Striving towards seamless service delivery for clients with cancer



  1. Palliative Care Coordinator, Central Gippsland Health Service
  2. Occupational Therapist

Clients with cancer often require intervention from a variety of health service providers. The National Cancer Institute1 identifies this as due to “health care continuing to increase in complexity”. Negotiating systems is often an added stress to a client who is already dealing with the multitude of issues that come with a diagnosis of cancer. The risk to the client and carer is that care can often become “fragmented and disorganized”1.

Optimal care is now dependent on careful planning across different settings to ensure a continuum of care. This article will outline the model of service delivery that has been adopted by Central Gippsland Health Service (CGHC). A case study will be used to illustrate how this system operates.

This system uses a single assessment process, a single care coordinator as well as involvement of all stakeholders utilising processes, protocols, co-location and effective methods of communication. The concepts of shared/managed care are well-recognised2,3.

This is the story of Mr T and his journey through CGHS

In 1998 at 59 years of age Mr T was diagnosed with throat cancer; he was transferred to a Metropolitan hospital for surgery and radiotherapy and was transferred to CGHS as an inpatient. At this point his details were taken and a UR number issued. He was referred to the dietitian and speech pathologist; then discharged to a supportive family, requiring no further services.

Fifteen months later Mr T sustained a left CVA resulting in a dense right hemiparesis. During the lengthy rehabilitation process Mr T received services from medical and nursing staff, a physiotherapist, occupational therapists, dietitian and speech pathologist. Mr T’s voice had been affected by previous surgery and radiotherapy and he often resorted to writing for communication. This was now impossible due to the decreased strength and coordination of his right hand. Fortunately he was already familiar with the use of a personal computer so this was used to facilitate communication, a joint project with speech pathology and occupational therapy.

A team approach was vital to the rehabilitation of Mr T. Frymark (1999) noted that a team can offer a variety of skills and a broad spectrum of knowledge and resources to help the individual to adapt to his or her situation. Through assessment and planning, mobility and self care was identified as a high priority for Mr T. This need was addressed by the ability to access a wide variety of services, with involvement of physiotherapy and occupational therapy and reinforced by nursing staff.

On discharge Mr T was able to walk short distances with supervision and required minimal assistance with self care. Fortunately his home was well set up except for two steps requiring modification. He was seen by Allied Health as an outpatient and had regular visits from the district nursing service. These services allowed Mr T and his family to regain control and confidence within their lives, as well as improve their quality of life.

Approximately six months later Mr T became acutely ill and was diagnosed with metastatic cancer. He was admitted as an inpatient and elected to have surgical intervention only. At this point he was referred to the Palliative Care Service. The palliative care coordinator became the case manager, liaising closely with Mr T, his physician, GP, district nurse, physiotherapist, occupational therapist, speech pathologist and dietitian, and arranging support services such as volunteer respite. A coordinator of the diverse array of health care professionals is imperative, and communication between the professionals is most important. At Central Gippsland Health Service, it is the palliative care coordinator who is directly responsible for engaging all service providers for palliative care clients. They support the client across any setting, ie at home, in hospital or in an aged care facility. The palliative care coordinator is able to arrange urgent admission as an inpatient into the acute care facility, and is the only agent that the treating doctor has to deal with in order to arrange this. The palliative care coordinator becomes the single point of contact for Mr T.

Communication processes also facilitate effective health care outcomes. Central Gippsland Health Service has developed a communication system to enable clients to participate in their own health care decisions and staff to be kept abreast of changes across settings. A “complex care meeting” enables team members from both inpatient and outpatient areas to provide information relevant to clients who are needing further care, eg impending discharges, impending admissions or for rehabilitation needs. Case conferences facilitate communication between clients, carers and their health care team. This enables appropriate care planning, and care planned around the “unique responses of people concerned”4.

Central Gippsland Health Service is a multifaceted organisation of six service sites including acute and community-based health care as well as co-located services such as the Aged Care Assessment Team.

