A distributed care model is one that relies on nurses, clinical practitioners and allied health professionals to deliver cancer services with cancer specialist support when needed.
Distributed care models are used in tertiary and community cancer centres. They can include virtual and in-person clinics, including those led by advanced practice nurses with specialty training.
Several randomized trials have compared traditional hospital-based follow-up care by a physician to specialty nurse-led care either virtually (telephone or video) or in-person. They found no difference in time to detection of recurrence but higher patient well-being and reduced cost to the healthcare system when nurses delivered care.1-6
Distributed care models offer several advantages, including:
- Potential for improved access to care that reflects a person’s culture and values by supporting delivery in local settings
- More equitable care for patients who live far from a cancer centre
- The availability of care coordinated between cancer and primary care for patients without a family doctor
- Improvements in resource use and reduction in healthcare costs and specialist visits
- Enhanced continuity of care by supporting coordination with primary care, allied health professionals, community care, patients and families
- Optimized scope of practice for healthcare professionals, often leading to improved job satisfaction7.
Nurse practitioners with BC Cancer are licensed to run independent medical practices covered by the Medical Services Plan. With a master’s degree and advanced clinical training, nurse practitioners care for patients with a cancer diagnosis who do not have a family doctor. Referrals from an oncologist are not required.
With special training in cancer care delivery, nurse practitioners can order diagnostic tests, diagnose cancer, and prescribe most medications. They also monitor short- and long-term effects of cancer and its treatment, and screen for cancer recurrence. Nurse practitioners have access to oncologists for consultation on their patients’ health.
The primary care nurse practitioner model supports the delivery of connected care, reduces the need for regular oncologist appointments after treatment and addresses the shortage of family physicians.
Specialized oncology nurse practitioners have a similar scope of practice to general practitioners in oncology.
In response to clinical practitioner in oncology shortages, nurse practitioners are employed in some community cancer centres in Alberta. In the model, a nurse practitioner in a tertiary cancer centre connects via telehealth to the community site for a weekly clinic. The site’s registered nurse participates in the virtual clinical encounter with the nurse practitioner and the patient. The nurse practitioner also supports the community team virtually outside of clinic hours.
The nurse practitioners-led virtual care model helps:
- Increase resources at community sites can help address capacity issues at tertiary centres
- Control disease progression and increases palliative home care referrals for patients receiving treatment
- Enhance access to equitable care by virtually connecting patients who live at a distance from a cancer centre
Connect with Alberta’s model lead.
Patients undergoing cancer treatment need access to around-the-clock support for crisis and urgent support. Bayshore’s CAREchart@home is an after-hours support program for patients receiving systemic and radiation therapy. Patients can connect virtually to a live nurse to help manage their symptoms through a digital health app on a computer, tablet, or phone. Patients are also prompted to answer questions regarding their symptoms before a visit.
Patients enrolled with Bayshore have access to 24-hour care, 365 days a year. It is available for over 70 hospitals in Ontario. CAREchart@home services are administered using evidence-based guidelines by registered oncology nurses.
The Bayshore program provides a range of supports:
- Real-time and shared access to patient health records, allowing the treatment team to monitor and follow-up if needed and is critical for coordinated care.
- Real-time report submission to members of the patient’s health care team after each visit, ensuring all relevant case information is shared in a confidential manner.
- Help to patients with symptom management, reducing reliance on oncologists and supporting patients living at a distance from the hospital.
- Access to advice that reduces unnecessary emergency room visits, improving patient satisfaction.
Management of hematological malignancies such as leukemia, lymphoma and myeloma is complex and requires interdisciplinary involvement in planning. Because treatment can last years, finding ways to support the long-term needs of patients is important.
As part of a quality improvement initiative, Ontario Health’s Cancer Care Ontario reviewed the roles of multidisciplinary teams involved in the care of this patient population. They used this review to support changes to optimize the role of registered nurses, nurse practitioners and physician assistants. Oversight for planning, care and follow-up is provided by hematologists, oncologists and/or transplant physicians.
While specific to malignant hematology, this model could be extended to other patient populations with complex needs.
Despite the key role of clinical pharmacists in oncology, many cancer care teams have limited access to clinical pharmacy services. The James Comprehensive Cancer Center in Ohio developed the hematology/oncology allocation tool (HOPAT) to determine which inpatient services benefit most from having a clinical pharmacist on their team. The tool includes five criteria and allows health system planners to allocate limited clinical pharmacy resources efficiently and equitably.
- Williamson S, Beaver K, Gardner A, Martin-Hirsch P. Telephone follow-up after treatment for endometrial cancer: A qualitative study of patients’ and clinical nurse specialists’ experiences in the ENDCAT trial. Eur J Oncol Nurs. 2018;34:61-67.
- Beaver K, Williamson S, Sutton CJ, Gardner A, Martin-Hirsch P. Endometrial cancer patients’ preferences for follow-up after treatment: A cross-sectional survey. Eur J Oncol Nurs. 2020;45(101722):101722..
- Beaver K, Williamson S, Sutton C, et al. Comparing hospital and telephone follow-up for patients treated for stage-I endometrial cancer (ENDCAT trial): a randomised, multicentre, non-inferiority trial. BJOG. 2017;124(1):150-160.
- Cohen PA, Webb PM, King M, et al. Getting the MOST out of follow-up: a randomized controlled trial comparing 3 monthly nurse led follow-up via telehealth, including monitoring CA125 and patient reported outcomes using the MOST (Measure of Ovarian Symptoms and Treatment concerns) with routine clinic based or telehealth follow-up, after completion of first line chemotherapy in patients with epithelial ovarian cancer. Int J Gynecol Cancer. Published online 2021:ijgc-2021-002999.
- Schenker Y, Althouse AD, Rosenzweig M, et al. Effect of an oncology nurse-led primary palliative care intervention on patients with advanced cancer: The CONNECT cluster randomized clinical trial: The CONNECT cluster randomized clinical trial. JAMA Intern Med. 2021;181(11):1451-1460.
- Komatsu H, Yagasaki K, Yamaguchi T, et al. Effects of a nurse-led medication self-management programme in women with oral treatments for metastatic breast cancer: A mixed-method randomised controlled trial. Eur J Oncol Nurs. 2020;47(101780):101780.
- Nelson S, Turnbull J, Bainbridge L, et al. Optimizing Scopes of Practice: New Models for a New Health Care System.; 2014. Accessed November 22, 2021. https://www.cahs-acss.ca/wp-content/uploads/2014/08/Optimizing-Scopes-of-Practice_REPORT-English.pdf