|Active ingredient||Personnel involved||Activities|
Duration: Up to 20 min
|Pharmacist and the patient||
• Obtain and record medication history including cancer and non-cancer therapy|
Note: The pharmacy review will be offered to all patients in the intervention arm and will be provided via teleconference or phone call based on the patient’s preference. Medication history completion (Y/N) will be recorded by the RN as a process measure and will therefore not be considered a protocol violation should patients decline this service.
Duration: 60 min
Mode: Teleconference or face to face
|Specialist cancer nurse and the patient||
• Treatment summary including follow-up appointment schedule|
• Co-developing the SCP (including planning for health goals)
• Post-treatment education
Note: The completed draft SCP will be sent to the GP prior to the case-conference. The research team or SCN will organize the case conference with the GP.
GP case conference and optional “booster” case conference|
Duration: Maximum 40 min
|SCN, GP (± one more healthcare professional).||
• The SCN will present the Treatment Summary, and the draft Survivorship Care Plan.|
• The SCN will negotiate follow-up responsibilities with the GP and will
• Answer any questions the GP may have.
• Additional education and support to the GP ± practice nurse if applicable regarding physical examination and blood analysis.
Note: A copy of the completed and agreed Survivorship Care Plan provided to the GP and the patient and scanned for IeMR. Where a full case conferencing is not possible, all efforts will be made to facilitate a teleconference of a shorter duration (~ 5 min) to deliver all key information on the Survivorship Care Plan. An additional “booster” case conference will be offered to GPs based on their preference should they require further support prior to participating in lymphoma surveillance activities.
Standardized shared follow-up care|
Mode: Face to face
|GP, SCN, patient, hematologist||
• The cancer specialist will review the patient history (i.e., fevers, sweats, loss of weight, infections), conduct a physical examination (i.e., lymphadenopathy, hepatosplenomegaly), and order/review blood tests (i.e., FBC, U+Es, LFTs LDH).|
• GPs who agree to participate in all aspects of follow-up care will review the patient history (i.e., fevers, sweats, loss of weight, infections), conduct a physical examination (i.e., lymphadenopathy, hepatosplenomegaly), and order/review blood tests (i.e., FBC, U+Es, LFTs LDH).
• As a safety measure the SCN/RN will ensure that surveillance activity is conducted as per clinical guidelines. Where the GP is unable to complete this activity, the SCN will ensure surveillance activity is transferred to the acute cancer center/specialist. This will be documented as a process measure or future studies in this area.
• The GP will also carry out care activities outlined in the SCP.
• The GP will follow an escalation pathway which utilizes the SCN as the rapid access point for rapid re-entry to the acute setting and point of contact for the GP for support and resources.
Note: The GP will be given the direct telephone number of the SCN responsible for the patient. At any time if the GP becomes concerned about the patient, he/she can ring the SCN for advice or request escalation to acute care for review.