Optimizing clinical and organizational practice in cancer survivor transitions between specialized oncology and primary care teams: a realist evaluation of multiple case studies.

BACKGROUND: Cancer is now viewed as a chronic disease, presenting challenges to follow-up and survivorship care. Models to shift from haphazard, suboptimal and fragmented episodes of care to an integrated cancer care continuum must be developed, tested and implemented. Numerous studies demonstrate improved care when follow-up is assured by both oncology and primary care providers rather than either group alone. However, there is little data on the roles assumed by specialized oncology teams and primary care providers and the extent to which they work together. This study aims to develop, pilot test and measure outcomes of an innovative risk-based coordinated cancer care model for patients transitioning from specialized oncology teams to primary care providers. METHODS/DESIGN: This multiple case study using a sequential mixed-methods design rests on a theory-driven realist evaluation approach to understand how transitions might be improved. The cases are two health regions in Quebec, Canada, defined by their geographic territory. Each case includes a Cancer Centre and three Family Medicine Groups selected based on differences in their determining characteristics. Qualitative data will be collected from document review (scientific journal, grey literature, local documentation), semi-directed interviews with key informants, and observation of care coordination practices. Qualitative data will be supplemented with a survey to measure the outcome of the coordinated model among providers (scope of practice, collaboration, relational coordination, leadership) and patients diagnosed with breast, colorectal or prostate cancer (access to care, patient-centredness, communication, self-care, survivorship profile, quality of life). Results from descriptive and regression analyses will be triangulated with thematic analysis of qualitative data. Qualitative, quantitative, and mixed methods data will be interpreted within and across cases in order to identify context-mechanism associations that explain outcomes. DISCUSSION: The study will provide empirical data on a risk-based coordinated model of cancer care to guide actions at different levels in the health system. This in-depth multiple case study using a realist approach considers both the need for context-specific intervention research and the imperative to address research gaps regarding coordinated models of cancer care.

Improving the Transition From Oncology to Primary Care Teams: A Case for Shared Leadership.

This article discusses the case of a 47-year-old woman who underwent primary therapy with curative intent for breast cancer. The case illustrates a number of failure events in transferring information and responsibility from oncology to primary care teams. The article emphasizes the importance of shared leadership, as multiple team members, dispersed in time and space, pursue their own objectives while achieving the common goal of coordinating care for survivors of cancer transitioning across settings. Shared leadership is defined as a team property comprising shared responsibility and mutual influence between the patient and the patient's family, primary care providers, and oncology teams, whereby they lead each other toward quality and safety of care. Teams, including the patient-family, should achieve leadership when their contribution is relevant in managing task interdependence during transition. Shared leadership fosters coordinated actions to enable functioning as an integrated team-of-teams. This article illustrates how shared leadership can make a difference to coordinate interfaces and pathways, from therapy with curative intent to the follow-up and management of survivors of breast cancer. The detailed case is elaborated as a clinical vignette. It can be used by care providers and researchers to consider the need for new models of care for survivors of cancer by addressing the following questions. Who accepts shared leadership, how, with whom, and under what conditions? What is the evidence that supports the answers to these questions? The detailed case is also valuable for medical and allied health professional education.