Participants’ characteristics
Between 19/02/2021 and 24/12/2021, 39 people were referred through the GL-CS referral pathway to participating community health services. Cancer care nurses referred most of the people (n = 28; 72%), followed by oncologists/ haematologists (n = 9; 23%), and allied health professionals (n = 2; 5%).
People referred had a mean age of 65.6 years (SD 11.0), 22 (56%) were women, and 34 (87%) spoke English at home. One person was excluded due to an ineligible diagnosis (see Fig. 2) and was re-directed to general physiotherapy of the community health service. The mean years since cancer diagnosis of the 38 patients was 2.14 years (SD 3.26). Of the 38, 14 people (37%) were diagnosed with stage 4 cancer, and 27/38 (71%) were receiving cancer treatment at the time of referral. Table 3 provides additional information about the participants’ sociodemographic and clinical characteristics.
Table 3
– Sociodemographic and clinical characteristics of people referred to GL-CS
Sociodemographic characteristics (n = 39) | | |
Place of birth | n | % |
Oceania (Australia, NZ) | 24 | 61 |
Europe (England, Italy, Netherlands) | 7 | 18 |
Asia (Iran, Malaysia, Sri Lanka, China, Hong Kong) | 5 | 13 |
Africa (Egypt, South Africa) | 2 | 5 |
Unknown | 1 | 3 |
Language spoken at home | | |
English | 34 | 87 |
Other (Dutch, mandarin, Cantonese, Persian) | 5 | 13 |
Socio-economic Index for area# | | |
Quintile 1 | 0 | 0 |
Quintile 2 | 1 | 3 |
Quintile 3 | 3 | 8 |
Quintile 4 | 17 | 43 |
Quintile 5 | 18 | 46 |
Accessibility/Remoteness index for Australia | | |
Major Cities | 37 | 95 |
Inner Regional | 2 | 5 |
Clinical characteristics (n = 38) | | |
Cancer type | | |
Lung | 11 | 29 |
Breast | 11 | 29 |
Bladder | 7 | 18 |
Other (Prostate, Colorectal, | 9 | 24 |
Cancer stage | | |
Non-metastatic (Stage 0-III) | 18 | 47 |
Metastatic (stage IV) | 14 | 37 |
Unknown | 6 | 16 |
Time since diagnosis (years) | | |
<= 1 | 17 | 45 |
> 1–3 | 12 | 31 |
> 3–5 | 6 | 16 |
> 5–10 | 3 | 8 |
Type of treatment received | | |
Immunotherapy | 22 | 58 |
Surgery | 19 | 50 |
Chemotherapy | 18 | 47 |
Radiation therapy | 11 | 29 |
Oral therapy | 10 | 26 |
#Quintile 1 is the relatively most disadvantaged area, and quintile 5 is the relatively most advantaged area.
A final cohort of 31 survivors were included in the study. Figure 2 describes participants’ referral process in further detail.
Community health services utilisation
Between 19/2/21 and 22/02/2022, a total of 162 community allied health appointments were scheduled with a median of four appointments per cancer survivor (range:1–15; IQR:5). Of the 162 appointments made, 142 (88%) were scheduled by 21/01/2022, and 126/142 (89%) were attended. The remaining 20/162 (12%) appointments were scheduled beyond the study period and were not included in the analysis. Nearly half of those appointments were Integrated Care Coordination (61/126, 48%), followed by physiotherapy (24/126, 19%), dietetics (14/126, 11%), exercise physiology (12/126, 10%), counselling/psychology (9/126, 7%), podiatry (5/126, 4%), and occupational therapy (1/126, 1%).
The number of allied health needs identified per participant ranged from one service need for 6 participants (19%), two services need for 14 participants (45%), three services need for six participants (19%), and four services needed by five participants (16%). Due to health deterioration three (10%) participants were transferred back to acute care utilising existing clinical care practices to support the escalation of care. At the conclusion of the data collection period, six participants (20%) remained on waiting lists for allied health services.
Relevance to implementation outcome: Consistent GL-CS referrals by hospital health professionals and 89% people taking up the referral demonstrated successful adoption of GL-CS. The appropriateness of GL-CS was demonstrated as most people had two or more allied health needs.
Consumers’ survey
Nine people (9/31; 29%) completed the online survey. Of this, one person (1/9; 10%) needed the help of a family member. Eight people (8/31; 26%) answered questions about their experience with their local community health service. All participants (8/8) strongly agreed that they had been treated with respect, most (7/8) ‘agreed’ to ‘strongly agreed’ to statements related to their health professional’s knowledge of medical and health history, their clear communication and respectful behaviour, their person-centred care and shared care planning approach, and the ease of the booking process (Supplemental material 1 - Consumer experience with local community health service). The overall experience of community health service use was ‘good’ to ‘great’ (6/8), ‘fair’ (1/8), and ‘unsure’ (1/8). Six participants (6/9; 67%) answered the open-ended questions about health behaviour changes and indicated they have or were considering making behaviour changes relating to: adopting new health care perspectives (“Taking on alternative ideas”), increasing physical activity (“…waiting for next appointment to do exercises. I would love to increase stamina and reduce tiredness”), increasing engagement and adherence to healthcare (“Can access caring, multiple services readily”; “By following the plan provided”; “Will be following up with GP for referrals for additional testing and alternative medications”), increasing own health knowledge (“…become more knowledgeable”).
