Network Supportive Care Pathway - North East Yorkshire and ...

HYCCN HIGH LEVEL SUPPORTIVE CARE PATHWAY
The pathway has four key components identified that would significantly mprove the patients’ experience
a = Holistic Assessment
© = Key Discussion Point
♦ = Single Contact with the
assigned Key Worker
i = Patient/carer information
Identified Key Components Stage on Pathway Dependant On
Information available and offered
i Pre- referral and Screening Programmes
Accessible Health Promotion Information .
Support and Advice from the Practice Nurse, (and
Triage if required). GP following NICE
guidelines for timely referral
Key discussion point
Fast Track system or what happens next
Information offered
i © GP / Symptoms
Will include all access routes (A & E, Emergency
Admission, GP Direct Access to tests etc)
GPs having the agreed timed site
specific pathways using a symptom based approach
to select the appropriate test / referral
Information offered
Key contact identified to navigate investigations
Patient support may not be Specialist CNS
Key worker(kw) identified - this may be the CNS
Meet kw contact details given
Holistic Assessment/Information offered
Key discussion point - diagnosis given next
steps explained
i ♦ Diagnostic tests
(MDT may occur after 1st test or later in the
pathway)
a © i ♦ Diagnosis and staging
Patient will be presented at MDT
Direct Access resources so tests can be carried
out before referral (not 2ww) Requesting the
appropriate test to inform diagnosis and practice
staff having
ability to offer support
Co-ordination of tests to reduce visits andadhere to
agreed time scales
Core member attendance at MDT to facilitate next
steps – referral to
oncology etc to happen at MDT.
Development of the patient management plan
Key worker same – contact / meet patient after
MDT Re-visit Holistic Assessment
Information offered
Key discussion point - treatment options
discussed
Consider change in Key- worker depending on
treatment modality – meet kw & contact numbers
given
Re-visit Holistic Assessment
beginning and end of each treatment Information
offered
Key discussion point - What happens next
Consider Key-worker change - may be to primary
care meet kw & contact numbers given
Discharge Holistic Assessment
Information offered
Key discussion point what happens next
a © i ♦ Treatment planning options
Decision to Treat – patient may need ‘thinking
time’
a © i ♦ Treatment
Surgery, Chemotherapy, Radiotherapy,
Watchful Wait
a © i ♦ Living with Cancer
Survivorship
Recurrence/ relapse suspected
Timely patient ‘hand-over’ of care with all relevant
information. Communication with GP / Community
Staff to enable timely & effective primary Care
support
Timely patient ‘hand-over’ of care with
all relevant information.
Communication with treatment Team &
GP / Community Staff to enable
primary Care support
Rapid access into secondary care for
investigation of possible recurrence/
further symptom management .Primary
care to be aware when to re-refer
At any stage of the pathway the patient referral for specialist palliative care input should be
considered based on assessed need. If and when patients are assessed to have 6 – 12months to live
they will move onto End of Life pathway
adapted from YCN supportive care pathway

HUMBER AND YORKSHIRE COAST CANCER NETWORK
High Level Supportive care pathway appendix
Introduction
Providing good supportive care is a vital element of the patients care pathway, highlighted in the
NICE Improving supportive and palliative care for adults with cancer guidance (2004) and the
Cancer reform strategy (2007).
Supportive care pathway
The aim of the supportive pathway is to support Network site specific groups to incorporate the
supportive care aspects into their individual cancer pathways.
The Cancer Clinical Nurse Specialist role is recognised to include a large element of supportive
care and will be vitally important to the implementation and delivery of the key elements in the
supportive pathway.
The supportive care pathway starts from pre referral through active treatment, living with cancer and
survivorship, recurrence and subsequent treatment. The pathway would end if a patient has been
assessed as having 6 – 12 months to live and they will be moved onto the Palliative/end of Life
Pathway. It is recognised that there is a potential overlap and dove-tailing required for patients as
they moved from the supportive pathway into the end of life pathway.
The supportive care pathway has been developed based on the four elements that were identified
to make the most difference to patient experience. These are as follows: -
Holistic Assessment (a)
The Holistic assessment also includes Supportive Care Planning & Appropriate Care Delivery The
following domains are covered in the national Holistic Needs assessment Guide, which has been
agreed to be adopted for use by the HYCCN:
1. Background information and assessment information/preferences
2. Physical well-being
3. Social and occupational well-being: including managing at home and in the community,
Work and finance, family and close relationships, social and recreational.
4. Psychological well-being
5. Spiritual well-being
Also included in the holistic assessment is: -
• the development of a care plan to meet the needs identified in the assessment
• the delivery of care required as part of the care plan
• appropriate referral to other services to enable the delivery of the care required as part of the
care plan
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Single Contact with the assigned Key Worker ()
The initial Single point of contact for patients will be identified for patients at the diagnosis of their
cancer, for some patients who have been fast tracked for investigations this may be sooner if
appropriate to coordinate care. It is expected that the Key worker will change along the pathway as
patient needs, treatments and care settings dictate
Key Discussion Point (©)
These are the points in the pathway where significant information/discussions take place e.g.
diagnosis and treatment discussions. It is expected that key discussions will occur and future
planning will take place at the beginning and end of each treatment episode e.g Surgery,
chemotherapy, radiotherapy and when the patient is discharged from active treatment into followup/living
with and beyond cancer or onto palliative/end of life pathway.
Patients will be supported during the key discussions to be as involved in the decision making
process as they want to be
Patient Information (i )
Patients and carers will be offered the minimum information identified on the site information
pathway, (which incorporates generic information). They will be assessed for any additional
information needs and offered additional information to meet that need. The will be provided with
support to understand and cope with the information provided. The information will be sufficient to
enable the patient to play as active a role in their own care and decision making processes as they
have decided is appropriate for them.
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