Implementing optimal care pathways into primary health

Implementing optimal care pathways into primary health

Victorians living in regional and remote locations commonly have a lower five year cancer survival rate than urban areas. Murray PHN is working with the Victorian PHN Alliance in  collaboration with the other five Victorian PHNs, the Department of Health and Human Services and the Regional Integrated Cancer Services network, to improve the quality of cancer care and patient experiences by implementing the Optimal Care Pathways for specific cancers in primary health settings.

The Optimal Care Pathways (OCPs) outline the best cancer care for specific tumour types by facilitating consistent care based on a standardised pathway of care. The OCPs can be applied in a range of different public and private settings.

This initiative aligns with key PHN activities and interests including:

  • The PHN national headline indicators to improve cancer screening rates and to reduce avoidable hospitalisation
  • PHN priorities including population health, supporting the health workforce, eHealth, and Aboriginal and Torres Strait Islander health
  • PHN roles in relation to general practice engagement, HealthPathways development, and integration of care for catchments and communities.

The Murray PHN Needs Assessment 2016 and 2017/18 has identified other key issues relating to cancer:

  • Cancer survivorship systems are missing
  • There is a need to develop systems to record cancer survivorship
  • Health services don't utilise existing chronic disease systems to support cancer patients
  • Some health and community agencies  report lack of health service capacity and patient access as key barriers to achieving quality cancer survivorship care

The OCP project is currently being delivered in two tranches:

  • Tranche 1 focused on lung and colorectal cancers
  • Tranche 2 focuses on prostate and oesophagogastric cancers

There are four main deliverables for the project: customisation and development HealthPathways to align with the OCPs, education and training, local network facilitation and data capture/measurements. Four focus areas have been identified:

Project Focus Area 1: Improve the quality of GP generated colonoscopy referrals to Bendigo Health
Project Focus Area 2:  Increase bowel cancer screening rates
Project Focus Area 3: Trial the effectiveness of a support assessment tool in general practice for cancer patients post treatment/discharge from hospital
Project Focus Area 4: Increase general practice awareness of the stages of OCPs through professional development opportunities


How are OCPs used

Optimal Care Pathways are national guides that describe the best possible cancer care for patients with specific types of cancer. The pathways describe the key stages in a patient's cancer journey, from diagnosis to survivorship or end-of-life care, and the expected optimal care at each stage to ensure all people diagnosed with cancer get the best care, regardless of where they live or have cancer treatment.

Currently there are fifteen OCPs for different cancers that have either been released or are in the process of being revised, under the auspices of the National Cancer Expert Reference Group.

The primary purpose of the OCPs is to improve patient outcomes by facilitating an understanding of the whole cancer pathway and its distinct components to promote quality cancer care and patient experiences.

Developed by clinical experts in collaboration with consumers, the Optimal Care Pathways have been endorsed by the National Cancer Expert Reference Group, Cancer Australia, Cancer Council Australia, and the Australian Health Ministers Advisory Council (AHMAC).

OCPs provide clinicians and health administrators with an agreed consistent nationwide approach to care that is based on current best practice including clinical guidelines, consensus statements, standards and research.

The OCPs:

  • Provide a mandate for service improvement
  • Are useful in deciding how best to organise service delivery to achieve the best outcomes for patients
  • Can assist drive service improvement priorities such as reducing unwanted variations in practice
  • Are relevant across all jurisdictions and have been adopted nationally
  • Are not intended to be or replace detailed clinical practice guidelines Optimal Cancer Care Pathway Map

Source: A framework for optimal cancer care pathways in practice. Supporting continuous improvement in cancer care, National Cancer Expert Reference Group.


Focus area 1: improve the quality of GP generated colonoscopy referrals to Bendigo Health project

This project is a focus area because the project team identified that referrals received for colonoscopies did not include all the key information required and were deemed to be incomplete. Incomplete referrals cannot be triaged effectively which causes preventable delays in time between referral and colonoscopy. The intent of the project is to reduce the number of incomplete referrals.

Focus are 2: Low bowel cancer screening rates adversely impacts early detection rates, resulting in greater rates of late detection and associated mortality.

By completing this project the intent is to increase bowel cancer screening rates, while improving GP awareness of OCPs, the National Bowel Cancer Screening Program and Murray HealthPathways.


Trial the effectiveness of a support assessment tool in general practice for cancer patients post treatment/discharge from hospital

There is an identified gap in screening patients for supportive services following treatment, especially those who undergo surgery only for colorectal cancer. Routine screening in the general practice setting will decrease gaps in provision of supportive services and lung cancer.

Optimal Care Pathways (Step 5 - Care after initial treatment and recovery) recommends Cancer survivors should be provided with supportive care services. Supportive care addresses a wide range of needs across the continuum of care and is increasingly seen as a core component of evidence-based clinical care and includes: physical, psychological, social, information and spiritual needs

An important step in providing supportive care is to identify, by routine and systematic screening (using a validated screening tool) of the patient and family, views on issues they require help with for optimal health and quality-of-life outcomes. This should occur at key points along the care pathway, particularly at times of transition - from hospital to community.

The Distress Thermometer (DT) is a widely used rapid screening tool for assessing psychological distress in people affected by cancer.

