Supporting seamless transitions between cancer programs and primary care

This scan looks at the need to improve coordination between cancer care and the primary and community care sectors and it also outlines seven educational approaches and resources that can help ease the transition into survivorship care

Key findings

  • As the number of people living with cancer increases, educational content and resources can facilitate a smooth transition to survivorship care.
  • Improved communication between care providers and patients, along with better coordination between providers, helps eliminate the barriers to effective care.
  • Self-management strategies help build survivors’ capacity to overcome challenges.
  • Digital health technologies improve the capacity of providers and patients to deliver and follow care plans.

The number of cancer diagnoses in Canada is rising, and so is the five-year survival rate. That means the number of people living with cancer or transitioning out of the cancer system into survivorship care delivered by primary or community care providers is also increasing.

This transition requires survivors and their families to change how they interact with the healthcare system. They also need supports for symptom management, psychosocial needs, lifestyle/behaviour adjustments, and physical and functional challenges.

With the right resources—and more effective communication and cooperation across sectors—primary and community care providers can inform and guide patient and family expectations on the transition to survivorship. Education is the key to delivering optimal care during and beyond the care transition, reducing barriers and addressing unmet needs for everybody involved.

Assessing the Canadian context

What kinds of educational content, resources and approaches are currently used across Canada to inform survivors about the transition from cancer programs to primary or community care?

Several key themes emerged from this review:

  • Improved communication and information flow between providers and patients – and among providers themselves – are needed to overcome barriers to effective care, such as confusion about roles and responsibilities.
  • Better cross-sector coordination and health system navigation programs are needed to facilitate the transition to survivorship care.
  • Providers’ capacity to respond to transitions needs and patients’ capacity to comply with care standards can be increased through the use of digital health information technologies.
  • Self-management strategies help build survivors’ capacity to overcome challenges they may face.
  • Different survivorship care structures and models (e.g., nurse-led care vs. shared care between oncologists and primary care physicians) may require different educational approaches or resources.

Seven ways to support cancer transitions

The Forum also identified seven main types of educational approaches or resources that can support cancer transitions:

  • Communication strategies
  • Skills training
  • System-navigation supports
  • Self-management supports
  • eHealth and mHealth technologies
  • Multi-faceted transition interventions
  • Care models that include transition supports

What’s next

All of the provincial health systems and most of the territories in Canada have educational content and resources related to survivorship for patients, families and primary care providers. These resources are available in various formats (e.g., programs and workshops delivered online and in-person, evidence-based tools and websites) and are designed to meet a variety of needs.

The findings from this rapid review are currently being used in Alberta to inform the planning, development and delivery of survivorship educational sessions. These sessions will help increase primary and community care providers’ ability to identify and address the full range of cancer survivor and family needs.

View this report

Identifying educational approaches and resources to support seamless transitions between cancer programs and primary care