Models of Care Toolkit

About this section

Virtual care, digital health and patient navigation were identified by partners as being key enablers in the implementation of models of care. In this toolkit you will find examples of how these innovations have been successfully implemented in jurisdictions. This section provides general information on how cancer programs can support the delivery of equitable care by capitalizing on digital innovations and navigation tools.

Virtual care

clip art of female doctor on computer screenPatients in rural and remote communities often travel great distances to access cancer services, and in some cases are forced to make treatment decisions based on factors such as the ability to arrange childcare for long periods of time, or the ability to take long periods of time away from work.

Using virtual care and digital health solutions to replace clinic visits, when appropriate, reduces the burden of treatment on patients and caregivers. It makes it more efficient for patients to manage medical appointments and monitor their health, as well as minimizes challenges experienced when accessing care. Virtual clinics can slow the spread of secondary infections for cancer patients by keeping them out of high-risk areas such as waiting rooms. Optimizing care solutions that take advantage of existing infrastructure and IT resources such as home consultations or follow-up can help improve access to the best care.

While historically there have been many perceived barriers to virtual appointments, such as patient privacy and reasonable clinician compensation, the need for social distancing because of the COVID-19 pandemic introduced more opportunities that may be sustained after the current crisis. However, adequate internet access continues to prove challenging in some of the most remote areas.

Digital health solutions – helping patients in real time

Digital health solutions are the provision of evidence-based therapeutic interventions to patients, through direct, patient-facing software applications designed to help patients and their care team monitor and manage symptoms, support prevention strategies and more.

These digital solutions can be connected to sensors for remote monitoring of symptoms and biometric data, or simply act as a platform for the collection of electronic Patient Reported Outcomes (ePROs). This helps to facilitate symptom management by the patients themselves, with or without real-time decision support.

Digital supportive care solutions present an opportunity to address unmet needs in the prevention or management of adverse events in patients with cancer including:

  • Increased communication between patients, providers and their communities
  • Education of patients and caregivers
  • Integration of standard clinical assessments with ePROs measured during routine clinical practice
  • Help for patients in monitoring their respective conditions
  • Improved patient empowerment and self-management
  • Prospective evaluations of supportive care interventions and real-world efficiency of care for cancer patients.

Digital solutions are associated with improved patient experience, increased adherence and treatment efficacy, and avoidance of unnecessary hospitalizations.1

clipart of hand holding a cell phone

Helping patients during the pandemic

In Quebec, some patients with cancer can report symptoms to their cancer care team using a mobile phone app. The collected information triggers stepped-care referral and clinical care pathways that integrate evidence-based, self-management resources tailored to patients’ and caregivers’ experiences.

Patients can also use their phones or tablets for appointment check-in and to complete their COVID-19 screening – both innovations designed to reduce in-person encounters during the pandemic.

Patient navigation

clipart of a person leading to a map pointVariability in coordination of care between health care providers poses challenges for patients and health care providers alike. For patients living with cancer, the experience is often difficult and overwhelming. Coordinating treatment visits, testing and follow-up appointments with care providers can leave patients feeling overwhelmed. Moreover, many patients are not aware of the services available to them, which can result in missed opportunities for supportive care services. The lack of navigation services can also lead to undiagnosed or untreated symptoms.

Supports are required to enhance continuity of care for individuals with cancer to help ensure that care is delivered in a logical, connected and timely manner so that the medical and personal needs of the patient are met.

Optimizing the role of patient navigators can support person-centered care, increase the value of supportive-care models and better balance the workload of other oncology care team members. This can result in greater patient satisfaction, improved communication among care providers and better patient outcomes.

Patient navigators can help coordinate appointments and testing, and are positioned to identify the need for, and coordinate access to, psychological supports during and after treatment.

Culturally appropriate navigation

Navigating the health system is complex for many First Nations, Inuit and Métis as it is ambiguous, multifaceted and multijurisdictional. There is significant value and utility in the community experience and knowledge of how to address these challenges, and engagement can facilitate improved communication and coordination of services, ultimately improving navigation.

To learn more on how the Partnership is supporting Indigenous partners in this work view the First Nations, Inuit and Métis section of the toolkit.

heart with a medical cross and First Nations, Inuit and Metis symbols

First Nations-led approach to patient navigation after treatment

The Cape Breton Home Care Discharge pilot is a patient navigation tool that includes a functional assessment and short-term service and community-based care coordination. The program was developed to inform a provincial home care framework for First Nations people living on reserves. The pilot’s evaluation report can provide a roadmap for other jurisdictions looking to collaborate with First Nations, Inuit and Métis communities in the creation of community-specific discharge protocols and/or cultural competency training.

  1. Aapro M, Bossi P, Dasari A, et al. Digital health for optimal supportive care in oncology: benefits, limits, and future perspectives. Support Care Cancer. 2020;28(10):4589-4612.