The concept of tumour streams includes the development of local collaborating tumour groups based on
the ten tumour streams, statewide mechanisms to support tumour stream development, standards of care
and facility standards, clinical and performance indicators and classification of cancer services based on the
range of services they can provide.
A4.4 Patient Management Frameworks
Cancer care in Victoria is guided by the Patient Management Frameworks (PMF), published by the Victorian
Department of Health (formerly the Department of Human Services) in 2006.16 The PMFs were developed
to provide a consistent statewide approach to care management across the ten tumour streams and are
intended to improve patient outcomes by focussing discussion on the critical steps of the patient journey in
order to identify priority areas for improvement. They aim to reduce unwanted variation in care and
describe optimal referral pathways for cancer care from diagnosis to end-of-life care, inclusive of treatment
and supportive care.
The PMFs have been developed in collaboration with a wide range of practitioners, consumers and carers.
Wherever possible, they are based on current best practice, including clinical guidelines, care pathways,
standards and research. In many cases, however, they are a statement of consensus regarding currently
accepted approaches to treatment. 17
15
A Cancer Services Framework for Victoria 2003 Department of Human Services
Patient management frameworks 2006 Department of Human Services
17
http://health.vic.gov.au/cancer/framework/pmfsnew.htm
16
Colorectal & Upper GI PPM Report
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The PMFs:



Provide a clear description of the care pathway, identifying the critical points along that pathway
and the optimal model of care
Set out the key requirements for the provision of optimal care
Guide the patient journey to ensure patients with cancer and their families receive optimal care
and support
The PMFs identify seven critical steps in the patient journey, as represented in Figure 5 below. Whilst these
seven steps are represented as a linear model, it is clear that in practice patient care does not always occur
this way. It is important for all patients to be assessed and managed appropriately throughout each stage of
their individual journey, however, not all patients will progress through each of the seven steps of the PMF
due to factors such as timing of diagnosis, prognosis, management decisions and patient decisions. It is also
important to note that the PMFs are not designed for accreditation purposes, but may be used to facilitate
local benchmarking, service mapping and service development. They are not rules and do not carry a sense
of prescription.
Figure 5: The seven steps of the patient journey identified in the PMFs
To accompany the PMFs, a toolkit was also developed by the Department of Health to assist the ICS to
identify priority areas when implementing the PMFs (Appendix 1).This toolkit provides a guide to evaluate
the implementation of the PMFs across the seven stages of the patient journey (as presented in Figure 5),
Colorectal & Upper GI PPM Report
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for each of the four priority service improvement areas for reform (multidisciplinary care, care
coordination, supportive care, reducing unwanted variation in practice). The guide contains a series of
prompts/questions in order to identify the gaps and successes in implementation of the PMFs. This guide
was adopted for use in the current project across all tumour streams in order to provide a direct link
between the relevant PMF and the successes/gaps in the implementation of the PMFs in the Hume region.
A4.5 The four priority service improvement areas for statewide reform
As described previously, the Cancer Services Framework for Victoria has identified the four priority service
improvement areas for reform as:




multidisciplinary care
care coordination
supportive care
reducing unwanted variation in practice (quality monitoring and support)
It is these priority areas that serve as the foundation for the seven steps in the care pathway. Therefore,
the focus of this Patient Pathways Mapping Project was to investigate the success with which the PMFs
have been implemented at each step of the patient pathway, across each of these four key priority areas.
Accordingly, the results of this project have been presented under these four headings, in order to describe
the successes and gaps in the care pathway for Head and Neck cancers in the Border/East Hume Cancer
Network. Further background information about these four priority areas is presented below.
A4.5.1 Multidisciplinary care
Multidisciplinary care can broadly be defined as an integrated team approach to health care in which
medical and allied health care professionals consider all relevant treatment options and develop
collaboratively an individual treatment plan for each patient.18 The evidence for improved survival as an
impact of multidisciplinary cancer care has not been strong, however, reduced time to diagnosis and
treatment, improved adherence to guidelines, improved inclusion in clinical trials, improved patient
satisfaction and improved education and collegiality for members of the MDT, have all been documented
through audits of MDT records and surveys of MDT members. The three strategic directions that guide the
improved multidisciplinary care in Victoria are: 19 creating and supporting effective multidisciplinary teams;
establishing and strengthening multidisciplinary meetings; and building effective team linkage across and
between ICS.
