Service Mapping Report Background and purpose One of the roles of the Southern Melbourne Integrated Cancer Service (SMICS) is to map cancer services provided to adults by Alfred Health, Cabrini Health, Peninsula Health and Southern Health for 10 tumour streams. The purpose of this report is to: provide quantitative and qualitative data regarding current cancer services that will be used by the SMICS Tumour Groups and SMICS Governance Committee to plan service improvements; provide baseline data that can be used to evaluate SMICS outcomes; and assist to identify gaps and opportunities for improving cancer service coordination. Report details This report provides a summary of services provided by: Tumour stream: Breast Site: Cabrini Malvern/Brighton Health service: Cabrini Health Data collection period: October December 2009 Date of report: November 2009 This report may need to be read in conjunction with tumour stream reports for other sites. Health service SMICS mapping report ( ) Cabrini Health Cabrini Malvern Cabrini Brighton Cabrini Prahran A joint initiative of Alfred Health, Cabrini Health, Peninsula Health & Southern Health Connecting cancer care, driving best practice and improving patient outcomes
Cancer services data: quantitative SMICS / breast tumour stream throughput 2005-09 SMICS / breast tumour stream catchment areas 2005-09 4000 3500 3000 2500 2000 1500 1000 500 0 2005-06 2006-07 2007-08 2008-09 2005-06 2006-07 2007-08 2008-09 2005-06 2006-07 2007-08 2008-09 2005-06 2006-07 2007-08 2008-09 Patients Separations 15% 6% 3% 8% 10% 12% 9% 2% 11% 7% 9% 8% Bayside Cardinia Casey Frankston Glen Eira Greater Dandenong Kingston Monash Mornington Peninsula Port Phillip Stonnington Alfred Health Cabrini Health Peninsula Health Southern Health Outside SMICS Catchment Cabrini Health / breast tumour stream throughput 2005-09 Cabrini Health / breast tumour stream catchment areas 2005-09 2500 2000 1500 1000 500 0 2005/06 2006/07 2007/08 2008/09 2005/06 2006/07 2007/08 2008/09 2005/06 2006/07 2007/08 Malvern Brighton Prahran 2008/09 Patients Separations 21% 11% 4% 2% 12% 14% 1% 7% 1% 13% 2% 12% Bayside Cardinia Casey Frankston Glen Eira Greater Dandenong Kingston Monash Mornington Peninsula Port Phillip Stonnington Outside SMICS Catchment 2.
Cancer services data: qualitative 1. General services available onsite Service Onsite Notes or comments Service Onsite Notes or comments Breast Care Nurse Malvern/Brighton Palliative Care Beds Prahran Cancer Support Nurses Breast and colorectal Palliative Care Consultation Service Prahran & Malvern Home Care Case Coordinators Nursing case coordinators Pain Service Consultant who specialises in pain management Chemotherapy Pathology - Anatomical Clinical Trials Coordination Pathology - Biochemistry Day Surgery Pathology - Haematology Dental Services Pathology - Genetics Outsourced to Peter MacCallum Diagnostic Imaging - General Digital Mammography Brighton Pathology - Microbiology Diagnostic Imaging - CT Malvern & Brighton Pathology - Synoptic Reporting Diagnostic Imaging - MRI Malvern Pastoral Care -Chaplain Diagnostic Imaging - PET - Pharmacy Diagnostic Imaging Nuclear Med Malvern Psychiatry Dietetics Psycho- Oncology Privatised Emergency Department Malvern Psychology Genetic Counselling Private consulting Physiotherapy GP Liaison Units - Pre-admission Clinic Immunotherapy Immune modifying therapy Prosthetics & Orthotics For Breast Cancer patients Interpreting Services - Radiation Oncology Radiation Oncology consultants Intensive Care Unit Rehabilitation Physician Hopetoun Lymphoedema Service - Speech Pathology Medical Oncology Short Stay Unit DPC Occupational Therapy Available Social Work Access to Bethlehem social worker -Brighton Access to Mercy social worker - Malvern Outpatient Clinics - Support Groups Prostate, Yesterday Today and Tomorrow, Look Good Feel Better 3.
