Models of care toolkit

Coordinating with primary careclipart of heart in the centre with puzzle pieces surrounding it

People undergoing cancer treatment face other acute and routine health concerns. Coordination between cancer specialists and primary care is important during both active cancer treatment and in the treatment of chronic and emerging conditions that are unrelated to a patient’s cancer treatment regimen. Patients without access to primary care face additional challenges.

Health systems that connect cancer and primary care can:

  • Streamline diagnosis and initiation of treatment
  • Address the physical, mental and social care needs that may affect treatment compliance
  • Enhance support during post-treatment care
  • Integrate community resources to ultimately improve patient outcomes

For many in Canada, the cancer system has limited integration with primary and community care1, which can create challenges for both patients and primary care providers.2 There may also be instances where primary care providers are better suited to meet the needs of their patients with cancer, especially during pre-diagnosis and post-treatment.

Increasing the role of primary care teams

Primary care providers enhance whole-person care by treating comorbidities and providing preventive services and psychosocial support.3 Involving a patient’s primary care team in cancer diagnosis, treatment and survivorship also supports equitable care.

Connected care models benefits:

  • Enhanced coordination between primary care and cancer care reduces wait times, stress and anxiety associated with a cancer diagnosis4
  • Appropriate health care utilization in primary, acute and hospice care settings, emergency departments and intensive care units reduces unnecessary care such as trips to emergency departments5,6
  • Access to specialist support helps primary care providers feel supported in the delivery of cancer-related services to patients7
  • Collaboration among all members of the health-care team yields greater patient and provider satisfaction with both the quality of care and treatment outcomes

Many existing models of care focused on diagnosis and post-treatment lack adequate information flow among care providers and diagnostic teams8, specialty training in how to provide effective and person-centred care9 and clarity about providers’ roles and responsibilities.

Post-treatment models are commonly oncology-led, constrained in capacity and limited in their approach to culturally appropriate, holistic care for First Nations, Inuit and Métis peoples. With increasing cancer survivorship rates and limited access to specialist expertise, it is critical that healthcare system leaders find ways to increase the role of primary care teams9.

Supporting patients without a primary care provider in the cancer system

Connected care models in the cancer system work best if patients have a primary care provider. In 2023, 20% of Canadians reported they did not have regular access to a family doctor or a nurse practitioner.10,11 That number is expected to grow significantly in the coming years.12

Cancer system partners in many jurisdictions report that the shortage of primary care providers impacts their ability to deliver efficient, equitable cancer care. Some cancer leaders indicate discharge can be delayed for patients who do not have a primary care provider to coordinate their care.

Learn more about how provincial and territorial governments are expanding access to primary care services.

Primary care for First Nations, Inuit and Métis

First Nations, Inuit and Métis partners have questioned whether attachment to a single provider is the best way to organize primary care services in their communities. The term “unattached” is widely used across Canada to identify patients who do not have a regular primary care provider. Using the term “unattached” to describe First Nations, Inuit and Métis implies a lack of connection to the entire health care system even as many are embedded in community, traditional knowledge and health systems.

Focusing the primary care system on attachment to one provider, rather than connection to community-based multidisciplinary care teams, may incentivize primary care providers to take an individualist approach to care rather than a wholistic one where the community’s health is as vital as the health of its individual members.

First Nations across Canada are designing, administering, managing and delivering their own health services that reflect their needs. In Ontario, 25 Indigenous primary care organizations, supported by the Indigenous Primary Health Care Council, are transforming primary care for Indigenous peoples in the province using a multi-disciplinary model that includes community-based approaches to healing.

British Columbia plans to create 15 First Nations Primary Health Care Centres which will be planned, governed and designed with First Nations and offer team-based care instead of attachment to a single provider. When designing and implementing primary care solutions, communities should prioritize team-based models that allow both service providers and community members to work collaboratively to achieve individual and community health goals.

Using Patient Reported Outcomes in connected care models

Patient reported outcome (PRO) tools help to ensure patients with cancer are regularly screened for physical and emotional symptoms. An easy-to-read dashboard in Alberta allows clinicians to track changes and trends in a patient’s symptoms from visit to visit and helps them connect patients with appropriate support.

Data analysis helps staff to better support patients by demonstrating which types of cancers require more symptom management by multidisciplinary teams including primary care.  Alberta is also exploring PROs to provide effective virtual cancer care for people living in rural and remote areas13.