Consumer interviews
Five participants (5/9; 56%) agreed to be interviewed, among whom one used the help of an interpreter. Three themes were identified illustrating the use of and access to community health allied healthcare services for cancer survivorship:
1) the cancer survivorship referral pathway was perceived as a gateway to cancer survivorship allied healthcare services, a convenient continuation of care, and a person-driven process, that needs to be better communicated to people.
2) continuation of survivorship care in community health settings was discussed in terms of coordinated and integrated care, participant’s physical health and wellbeing improvement, affordable services, and person-centred care.
3) opportunities for GL-CS program improvement included the provision of additional services, optimising the length of sessions, and language barriers. (Supplemental material 2 – Consumer thematic analysis).
When asked about the impact of COVID-19 restrictions, participants did not express any concerns about attending their community health services as they had telehealth as an alternative approach and felt comfortable with the density levels at their centre; "going to the community health where there’s fewer people, that sort of stuff, not a problem with it".
Relevance to implementation outcomes: The overall consumer satisfaction with GL-CS reported in the survey confirms acceptability. The program demonstrates feasibility as consumers valued the flexibility in accessing GL-CS.
Health professional interviews
Five community allied health professionals were interviewed including three occupational therapists, one dietician, and one community health nurse. They had worked in community health settings for a median of four years (range: 9 months − 11 years; IQR: 3 years) and were all involved in the Integrated Care Coordination role. All respondents (n = 5) were confident in selecting and performing appropriate assessment, accessing reliable and high-quality information and resources for the consumer, and knowing what general services or supports were available for the consumer. However, some were less confident in providing evidence-based management or treatment (n = 3/5; 60%), understanding the cancer survivorship model of care (n = 2/5; 40%), knowing what cancer-specific services or supports are available for people (n = 2/5; 40%), and finding information about best practice clinical intervention (n = 2/5; 40%).
Three main themes emerged from the interviews:
1) The impact of the GL-CS referral pathway on the communication between acute and community health settings, empowerment of the cancer survivor across the two care settings, addressing a gap in healthcare, and access to coordinated and integrated care.
2) Cancer survivorship care in community health. Cancer is perceived as a growing comorbidity in community health settings, where access to allied health care is affordable and convenient but dependant on consumer engagement and personal situation.
3) Sustainability of GL-CS was discussed in the context of multi-level communication needs, ongoing training requirements to support additional integrated care coordination roles in community health services, considerations to streamline different funding schemes, and workload management to address staffing issues, work allocations and support. The possibility of expanding the program beyond cancer survivorship was also discussed.
A detailed description of these themes is provided in Supplemental material 3 with quotes from allied health professionals to illustrate the meaning of these themes.
One focus group and three semi-structured interviews were conducted due to scheduling difficulties with hospital health professionals. One inpatient social worker and six oncology nurses participated in either the focus group or interviews. Areas of expertise of the oncology nurses included prostate cancer, breast cancer, lung cancer, urology, and outpatient clinics. The median years of experience in acute care settings was six years (range: 6 months to 30 years; IQR = 7.75 years).
Four main themes emerged from the focus group and interviews:
1) A holistic and complementary model of care. GL-CS was described as a continuation of cancer survivorship care that is holistic, flexible, convenient, supportive, and complementary. Additional service needs were also discussed regarding smoking cessation, social worker support, and difficulties in timely access to some services.
2) The referral process was perceived as easy to apply. Sharing patient information called for caution and was guided by community health professionals. Participants acknowledged good communication flow between the two healthcare settings and reflected on ways to streamline the process within existing systems and implement a central point of contact beyond the study period. Participants discussed the possibility of broadening eligibility criteria, the impact of COVID-19 on service disruptions and re-prioritisation, and the use of telehealth.
3) A consumer-driven process. Participants acknowledged the central role of cancer survivors in the referral process and discussed how sex differences, the role of carers, the stage of recovery, and providing purpose for the referral influenced people’s decision to take up the referral.
4) Promoting GL-CS by raising awareness in acute care settings, in the community, among survivors, and by survivors was considered important. Maintaining awareness of GL-CS in acute settings through various pragmatic communication strategies, via consumer feedback and by increasing knowledge around cancer survivorship and services offered by GL-CS was regarded as an important promotion aspect for sustainability.
Supplemental material 4 describes these themes in more detail with quotes from health professionals to illustrate the meaning of these themes.
Relevance for implementation outcomes: Health professionals demonstrated that the program was acceptable as they reported perceived benefits of the GL-CS referral pathway, appropriate as cancer survivorship was recognised as a chronic condition in community health settings, and hospital and community health staff highlighted the importance of continued survivorship care in community health services, and feasible as GL-CS was successfully carried out within existing service systems, hospital staff perceived the referral process easy to action, and the Integrated Care Coordinator role was recognised to facilitate the process.