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Integrated Care

 

As people transition through the different stages of the cancer care continuum, and into and out of the cancer system, they will see many care providers in many settings. We’re working to ensure that care is person-centred, coordinated and continuous through the cancer system and across settings.

In particular, we have identified palliative care as one facet of care that benefits from an integrated care approach. We will facilitate integrated care by standardizing care, improving information-sharing, optimizing relationships, and empowering patients to understand their care plan, to navigate the system, and to always know who they can turn to for help.

Goal

Image of Carly G.

“When someone starts treatment, they and their families have so many questions: What’s going to happen, what will it be like, where do we go next? Having a plan in place gives them a better idea of what to expect, lets them prepare and helps them feel confident about their care. I think having navigators or care consultants to assist patients—and their information—move through the system is a great idea.”

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Ensure the delivery of integrated care across the cancer care continuum

Strategic Objectives

  • Stratify patients by risk, based on clinical factors, comorbid conditions and social determinants of health, to determine the supports that patients and families require to navigate their care pathway.
  • Ensure that standardized care plans are developed and communicated to all members of the care team, across the cancer care continuum, to facilitate an integrated approach to care that is centred on the patient.
  • Enhance communication among all providers across the cancer care continuum and care settings to facilitate smoother care transitions.
  • Increase the availability of relevant patient clinical information to patients and providers across care settings to support informed decision-making.
  • Determine opportunities for improving the transition of adolescent and young adults, when appropriate, from the pediatric to adult cancer care system.

By 2019

  • Patients will have appropriate supports throughout their care pathway, and providers will have the necessary tools to assist their patients with navigation.
  • Standardized care plans will be available for selected disease sites, treatments and patient populations, across care settings. These plans will be used to improve communication of goals of care and expected outcomes among patients, families and providers.
  • Use of technology will be expanded to improve communication among providers across the cancer care continuum and care settings.
  • Patient care information is made available to patients and providers to support joint decision-making (e.g., Diagnostic Assessment Program – Electronic Pathway Solution and Interactive Symptom Assessment and Collection).
  • A strategy will be developed with provincial partners to improve transitions for adolescents and young adults.

Examples of Initiatives

  • Design and implement a risk assessment tool to determine supports for complex cancer patients (e.g., multi-morbidity, mental health) and other high-need populations.
  • Work with primary care providers to develop supports for providing on-going followup care to cancer survivors.
  • Implement Navigating the Diagnostic Phase of Cancer: Ontario's Strategic Directions 2014-2018 and expand the Diagnostic Assessment Program – Electronic Pathway Solution (DAP-EPS) roadmap across the province.
  • Collaborate with partners to broaden linkages to electronic medical records and facilitate comprehensive and complete electronic health records in Ontario.
  • Expand synoptic reporting to facilitate sharing of information.