Other provinces are shifting to collecting PROs electronically. Radiation Oncology Centres in Nova Scotia and New Brunswick are using an online tool called Noona to provide patients an opportunity to electronically report and record cancer-related symptoms as well as highlight information about their wellbeing. Symptoms are reviewed by the care team and a follow-up care plan is created with patients when they come into the clinic. This innovative approach to electronic patient-reported outcomes reporting will be expanded to other settings beyond radiation therapy centres in Nova Scotia.

  1. Lavis JN, Hammill AC. Care by sector. In Lavis JN (editor), Ontario’s health system: Key insights for engaged citizens, professionals and policymakers. Hamilton: McMaster Health Forum; 2016, p. 209-69.
  2. Tremblay D, Latreille J, Bilodeau K, et al. Improving the transition from oncology to primary care teams: A case for shared leadership. J Oncol Pract. 2016;12(11):1012-1019.
  3. Kang J, Park EJ, Lee J. Cancer survivorship in primary care. Korean J Fam Med. 2019;40(6):353-361.
  4. Cancer Quality Council of Ontario. Programmatic Review on the Diagnostic Phase: Environmental Scan.; 2016.
  5. Gorin SS, Haggstrom D, Han PKJ, Fairfield KM, Krebs P, Clauser SB. Cancer care coordination: A systematic review and meta-analysis of over 30 years of empirical studies. Ann Behav Med. 2017;51(4):532-546.
  6. Mittmann N, Beglaryan H, Liu N, et al. Examination of health system resources and costs associated with transitioning cancer survivors to primary care: A propensity-score–matched cohort study. J Oncol Pract. 2018;14(11):e653-e664.
  7. Zhao Y, Brettle A, Qiu L. The effectiveness of shared care in cancer survivors-A systematic review. Int J Integr Care. 2018;18(4):2.
  8. Tremblay D, Prady C, Bilodeau K, et al. Optimizing clinical and organizational practice in cancer survivor transitions between specialized oncology and primary care teams: a realist evaluation of multiple case studies. BMC Health Serv Res. 2017;17(1).
  9. Meiklejohn JA, Mimery A, Martin JH, et al. The role of the GP in follow-up cancer care: a systematic literature review. J Cancer Surviv. 2016;10(6):990-1011
  10. Angus Reid Institute. (2023). Health Care Access Priorities. Angus Reid Institute. Accessed December 4 2023. Available: https://angusreid.org/cma-health-care-access-priorities-2023/
  11. Kiran, T. (2023). Our Care National Survey. Our Care. Accessed October 13 2023. Available: https://data.ourcare.ca/all-questions.
  12. Watson L, Qi S, Delure A, et al. Virtual cancer care during the COVID-19 pandemic in Alberta: Evidence from a mixed methods evaluation and key learnings. JCO Oncol Pract. 2021;17(9):e1354-e1361.
  13. Canadian Residency Matching Service. 2023 CaRMS Matching Results. Accessed December 12 2023. Available: https://www.cfpc.ca/en/education-professional-development/2023-carms-match-results.
  14. Walsh J, Young JM, Harrison JD, et al. What is important in cancer care coordination? A qualitative investigation: What is important in care coordination? Eur J Cancer Care (Engl). 2011;20(2):220-227.
  15. Wong WF, LaVeist TA, Sharfstein JM. Achieving health equity by design. JAMA. 2015;313(14):1417-1418.
  16. Canadian Partnership Against Cancer. Leading Practices to Create a Seamless Patient Experience for the Pre-Diagnosis Phase of Care: An Environmental Scan. 2018. Accessed November 22, 2021. https://canimpact.utoronto.ca/wp-content/uploads/2018/04/Leading-Practices-to-Create-a-Seamless-Patient-Experience-for-the-Pre-Diagnosis-Phase-of-Care-CPAC-2018.pdf
  17. Cancer Council Victoria. Optimal Care Pathway for Aboriginal and Torres Strait Islander People with Cancer Draft for National Public Consultation.; 2017. Accessed November 22, 2021. https://apo.org.au/sites/default/files/resource-files/2017-09/apo-nid108366.pdf
  18. Jefford M, Koczwara B, Emery J, Thornton-Benko E, Vardy JL. The important role of general practice in the care of cancer survivors. Aust J Gen Pract. 2020;49(5):288-292.
  19. Healthcare Excellence Canada, the Canadian Partnership Against Cancer, and Paramedics and Palliative Care teams. How Paramedics and Palliative Care contributed to better healthcare in Canada. August 2023.
  20. JE Terride, D Stennett, AC Coronado R Shaw Moxam, JHE Yong et al. Economic Evaluation of the “paramedics and palliative care: bringing vital services to Canadians” program compared to status quo. Canadian Journal of Emergency Medicine. 2024 26: 671-680.
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