18
19
Achieving best practice cancer care, A guide for implementing multidisciplinary care 2007 Department of Human Services
Multidisciplinary Care Literature review June 2012 Department of Health
Colorectal & Upper GI PPM Report
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Figure 6: Victoria’s model for multidisciplinary care
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Multidisciplinary Team Meetings (MDTMs) are defined as regularly scheduled meeting of core and invited
team members for the purpose of prospective treatment and care planning of newly diagnosed cancer
patients, as well as those requiring review of treatment plans or palliative care.20
The objectives of MDTMs are:




to provide an opportunity for multidisciplinary team discussion of all newly diagnosed and review
cases of cancer within an appropriate timeframe to facilitate effective treatment planning
to determine, in light of all available information and with reference to the evidence base, the most
appropriate treatment plan for each individual patient
to provide educational opportunities for team members and trainees
to provide peer support to team members 21
A4.5.2 Care coordination
Cancer care coordination aims to ensure that care is delivered in a logical, connected and timely manner so
that the medical and personal needs of patients and their families and carers are met. 22 Cancer patients
are often seen by variety of health professionals across multiple health services and across different health
sectors – public/ private, acute/ primary health, metropolitan and rural. It is acknowledged that effective
care coordination requires strategies for improvement at every level – systems, organisational, team and
individual levels.
In the context of cancer, care coordination encompasses multiple aspects of cancer care delivery including
multidisciplinary team meetings, psychosocial assessment and the provision of required care, referral
practices, data collection, development of common protocols, information provision and individual clinical
treatment.
A4.5.3 Supportive care
Supportive care is an ‘umbrella’ term for all services, both generalist and specialist, that may be required to
support people with cancer and their carers’.23 It includes self-help and support, information, psychological
support, symptom control, social support, rehabilitation, spiritual support, palliative care and bereavement
care. Supportive care is required throughout the diagnostic, treatment and follow-up phases of care and is
increasingly seen as a core component of cancer care for those affected by cancer.
In the context of cancer, supportive care needs include: physical needs (for example, pain, fatigue),
psychological needs (for example, anxiety, distress), social needs (for example, practical supports, carer
needs), information needs (for example, regarding diagnosis, prognosis, types of treatment), spiritual needs
(for example, addressing hopelessness, despair).24
20
Multidisciplinary Team Meeting Toolkit 2006 Department of Human Services
Multidisciplinary team meetings in Victoria, Monitoring progress towards achieving best practice cancer care 2010–11
Department of Health
22
Linking cancer care: A guide for implementing coordinated cancer care 2007 Department of Human Services
23
Patient management frameworks 2006 Department of Human Services
24
Patient management frameworks 2006 Department of Human Services
21
Colorectal & Upper GI PPM Report
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A4.5.4 Reducing variations in care
Unwanted variations in care can be reduced by the introduction of processes and guidelines that assist in
the standardising of cancer care. These have the potential to improve the safety and quality in Victorian
cancer services.25 One approach to reduce unwanted variations in cancer care was the development of
defined tumour streams, in order to provide a framework for a consistent, evidence-based approach to
care and hence reduce unacceptable variations. Tumour streams include consistent approaches to care for
a particular tumour stream supported by: agreed treatment protocols, monitoring of best practice,
identifying areas for service improvement, implementing system change to support service improvement
and evaluating the impact of service improvement.
The Department of Health framework document “Clinical Excellence in Cancer Care” provides a model for
safety and quality in Victorian cancer services. It is not an accreditation system, but instead is designed to
support and strengthen the fundamental aspects of cancer care. This model recognises that cancer services
operate within an existing health care system and therefore does not seek to duplicate systems, but instead
to align cancer service priorities with those of the health services.
The key elements of the model (presented in Figure 7) are:





Collaboration and partnerships between quality units and cancer services
Clinician and consumer led service improvement
Valid and reliable data used to identify gaps in safety and quality and to monitor improvements
following change
Based on best practice and evidence based care
Use of clinical quality tools such as indicators, case and peer review, and audit in a systematic cycle
of analysis, discussion, action, follow up and feedback to participating health services
As described by the Department of Health, the model identifies six clinical dimensions of cancer care
quality to guide patient care monitoring and improvement; and four structural components necessary to
provide a solid organisational foundation for quality.