2. Overview of treatment and care Community level Patient recognises symptoms or receives abnormal screening result (if applicable) and sees general practitioner (GP). Breast Screen There are seven screening sites in the southern Melbourne region that do all the initial screening of patients. There is also the main Breast Screen site located at MMC Moorabbin. Those patients that have a positive mammogram will get called back to MMC Moorabbin for further testing and a definitive diagnosis. This is about 10% of all patients screened at the seven screening sites. Once Breast Screen has given the patient a definitive diagnosis the patient will be referred back to their GP. There is also a Breast Screen site located at St Vincent s Hospital which services patients within the Cabrini Health core local government areas (LGAs). Initial diagnosis & referral Private consultant The GP refers the patient to a private breast surgeon or general surgeon. The general surgeon refers the patient to a private breast surgeon when required. The GP creates a referral letter, referral proforma from their practice software or telephones the surgeon regarding the patient. Determine treatment program Surgery Private consultant The patient is seen by the breast surgeon /general surgeon in their private rooms where they discuss the patient s treatment path for surgery. Multidisciplinary team meeting There is a Breast Cancer Multidisciplinary Team Meeting which is held fortnightly, on Mondays at 6pm, and attended by a breast surgeon, medical oncologist, radiation oncologist, pathologist, radiologist, psychologist, chemotherapy day centre nurse, breast care nurse and research staff. The purpose of this meeting is to discuss treatment planning and discharge planning. Referral decisions are made at this meeting. Discussion of the patient s suitability for a clinical trial is also discussed at this meeting. Recommendations from the meeting are documented by the consultants in the patient s private medical record. Coordination of the meeting is carried out by the administrative staff in one oncologist s office. Communication with the GP regarding the patient s diagnosis and treatment 1 Ministerial Taskforce for Cancer 2006 Critical points of Patient Management Framework 4.
options usually occurs via letter from the consultant who refers the patient into the MDT meeting. Some consultants utilise the Argus communication system to send letters to GPs. The progression of care from the surgeons office is co-ordinated by the surgeons in conjunction with their office staff. Surgeons private rooms The medical oncologists private rooms are located at: o Suite 7 Cabrini Health Malvern o Suite 56 Cabrini Health Malvern o Suite 45 Cabrini Health Malvern. Radiation oncology Patients requiring radiation oncology are referred to private radiation oncology consultants to discuss their treatment path. They are seen as an inpatient or, as an outpatient, in the radiation oncologist s private rooms. Medical oncology Patients requiring chemotherapy are referred to the medical oncologist by the, general surgeon, breast surgeon, or sometimes by the GP. Further investigative/diagnostic tests are requested if required, and following diagnosis, treatment options are discussed. Any relevant clinical trials are discussed with the patient. The medical oncologists are available to treat patients from Monday to Friday. When required the medical oncologist will see patients in the Emergency Department. Radiation oncology private rooms The radiation oncologists private rooms ate located at: o Suite 19 at Cabrini Health Malvern o Suite 51 at Cabrini Health Malvern. Medical oncology private rooms The medical oncologists private rooms are located at: o Suite 19 Cabrini Health Malvern o Suite 25 Cabrini Health Malvern o Suite 45 Cabrini Health Malvern o Suite 5 Cabrini Health Brighton. Implement treatment program Surgery Private patients assessed as appropriate for surgery have their name placed on the waiting list at Cabrini Malvern or Cabrini Brighton. If patients have complex medical conditions they are referred to the appropriate physician for medical assessment prior to surgery. Patients with co-morbidities usually have their surgery at Cabrini Malvern which has more extensive on site services. Surgery Communication with the GP regarding the patient s surgery usually occurs via letter from the surgeon. Psychosocial support During the patient journey, clinicians undertake an informal assessment of psychosocial needs, and where necessary facilitate referral to the Cabrini Health 5.
