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Promoting innovation in cancer services

Issue 2, December 2009

Health Services Innovation Grants (HSIG) aim to harness innovation in cancer services in NSW and support project teams to pilot and develop these ideas.

Program objectives

The objectives of the HSIG are to:

facilitate the strategic development of smarter models of care to produce better outcomes for cancer patients;
enable the redesign of clinical practice models to deliver high quality coordinated cancer care in a timely manner;
improve outcome measures for cost effective and efficient service delivery of cancer services;
provide the catalysts for future Cancer Institute NSW projects and funding initiatives;
implement financially sustainable programs beyond the conclusion of the project;
enable shared learning between cancer service providers across NSW through participation in a health services forum at the conclusion of the program and various information dissemination strategies.

The HSIG has also aimed to provide project management and evaluation methodology support to each project team to build further skill capacity across the cancer services workforce.

Funding

The program has comprised two separate competitive grant rounds, Round 1 covering 2007-08 and Round 2 covering 2008-09, respectively.

Twenty four pilot projects were funded under HSIG Round 1 under the following themes:

Workforce development
Service redesign
Improvements through information technology and related initiatives
Complementary service arrangements

The table below details the funding allocated to the projects under various themes:

Health Service Innovation Grants - Round 1 Funding Allocation

Outcomes

A collated report of project outcome summaries under HSIG Round 1 has been prepared and is available on the Cancer Institute NSW (CINSW) website. The report describes project design, methodology and outcomes for the individual projects and includes contact details for further information. A similar report will be prepared for the twelve projects funded under HSIG Round 2 after completion.

It is very pleasing to note that around 50 per cent of projects under HSIG Round 1 continue to make progress and are sustained even after the conclusion of funding from the Cancer Institute NSW.

A 'shared care' pilot project: The Cooma Oncology Unit Greater Southern Area Health Service and the Monaro Committee for Cancer Research sought to establish a pilot 'shared care' oncology service in Cooma, NSW. The aim of the project was to establish and evaluate a new model of oncology service delivery through partnerships between metropolitan oncologists, local rural GPs and nursing staff. The model was designed differently from other rural oncology services in that there were to be no visiting oncologists to the site. The pilot program also provided an opportunity to assess sustainability from financial, resource and skilled workforce perspectives. Overview of approach The expected objectives of the project were to: Develop a shared care model of service that could be implemented in other rural areas across NSW. Increase access for rural patients to a local treatment service that assists in supporting patients throughout their cancer journey. Develop a model of service that addresses community need, allows patients to access services closer to home, meets chemotherapy administration standards and ensures optimal patient outcomes. Develop a model that is sustainable from both a financial, resource and skilled workforce perspective. Reduce the burden of isolation from family who stay overnight for treatment (Canberra), and the financial hardship for rural patients and carers having to access services in a metropolitan or regional location. Review the hardships of travel for patients including such issues as feeling unwell from the effects of chemotherapy, family disruption and loss of work time and income. Design, implement and evaluate a shared care model of service that has community input and support and will assist with future demands on oncology services. Develop a partnership arrangement of 'shared care' between metropolitan medical oncologists and local rural GPs. Increase trained local staff accredited to administer certain oncology treatments locally. The focus of the pilot was to develop a 'shared care model' with GPs, oncologists and nursing staff as opposed to the models working in other units with shared care between the oncologist and the nursing staff. The challenge for this pilot was to determine how the GP would be involved beyond the contributions already being made by them within the hospital. Project Methodology The GSAHS employed a collaborative approach to the development of the model through consultation with ACT Health, local health professionals, representatives of the Cooma Community, the Cooma Monaro Cancer Research Committee and the local AHS. The AHS's approach was to use the buy-in of key stakeholders and the experience of the clinicians to build on the existing framework of oncology services in the Southern Cancer Network. A 'shared care' approach involved the training of local nursing staff in order to provide a local oncology treatment service that meets the needs of the community and is safe and consistent with the skill level of providers. It was essential that the project optimise the limited available time of the clinicians to be involved and this was achieved by their limited direct involvement with treatment procedures but their ongoing backup support being provided at all times. This project facilitated effective communication and collaboration between the oncology specialists, the local GPs and the local oncology nurses and obtained their support and feedback in the model. The oncology specialists developed criteria for chemotherapy treatments appropriate to be administered locally under a shared care arrangement and with appropriate training of local staff. They also were responsible for assessing the patient, establishing and prescribing the treatment plan. Once the treatment plan was determined, the oncology specialist communicated with the oncology nurses about the delivery of that treatment plan. Any proposed deviation from the prescribed treatment plan was further assessed by the oncology specialist through communication with the oncology nurses and local GPs. There was appropriate training of nursing staff, including a 6 week placement at The Canberra Hospital in the ACT. Training and ongoing mentoring and support were provided to the oncology staff by the area CNC in addition to their enrolling in further tertiary cancer care studies. To administer intravenous chemotherapy safely, initially two RN's were identified and chemotherapy oncology trained. In addition, two additional staff members were then recruited, trained and became available to cover for leave. Continuity of care was required around the organisational aspects of chemotherapy administration (ie booking of appointments and treatments, referral to other health care providers, organising pathology tests, medical imaging, outpatient scripts, ordering of chemotherapy, supportive drugs, etc). There were also numerous administrative duties and organisational aspects that were undertaken during the beginning of the Unit's operations. Project Results The development of the oncology unit came about primarily through community support for the project. By being developed through an identified funding opportunity to support the development of the unit, it presented several challenges. Preparation time to get the program running was limited. There were also few change management processes undertaken and with no project manager appointed, the setting up of the service resulted in additional workloads for some management and staff causing additional stress and anxiety. Once the unit was operating, however, most staff were satisfied with the outcomes and daily running of operations. Expressions of interest for staffing of the new unit were at times rushed as was the intensive short term training required. The new oncology staff appointed also had to learn the 'clerical' duties required as well as put into practice their new clinical skills. The number of patients that the unit would cater for was relatively difficult to predict but advice received by oncologists and from the establishment of other units was that the unit would start slowly for the first 12 months. The slower development of the unit also allowed staff to gain confidence and experience, patients to feel reassured about the services and standard of care, and the oncologist to be comfortable in referring according to the level of criteria. The referral processes from the oncologists from Canberra was initially mixed with many referrals coming directly from requests from the patients who informed the oncologists of the Cooma Oncology Unit, and asked if they could receive treatment there. The referral process, however, was well defined with the oncologists being involved in the development of the criteria. The complexity of treatment would increase as the skill level of the nurses increased. Key findings were that: A total 271 Occasions of Service were provided within the oncology unit from September of 2007 to September 2008. The predominant tumour streams were colorectal cancer and breast cancer. These two groups accounted for 97 and 35 occasions of service. Urology and haematology accounted for 11 and 9 occasions of service. Non oncology treatments accounted for 7 occasions of service. Overall, the Cooma Oncology Unit Pilot Project delivered in its main objectives to develop a model of service that addresses community need, allows patients to access services closer to home, meets chemotherapy administration standards and ensures optimal patient outcomes. The development of a shared care model was largely successful from with the Cooma oncology nursing staff having close communication links with the Canberra oncologists. Although this pilot project intended that the Cooma GPs would be key partners, in practice their role has been one of providing backup support for emergencies and keeping informed of patient outcomes. Local staff were appropriately trained to administer oncology treatments from Cooma and have continued to receive ongoing training programs. Initially, the staff and management indicated that establishing the unit in such a short time frame created some stress and frustration amongst the Cooma staff. A longer lead time to accommodate a more planned approach with appropriate time frames and a full change management process before the introduction of any service would have probably reduced the identified staff stress. Adding to these difficulties was a delay in recruiting oncology nursing staff and, despite available funding, a designated project manager to oversee and direct the introduction of the new service was never appointed. Many of these tasks had to be undertaken by the local manager, cancer program manager and area CNC adding to their existing workloads. Future Directions The Cooma Oncology Unit demonstrated its ability to provide a quality and safe rural oncology service for its local community. It therefore could remain as a viable operational unit if it continually addresses the sustainability issues, being: ongoing staffing issues including training and succession planning; financial and staff resources; and patient numbers and occasions of service justifying the continuation of the service. This pilot project and aspects of this model could be transferred to other rural sites within NSW. If the Cancer Institute NSW is interested in developing other rural models of care, the Cooma model should be carefully considered for its strengths and weaknesses and how it could be included at other rural sites.

