Risk Stratified Pathways of Care
Pathways of care
The transformed care pathway for cancer survivors is based on a model of care for people with long term conditions. A risk stratification process will help to identify which care pathway is most suitable for each patient, based on the level of risk associated with the disease, the treatment and the patient’s ability to manage, and therefore what level of professional involvement will be required.
The NCSI has developed a series of principles for supporting people living with and beyond cancer. Following cancer treatment patients should be offered:
- A holistic needs assessment which builds on previous assessments and focuses on a patient’s medical, psychological, social, spiritual, financial and informational needs following treatment. Through this holistic needs assessment the clinician and patient develop a care plan in partnership.
- An end of treatment summary created by the hospital with copies going to the patient and the patient’s GP.
- Where patients are assessed as being able to ‘self manage’, support should be offered in terms of access to appropriate information and support including lifestyle advice and interventions, physical activity programmes and vocational rehabilitation support.
- New pathways of care which are underpinned by care co-ordination systems, robust remote surveillance, so that patients will automatically be recalled if there is a problem identified in their tests, and rapid access to appropriate services if the patient has a concern or there is suspicion of further disease.
- Planned and informed transition from paediatric to young person and adult services, where appropriate, and support to continue in education or begin a career.
The NCSI is testing new risk stratified pathways of care for those living with and lung, breast, colorectal and prostate cancer in 7 prototype sites across England. You can download further information on the pathways below.
Evaluation of adult cancer aftercare
A survey of NHS Improvement prototype site was carried out by IPSOS-MORI this summer. The survey aims to provide a baseline for the 11 tumour projects within the seven Test Communities, who are currently testing a new model of care which includes risk stratified care pathways in Adult Cancer Survivorship services. This project is part of the National Cancer Survivorship Initiative.
Last updated on December 5, 2011