Models of Care Toolkit
For patients living with cancer, and their families, the experience is often difficult and overwhelming.
Coordinating treatment visits, testing and follow-up appointments with care providers can leave patients feeling overwhelmed, and many patients are unaware of available supportive care services.
The lack of navigation services can lead to undiagnosed or untreated symptoms and can be particularly difficult for Indigenous peoples and other equity-deserving populations.
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
The health system in Canada has historically failed First Nations, Métis and Inuit when it comes to providing access to health care, the delivery of culturally appropriate care, availability of care close to home and other factors.
Understanding the community experience and engaging communities in the design and implementation of patient navigation models can improve timely access to culturally appropriate care, help patients receive care closer to home and ultimately improve patient outcomes.
Indigenous navigation models also offer translatable lessons for health system leaders looking to enhance patient navigation services for all cancer patients.
How far do you need to travel to access care?
Learn how differences in access to health programs, the importance of care close to home and support for medical travel affect First Nations, Métis and Inuit to bring focus to the importance of navigational supports for communities.
The Cape Breton Home Care Discharge Planning Program in Nova Scotia provides a home care discharge plan for First Nations clients who require one when they leave the hospital.
The program includes a functional assessment that provides high-level information on a patient’s mobility and their capacity to function outside of the hospital setting. It also provides short-term service in the home until a community-based care coordinator can conduct a home assessment and develop a customized home care plan.
Initiated by First Nations in Unama’ki and the Cape Breton District Health Authority (now the Eastern Zone of Nova Scotia Health), the program improves the procedure for handling the discharge of people living on Reserves. The program’s success is attributed to its community-led approach, seamless integration of the model into the existing system and conservative use of resources.
The pilot’s evaluation report provides 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.
Learn more about Nova Scotia’s Home care discharge program.
Located at the Hotel Dieu Hospital site of the Kingston Health Sciences Centre, the Ininew Patient Services program facilitates culturally safe health care services for Cree patients and their families from northern Ontario communities.
The program supports patient admission and discharge planning and provides medical education and interpretation services to ensure patients are able to participate fully in their care.
The program also recognizes that coordinating travel can be a barrier to accessing care for patients living in remote communities. Ininew Patient Services has a charter flight operating regularly between Kingston and Weeneebayko to facilitate patient travel.
Learn more about Kingston’s Ininew Patient Services.
Established to help improve the cancer care experience for First Nations, Inuit and Métis, the Champlain Indigenous Cancer Program works closely with patients and family members to improve access to services in a respectful, culturally appropriate way.
The hospital’s Indigenous Cancer Program provides a more holistic support for patients through its unique team-based approach that includes an Indigenous Clinical Lead, an Indigenous Nurse Navigator and an Indigenous Program Coordinator.
It supports patients and families by:
- Helping navigate the health care system and coordinate care and other services
- Liaising with members of the health-care team to ensure continuity of care
- Facilitating access to language and translation services
- Providing direct patient and family member support during clinic visits and other appointments
- Preparing patients for their first appointment within the cancer program
The Indigenous Cancer Program also provides education and training to advance cultural competency within the organization and ensure the delivery of culturally appropriate and safe care.
Learn more about the Ottawa Hospital’s Indigenous Cancer Program.
Eastern Health has an extensive patient navigation program with specialized navigation services in several areas including palliative care and cancer. With the ultimate objective of improving the patient experience, navigators help patients take a more active role in their care by removing the burden of care coordination from a patient’s shoulders.
Cancer patient navigators are specially trained oncology nurses who assist patients, families and caregivers in understanding and working through treatments, services and other challenges along the cancer journey. They also help monitor patient symptoms and assist with counseling and coordination of supportive care services through referrals.
Due to Newfoundland and Labrador’s large, sparsely populated geographic area, many patients travel to visit their oncologist. To better support patients, Eastern Health’s Cancer Patient Navigation program has navigation services in seven regions of the province.
With an understanding of local context, navigators can link patients with community health services, support groups and programs in their area, enhancing the continuity of care and provision of care closer to home.
Cancer patient navigators are specially trained to provide care that respects and values a patient’s cultural and spiritual backgrounds. The province also has Indigenous patient navigators who provide whole person care, incorporating traditional and spiritual aspects of supportive care into the cancer journeys of First Nations, Inuit and Métis patients.
Learn more about Newfoundland and Labrador’s Cancer Patient Navigation program and its Indigenous Patient Navigation program.