A 'shared care' pilot project: The Cooma Oncology Unit

Greater Southern Area Health Service and the Monaro Committee for Cancer Research sought to establish a pilot 'shared care' oncology service in Cooma, NSW. The aim of the project was to establish and evaluate a new model of oncology service delivery through partnerships between metropolitan oncologists, local rural GPs and nursing staff. The model was designed differently from other rural oncology services in that there were to be no visiting oncologists to the site. The pilot program also provided an opportunity to assess sustainability from financial, resource and skilled workforce perspectives.

Overview of approach

The expected objectives of the project were to:

Develop a shared care model of service that could be implemented in other rural areas across NSW.
Increase access for rural patients to a local treatment service that assists in supporting patients throughout their cancer journey.
Develop a model of service that addresses community need, allows patients to access services closer to home, meets chemotherapy administration standards and ensures optimal patient outcomes.
Develop a model that is sustainable from both a financial, resource and skilled workforce perspective.
Reduce the burden of isolation from family who stay overnight for treatment (Canberra), and the financial hardship for rural patients and carers having to access services in a metropolitan or regional location.
Review the hardships of travel for patients including such issues as feeling unwell from the effects of chemotherapy, family disruption and loss of work time and income.
Design, implement and evaluate a shared care model of service that has community input and support and will assist with future demands on oncology services.
Develop a partnership arrangement of 'shared care' between metropolitan medical oncologists and local rural GPs.
Increase trained local staff accredited to administer certain oncology treatments locally.

The focus of the pilot was to develop a 'shared care model' with GPs, oncologists and nursing staff as opposed to the models working in other units with shared care between the oncologist and the nursing staff. The challenge for this pilot was to determine how the GP would be involved beyond the contributions already being made by them within the hospital.