25
Clinical excellence in cancer care, a model for safety and quality in Victorian cancer services 2007 Department of Human Services
Colorectal & Upper GI PPM Report
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Figure 7: Model for safety and quality in Victorian cancer services
Colorectal & Upper GI PPM Report
Page 97 of 109
Appendix 5: Profile of the Hume Region
A5.1 Geographic coverage
A5.1.1 Overview of the Hume cancer networks
Following extensive consultation and in line with the policy, "Clinical Networks: A Framework for Victoria",
Hume RICS formed two clinical networks in December 2008 – the West Hume and Border / East Hume
Cancer Networks, as depicted in Figure 8 below. This is considered to better mirror clinical practice across
the Goulburn Valley and Hume Highway corridors and enable more rapid cancer service development.
Figure 8: Map of the Hume RICS West Hume and Border/East Hume Cancer Networks
Whilst the ICS are a Victorian Department of Health Initiative, Hume RICS also works closely with cancer
services in southern New South Wales (NSW). In May 2009, the Border Cancer Collaboration (BCC)
transitioned into the Border / East Hume Cancer Network of Hume RICS and continues to address issues for
the community to support cross border cancer services.
As shown in Table 16 and Figure 9, there are a number of LGAs from northeast Victoria and
Southern/Border NSW that collectively form the catchment for cancer services provided in the Hume
region. The LGAs that have been considered for both cancer incidence and population data in this Patient
Pathway Mapping Project are listed in Table 16.
Colorectal & Upper GI PPM Report
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Table 16: Victorian and NSW LGAs considered in this Patient Pathways Mapping Project
Victorian LGAs
NSW LGAs
Wodonga
Albury
Indigo
Greater Hume Shire
Towong
Corowa Shire
Alpine
Urana
Wangaratta
Jerilderie
Benalla
Berrigan
Mansfield
Murray
Moira
Deniliquin
Greater Shepparton
Strathbogie
Mitchell
Murrindindi
Figure 9: Map of the Local Government Areas from Victoria and NSW that form part of the broader
population catchment for cancer services in the Hume region26
26
PCP and ML regional and southern NSW boundaries 2011, Extract from http://www.health.vic.gov.au/pcps/pcps_mls.htm
Colorectal & Upper GI PPM Report
Page 99 of 109
A5.1.2 Sub regions within the Hume cancer networks
For the specific purposes of patient flow data analysis in this project (as presented in Section 5.2), the
Hume region was divided into four sub regions: Goulburn Valley, Lower Hume, Central Hume and Upper
Hume to align with the Primary Care Partnership (PCP) Local Government Area (LGA) divisions, as
presented in Figure 10.This division allowed analysis of data to determine whether residents of each the
four sub-regions travelled to another sub-region (or outside of the Hume region altogether) to receive
cancer care. Unfortunately, as the Albury Wodonga Health- Albury Campus does not yet submit data in to
the VAED, inpatient activity delivered at this service site was not able to be determined and is not included
in this analysis.
Figure 10: Primary Care Partnership divisions in the Hume region27
A5.2 Population
The population of the Hume region (Victoria) by Local Government Area is presented below in Table 17.
Also included in Table 17 are population data for NSW LGAs that are part of the broader population
catchment for cancer services provided in the Hume region. Presented in this table are the population
figures for Albury, as well as the combined population figures for Corowa, Greater Hume, Berrigan,
Deniliquin, Murray, Conargo, Jerilderie and Urana (collectively referred to in this report as Southern/Border
NSW).
As shown in Table 17, in 2011 there were nearly 380,000 residents of these Victoria and NSW Local
Government Areas, which is projected to increase by 9.7% to 413,000 in 2021 and by 14.4% to 431,000 in
2026.