The organisation has also achieved a structure whereby an assessment officer is also a care coordinator, no matter which division (ie acute, community or residential care) is involved, and has developed a series of protocols with other agencies such as the Aged Care Assessment Team to ensure that assessment is not a repetitive and duplicative process but a building process where information is collated into a centralised document.

Our palliative care coordinator is the case manager (across all service sectors) for the client, and the community care services department head of assessment is the discharge planner of acute services. There is a single referral form, a single consent form for information exchange and a single client file along with secure/confidential electronic storage/transfer of client service delivery information, which can be accessed only by password/client consent from multiple sites/program staff.

How does this work for Mr T? Under this model the palliative care coordinator conducts the holistic assessment and acts as case manager. The care plan involves all of the service providers working with Mr T and his family to achieve the best possible outcomes for the remaining part of his life.

Utilising the single assessment tool, the palliative care coordinator is able to coordinate and access services.

It means that by contact of only one person Mr T can have a “fast tracked admission” as well as a smooth transition back into community care, and that all service providers have a mechanism for communication and are involved in developing the case plan.

The family can feel confident that they only have to tell their story once. The doctor only has to communicate his directions to one person and they will be communicated to all. Provision of care from multiple sectors, for people like Mr T, requires seamless care to make his life a little more bearable.

How does this process work from an Occupational Therapy perspective? I was introduced to Mr T when he was admitted with his CVA.

We were involved with retraining in self-care, home modifications and return to work. Mr T was an accountant, and minor modifications of his workstation and connection to the Internet allowed him to return to part time work. This became far more important when he became palliative as it allowed him to complete his case load and retire with his work complete.

As the occupational therapy case load is based geographically rather than programatically it allowed us to be involved with Mr T as an inpatient, outpatient, community and palliatively; it allowed us to build rapport and provide a consistent service. It also was a big issue for Mr T in his palliative phase. He had been a very busy man and struggled with boredom. His main leisure interest was following horseracing, and with a little modification, a little patience and lots of laughter we were able to set up an Internet betting account for Mr T. It filled in his days in a way that was meaningful to him (and I learned how to pick first, second and fourth in a trifecta).

As Mr T’s health altered, care could be provided that was timely and appropriate. This was achieved by regular reviews from the palliative care coordinator and involvement of a comprehensive health care team. While physical function may not be restored, a carefully planned rehabilitation program has a positive impact on dignity and self-esteem. As seen with Mr T, by implementing an integrated approach to care, not only did his quality of life improve, but also confidence was instilled in his family, choices were provided for health care settings and treatments, and the anxieties of multiple assessments were avoided. Mr T was able to make decisions about his own health care needs, and to plan and set goals which enabled him to die peacefully at home surrounded by his family.


1  Cancerweb,, 1996/1997.

2  M Homewood, D Harley. “Shared care in oncology”. Oncology Shared Care Project (unpublished). General Practice Division, Geelong (1997): 54.

3  Peter MacCallum Cancer Institute. “Literature review” (unpublished). Peter MacCallum Cancer Institute, Melbourne, 21 May 1997.

4 P Hodder, A Turley. The Creative Option of Palliative Care. A manual for health professionals. Melbourne City Mission, Melbourne, 1989.

Other references (not cited)

1 Human Services Victoria. A Guide for Developing Assessment Services, 1991.

2 K Jamrozik, S Sadler. Medical and Other Care in Western Australia for Patients with Cancer. Department of Public Health, Perth, 1997.

3 Lincoln Gerontology Centre. Discussion and Resource Document – National Framework for Comprehensive Assessment in HACC. 1998.

4 L J Mann. Classification of characteristics which are common. Report to the Victorian Department of Human Services. Melbourne, April 1998.

5 L J Mann. Mystery and Mastery of Assessment. Presentation to the Department of Human Services. Victorian Research and Practice Forum, Melbourne, September 1999.

6 Victorian Department of Human Services Consultation Paper. A Guide for Allocating Home and Community Care Services, 1997.

7 Victorian Department of Human Services Consultation Paper. Towards a Stronger Primary Health and Community Support System. June 1998.

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