Project Methodology

The GSAHS employed a collaborative approach to the development of the model through consultation with ACT Health, local health professionals, representatives of the Cooma Community, the Cooma Monaro Cancer Research Committee and the local AHS. The AHS's approach was to use the buy-in of key stakeholders and the experience of the clinicians to build on the existing framework of oncology services in the Southern Cancer Network.

A 'shared care' approach involved the training of local nursing staff in order to provide a local oncology treatment service that meets the needs of the community and is safe and consistent with the skill level of providers. It was essential that the project optimise the limited available time of the clinicians to be involved and this was achieved by their limited direct involvement with treatment procedures but their ongoing backup support being provided at all times. This project facilitated effective communication and collaboration between the oncology specialists, the local GPs and the local oncology nurses and obtained their support and feedback in the model.

The oncology specialists developed criteria for chemotherapy treatments appropriate to be administered locally under a shared care arrangement and with appropriate training of local staff. They also were responsible for assessing the patient, establishing and prescribing the treatment plan. Once the treatment plan was determined, the oncology specialist communicated with the oncology nurses about the delivery of that treatment plan. Any proposed deviation from the prescribed treatment plan was further assessed by the oncology specialist through communication with the oncology nurses and local GPs.

There was appropriate training of nursing staff, including a 6 week placement at The Canberra Hospital in the ACT. Training and ongoing mentoring and support were provided to the oncology staff by the area CNC in addition to their enrolling in further tertiary cancer care studies.

To administer intravenous chemotherapy safely, initially two RN's were identified and chemotherapy oncology trained. In addition, two additional staff members were then recruited, trained and became available to cover for leave. Continuity of care was required around the organisational aspects of chemotherapy administration (ie booking of appointments and treatments, referral to other health care providers, organising pathology tests, medical imaging, outpatient scripts, ordering of chemotherapy, supportive drugs, etc). There were also numerous administrative duties and organisational aspects that were undertaken during the beginning of the Unit's operations.

Project Results

The development of the oncology unit came about primarily through community support for the project. By being developed through an identified funding opportunity to support the development of the unit, it presented several challenges. Preparation time to get the program running was limited. There were also few change management processes undertaken and with no project manager appointed, the setting up of the service resulted in additional workloads for some management and staff causing additional stress and anxiety. Once the unit was operating, however, most staff were satisfied with the outcomes and daily running of operations.
Expressions of interest for staffing of the new unit were at times rushed as was the intensive short term training required. The new oncology staff appointed also had to learn the 'clerical' duties required as well as put into practice their new clinical skills.

The number of patients that the unit would cater for was relatively difficult to predict but advice received by oncologists and from the establishment of other units was that the unit would start slowly for the first 12 months. The slower development of the unit also allowed staff to gain confidence and experience, patients to feel reassured about the services and standard of care, and the oncologist to be comfortable in referring according to the level of criteria. The referral processes from the oncologists from Canberra was initially mixed with many referrals coming directly from requests from the patients who informed the oncologists of the Cooma Oncology Unit, and asked if they could receive treatment there. The referral process, however, was well defined with the oncologists being involved in the development of the criteria. The complexity of treatment would increase as the skill level of the nurses increased.

Key findings were that:

A total 271 Occasions of Service were provided within the oncology unit from September of 2007 to September 2008. The predominant tumour streams were colorectal cancer and breast cancer. These two groups accounted for 97 and 35 occasions of service. Urology and haematology accounted for 11 and 9 occasions of service. Non oncology treatments accounted for 7 occasions of service.
Overall, the Cooma Oncology Unit Pilot Project delivered in its main objectives to develop a model of service that addresses community need, allows patients to access services closer to home, meets chemotherapy administration standards and ensures optimal patient outcomes. The development of a shared care model was largely successful from with the Cooma oncology nursing staff having close communication links with the Canberra oncologists. Although this pilot project intended that the Cooma GPs would be key partners, in practice their role has been one of providing backup support for emergencies and keeping informed of patient outcomes. Local staff were appropriately trained to administer oncology treatments from Cooma and have continued to receive ongoing training programs.
Initially, the staff and management indicated that establishing the unit in such a short time frame created some stress and frustration amongst the Cooma staff. A longer lead time to accommodate a more planned approach with appropriate time frames and a full change management process before the introduction of any service would have probably reduced the identified staff stress. Adding to these difficulties was a delay in recruiting oncology nursing staff and, despite available funding, a designated project manager to oversee and direct the introduction of the new service was never appointed. Many of these tasks had to be undertaken by the local manager, cancer program manager and area CNC adding to their existing workloads.

Future Directions

The Cooma Oncology Unit demonstrated its ability to provide a quality and safe rural oncology service for its local community. It therefore could remain as a viable operational unit if it continually addresses the sustainability issues, being:

ongoing staffing issues including training and succession planning;
financial and staff resources; and
patient numbers and occasions of service justifying the continuation of the service.

This pilot project and aspects of this model could be transferred to other rural sites within NSW. If the Cancer Institute NSW is interested in developing other rural models of care, the Cooma model should be carefully considered for its strengths and weaknesses and how it could be included at other rural sites.

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