27
Service and Workforce Planning, Portfolio Services and Strategic Projects Division Feb 2009 Department of Human Services
Colorectal & Upper GI PPM Report
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Table 17: Hume region, Albury and Southern/Border NSW population forecasts28 29
LGA Name
2006
2011
2016
2021
2026
Greater Shepparton
59,202
63,127
66,282
69,047
71,509
Moira
27,946
29,478
30,688
31,816
32,920
Strathbogie
9,615
9,843
10,067
10,297
10,547
Mitchell
32,040
37,055
42,510
48,624
55,290
Murrindindi
14,179
14,316
14,666
15,244
15,944
Wodonga
34,504
37,367
39,736
42,128
44,337
Indigo
15,367
16,207
16,758
17,253
17,873
Towong
6,247
6,268
6,190
6,098
6,020
Benalla
13,968
14,418
14,748
15,118
15,536
Alpine
12,574
13,049
13,406
13,773
14,152
Wangaratta
27,318
28,199
28,910
29,655
30,457
Mansfield
7,445
8,251
9,072
9,958
10,914
Albury (NSW)
48,545
50,617
52,430
54,120
55,583
Southern/Border NSW*
49,033
48,857
50,273
50,496
50,521
TOTAL
357,983
377,052
395,736
413,627
431,603
* Combined figures for the LGAs of Corowa, Greater Hume, Berrigan, Deniliquin, Murray, Conargo, Jerilderie and Urana
28
Victoria in Future 2012: Population and household projections for Victoria and its regions 2011-2031, Department of Planning and
Community Development
29
NSW Statistical Local Area Population Projections 2006 – 2036, NSW Department of Planning
Colorectal & Upper GI PPM Report
Page 101 of 109
The LGAs with the most dramatic projected growth in the decade between 2011 and 2021 as shown in
Table 18 are Mitchell (31%), Mansfield (21%), Wodonga (13%), and Greater Shepparton (9%). This
highlights the need for appropriate service planning to accommodate the population growth in these
geographic areas.
Table 18: Hume, Albury and Southern/Border NSW population change 2011 - 2021
LGA Name
2011
2021
% Change
Greater Shepparton
63,127
69,047
9.38%
Moira
29,478
31,816
7.93%
Strathbogie
9,843
10,297
4.61%
Mitchell
37,055
48,624
31.22%
Murrindindi
14,316
15,244
6.48%
Wodonga
37,367
42,128
12.74%
Indigo
16,207
17,253
6.45%
Towong
6,268
6,098
-2.71%
Benalla
14,418
15,118
4.86%
Alpine
13,049
13,773
5.55%
Wangaratta
28,199
29,655
5.16%
Mansfield
8,251
9,958
20.69%
Albury
50,617
54,120
6.92%
Southern/Border NSW*
49,857
50,496
1.28%
* Combined figures for the LGAs of Corowa, Greater Hume, Berrigan, Deniliquin, Murray, Conargo, Jerilderie and Urana
Colorectal & Upper GI PPM Report
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A5.3 Cancer Profile
Figure 11 presents the total cancer incidence for the 5 year period 2004-2008 by Local Government Area
for the Hume region (Victoria), the NSW LGA of Albury, and the combined LGAs of Corowa, Greater Hume,
Berrigan, Deniliquin, Murray, Conargo, Jerilderie and Urana (referred to collectively as Southern/Border
NSW).
Figure 11: Total cancer incidence by LGA, Hume region, Albury and Southern/Border NSW for the 5-year
period 2004-2008 30
1,447
Greater Shepparton
Moira
Strathbogie
Mitchell
Murrindindi
Wodonga
Indigo
Towong
Benalla
Alpine
Wangaratta
Mansfield
Albury
Southern NSW
937
380
755
475
808
476
203
450
406
871
194
1234
1659
0
30
200
400
600
800
1000
1200
1400
1600
1800
Data obtained from Victorian Department of Health and NSW Cancer Registry
Colorectal & Upper GI PPM Report
Page 103 of 109
As shown in Figure 12, the incidence of cancer each year is approximately 1800 cases across the Hume
region and the LGA of Albury (please note that this excludes the other Southern/Border NSW LGAs
referenced previously as it was not possible to obtain these data in the format required). This is comprised
of 1055 males and 759 females, with the greatest number of cases being from the 65 – 79 years age
bracket. It is worth noting that in this particular age bracket, the burden of cancer amongst males is almost
double that for females.
Figure 12: Average annual cancer incidence by sex and age group, Hume region and Albury for the 5-year
period 2004-2008 31
2000
1800
1600
1400
1200
Cases Male
1000
Cases Female
800
Cases Person
600
400
200
0
0-49
50-64
65-79
80+
All age groups
* Please note this excludes the NSW LGAs of Corowa, Greater Hume, Berrigan, Deniliquin, Murray, Conargo, Jerilderie and Urana
31
Data obtained from Cancer Council Victoria and NSW Cancer Registry
Colorectal & Upper GI PPM Report
Page 104 of 109
Similarly, as shown in Figure 13, average annual cancer mortality is greater in males (n = 405) than in
females (n = 294) across the Hume region and Albury (please note that this excludes the other
Southern/Border NSW LGAs referenced previously as it was not possible to obtain these data in the format
required). This gender difference is particularly noticeable in the 65 – 79 years age bracket.