This projects aim is to embed routine and systematic screening for patients returning to general practice management following colorectal and lung cancer treatment.


Implement the optimal care pathways for people with prostate cancer or oesophagogastric cancer in general practice

Prostrate cancer
General practitioners currently play a central role across the care continuum for prostate cancer patients, including examination, investigation, referral, support throughout the treatment phase including supporting the patient to make an informed decision regarding their treatment options, managing side effects and comorbidities, and survivorship and/or end of life care.

General practice education and health system improvement regarding the identification of symptoms, PSA testing, diagnosis, referral pathways, treatment options and supportive care needs has the potential to significantly improve the patient experience and health outcomes. There is a notable absence of population health monitoring mechanisms in primary care for this OCP. Potential areas for system improvement include:

There are currently no cancer specific reports incorporated into general practice clinical auditing software (CAT Plus) and such there is a role for stablishing primary care population health monitoring mechanisms for quality improvement and assurance purposes.

Supporting the update of new PSA testing guidelines, targeting general practice systems and enabling workforce development regarding the treatment of prostate cancer and survivorship care.

Oesophagogastric cancer
In the absence of a screening test for Oesophagogastric cancers, cancers are usually identified when signs and symptoms indicate further the need for further investigation. Oesophagogastric cancers can be aggressive so the timeliness of the identification of signs and symptoms, appropriate investigation and referral are paramount to reduce time to treatment. This requires a high level of clinical suspicion which is at odds with the rarity of the cancer.

Once diagnosed, GPs have an important role in supporting the patient as needed with managing side-effects of treatment, managing co-morbidities, coordinating supportive care and potentially providing end of life support.


Improve patient flow between general practice and other health settings with a view to improving patient experience and health outcomes

Murray PHN is currently working with general practice, Regional Integrated Cancer Services and Hospitals to improve patient outcomes and process around patients entering a service, collaboration with other primary health care services, enabling shared care and timely discharge that improves patient outcomes, as well as the burden on secondary and tertiary services. In addition, we are working with clinical experts to develop a suite of   localised HealthPathways for oesophagogastric and prostate cancers.

Across our region,  Murray Healthpathways  provides localised clinical information, referral details and other resources free to GPs and other clinicians.  If you do not currently access HealthPathways, you can register free  here.

  • Iron deficiency anaemia
  • Abdominal pain
  • Unexplained weight loss
  • Non-acute gastroenterology assessment
  • Haematemesis and malaena
  • Helicobacter Pylori
  • Dyspepsia and heartburn/GORD
  • Non-acute oncology assessment (referral)
  • Urology
  • Urinary catheters
  • Prostate cancer
  • Benign prostatic hypertrophy

Oesophagogastric Cancer OCPs

Oesophagogastric cancers have a low incidence and poor prognosis, with 5-year survival rates ranging from 20 to 30%, and the 1-year survival rate being 55% (Cancer Council, 2017).

OCP resources from Cancer Council Victoria:


Prostate Cancer OCPs

Prostate cancer is the most common cancer diagnosed in men in Australia with 16,665 estimated new diagnoses in 2017 (Cancer Australia, 2017). The five-year survival rate is 94% however due to the high incidence, prostate cancer was the second most common cause of cancer deaths among males in 2014 (Cancer Australia, 2017).

OCP resources from Cancer Council Victoria:

PSA Testing for Prostate Cancer
Prostate cancer is the most common cancer diagnosed in men in Australia and fortunately has a very high five-year survival rate (94%). However, a significant sub-group of patients report poor quality of life post treatment, such as erectile dysfunction and urinary incontinence.

The Optimal Care Pathway has the potential to significantly improve the experience for patients by building general practice's awareness of symptoms, PSA testing guidelines, referral pathways, management options and supportive care needs. Men should be fully informed before making final decisions on either PSA testing or management of prostate cancer if found.

Click here for a PSA testing factsheet

Talking about PSA Testing for Prostate Cancer videos:

1. Full video - 3 Patients Scenarios: GP Dr Jane Crowe talks to patients about the pros and cons of PSA testing and the importance of shared decision making. (Approx. 17 minutes)

2. Short video - Patient A: GP Dr Jane Crowe talks to a patient with no symptoms, who has specifically come in for a PSA test. (Approx. 8 minutes)

3. Short video - Patient B: GP Dr Jane Crowe introduces the idea of PSA testing to a patient who has come in for an unrelated reason. (Approx. 8 minutes)

Eastern Melbourne PHN have also recorded "What's new in prostate cancer treatment" video, that can be watched in whole or several parts, covering: current issues and diagnosis, active surveillance, surgery, radiation therapy, deciding which treatment, side effects and supportive care and hormone therapy.


Bowel Cancer OCPs and resources

Around 80 Australians die of bowel cancer every week, but if detected early, up to 90% of cases can be successfully treated.

While people aged over 50 are encouraged to take part in the free National Bowel Cancer Screening Program, only 38 per cent of eligible Victorians take it up. Click here for age eligibility criteria information.

OCP resources from Cancer Council Victoria:

Other resources  


Lung Cancer OCPs and resources

Lung cancer was the 5th most commonly diagnosed cancer in Australia in 2013 and in 2014, it was the leading cause of cancer deaths (8,251) in Australia.

OCP resources from Cancer Council Victoria:

Other resources:


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