Figure 13: Average annual cancer mortality by sex and age group, Hume region and Albury for the 5-year
period 2004-2008 32
800
700
600
500
Deaths Male
400
Deaths Female
Deaths Person
300
200
100
0
0-49
50-64
65-79
80+
All age groups
* Please note this excludes the NSW LGAs of Corowa, Greater Hume, Berrigan, Deniliquin, Murray, Conargo, Jerilderie and Urana
32
Data obtained from Cancer Council Victoria and NSW Cancer Registry
Colorectal & Upper GI PPM Report
Page 105 of 109
Figure 14 presents data related to the average annual cancer incidence by tumour type in the Hume region
(Victoria) only. NSW data have been presented separately in Figure 15 due to differing approaches to the
grouping of ICD codes.
This graph shows that the highest incidence occurs in prostate cancer with over 280 cases diagnosed per
year, followed by bowel, breast, lung cancers and melanoma.
Figure 14: Average annual cancer incidence by sex and cancer type in the Hume region for the 5-year
period 2004-2008 33
300
250
200
150
100
Cases Male
Cases Female
0
Cases Person
Bladder
Bowel
Brain & CNS
Breast
Cervix
Kidney
Larynx
Leukaemia
Liver
Lung
Lymphoma
Melanoma
Mesothelioma
Multiple myeloma
Oesophagus
Oral cavity & pharynx
Ovary
Pancreas
Prostate
Stomach
Testis
Thyroid
Uterus
Unknown site
All other cancers
50
33
Data obtained from Cancer Council Victoria
Colorectal & Upper GI PPM Report
Page 106 of 109
Figure 15 illustrates the total cancer incidence in the Albury LGA only for the five-year period 2004-2008,
and consistent with the Victorian data, the highest incidence occurs in prostate cancer, followed by breast,
colon and rectal (bowel), lung and melanoma (please note that this excludes the other Southern/Border
NSW LGAs referenced previously as it was not possible to obtain these data in the format required).
Figure 15: Total cancer incidence by sex and cancer type in Albury for the 5-year period 2004-2008 34
300
250
200
150
Cases Male
100
Cases Female
Cases Person
50
Breast
Colon
Lung
Melanoma
Rectal
Unknown site
Ovarian
Other Cancers
Pancreatic
Uterus
NHL
Thyroid
Leukaemia
Stomach
Kidney
Lip
Cervical
Bladder
Brain
Head and Neck
Prostate
Oesophagus
Testicular
Myelodyplasia
Liver
0
34
Data obtained from NSW Cancer Registry
Colorectal & Upper GI PPM Report
Page 107 of 109
Figure 16 presents the average annual cancer mortality by sex and cancer type for the Hume region only.
This graph shows that the highest mortality occurs in lung cancer, followed by bowel, prostate, breast and
pancreas cancer.
Figure 16: Average annual cancer mortality by sex and cancer type in the Hume region for the 5-year
period 2004-2008 35
140
120
100
80
60
40
20
0
Deaths Male
Bladder
Bowel
Brain & CNS
Breast
Cervix
Kidney
Larynx
Leukaemia
Liver
Lung
Lymphoma
Melanoma
Mesothelioma
Multiple myeloma
Oesophagus
Oral cavity & pharynx
Ovary
Pancreas
Prostate
Stomach
Testis
Thyroid
Uterus
Unknown site
All other cancers
Deaths Female
35
Deaths Person
Data obtained from Cancer Council Victoria
Colorectal & Upper GI PPM Report
Page 108 of 109
Consistent with the Victorian data, Figure 17 shows that the highest mortality within the Albury LGA occurs
within lung, colon and rectal (bowel), pancreas, breast and prostate cancer. Please note that this excludes
the other Southern/Border NSW LGAs referenced previously as it was not possible to obtain these data in
the format required.
Figure 17: Total cancer mortality by sex and cancer type in Albury for the 5-year period 2004-2008 36
100
90
80
70
60
50
Deaths Male
40
Deaths Female
30
Deaths Person
20
10
36
Oesophagus
Head and Neck
Kidney
Liver
Bladder
Melanoma
Prostate
Stomach
Leukaemia
Brain
Ovarian
Rectal
Other Cancers
NHL
Pancreatic
Unknown site
Colon
Breast
Lung
0
Data obtained from NSW Cancer Registry
Colorectal & Upper GI PPM Report
Page 109 of 109