Some patients are referred by the surgeon to the nurse led pre admission clinic prior to surgery and where required attend the clinic for assessment. The majority of patients are admitted on the day of surgery, however complex cases, are admitted the day prior to surgery. Patients attending Cabrini Malvern for breast surgery are generally admitted to Ward 1 Central. Patients attending Cabrini Brighton for breast surgery are generally admitted to the Ground Floor South Ward. Psycho-oncology service or appropriate support services where required. Breast care nurse Patients have access to the breast care nurse who provides supportive care and refers patients to internal and external support services. Radiation oncology Patients who attend Cabrini Health for breast cancer treatment, and require radiation oncology services, are referred to: o William Buckland Radiation Therapy Centre(WBRC)at the Alfred o Peter MacCallum Radiation Therapy Centre (PMRTC) at Moorabbin, East Melbourne or Box Hill (Epworth Eastern) o Radiation Oncology Victoria located at East Melbourne, Ringwood or Frankston. Patients will often elect to attend the centre closest to their home. Patients are reviewed weekly while having treatment. Medical oncology Some patients, if appropriate, will commence or receive their chemotherapy treatment on Ward 2 Central at Cabrini Malvern. Patients receiving chemotherapy as outpatients, attend the Chemotherapy Day Procedure Centre (DOU) at Cabrini Malvern or Cabrini Brighton for their medical oncology treatment. If patients are unwell during treatment they are generally admitted to Ward 2 Central at Cabrini Malvern or Ground Floor South Ward at Cabrini Brighton. Patients are reviewed weekly while having treatment. Radiation oncology If the patient is suitable for a current radiation oncology clinical trial the radiation oncologist will discuss this with the patient. Surgeons have a role in recruiting patients for these trials. Communication with the GP regarding the patient s treatment usually occurs via letter from the radiation oncologist. Communication with the GP regarding the patient s treatment usually occurs via letter from the medical oncologist. Medical oncology If the patient is suitable for a current medical oncology clinical trial the medical oncologist will discuss this with the patient. Surgeons also have a role in recruiting patients for these trials. Communication with the GP regarding the patient s treatment usually occurs via letter from the medical oncologist. Inpatient chemotherapy Chemotherapy is provided to inpatients on Ward 2 Central Cabrini Malvern by nursing staff who are accredited to administer chemotherapy. Cabrini Health provides a Module 1 Chemotherapy course. Nurses are encouraged to advance their skills by undertaking a Module 2 chemotherapy course at PMCC East Melbourne. Day Oncology Unit (DOU) Malvern There are 28 chairs, 5 beds and a 2 bed aphaeresis unit in the DOU at Cabrini Malvern. 6.
Referrals into the unit are received via phone, fax, email or letter. Patients attend a nurse led pre-admission clinic prior to attending the DOU as per patient or consultant preference. CI Scat (now EVIQ) chemotherapy treatment protocols are in place to guide practice. Education and support group information is provided to all patients as required Pastoral care is available. A social worker from Mercy Health is available to consult with patients upon referral. The psycho-oncology unit at Cabrini is available for referrals where required. The palliative care liaison nurses and the breast care nurse are available to organise palliative care services, however the staff of DOU also organise palliative care services when required. The DOU will be migrating to the Charm clinical information system next year which will incorporate modified PMCC chemotherapy protocols. All staff working within the DOU undertake Module 1 chemotherapy training in the first instance and then undertake Module 2 to advance their skills. It is expected that staff undertake annual competencies to maintain the standards of the DOU. Day Oncology Unit (DOU) Brighton There are 24 chairs, in the DOU at Cabrini Brighton. There are similar standards, protocols and services as per Cabrini Malvern. The exceptions are as follows: o access to a dietitian 2 half days a week o access to a social worker at Calvary Health Bethlehem o 3 chairs are also used for the sleep medicine clinic at night o there are no palliative care liaison nurses on site. Emergency Department Patients presenting to the Cabrini Emergency department with suspected neutropenia are classified as a category 2 patient and administered antibiotics within 12 hour of presentation. 7.
Clinical support and other services Patients have access to the breast care nurse who provides supportive care and refers patients to internal and external support services. Patients with lymphoedema are referred to external providers by the breast care nurse. The ward nursing staff and allied health staff refer patients to external supportive services such as Royal District Nursing Service, Hospital in the Home and Rehab in the Home. Nursing case managers are in place to facilitate discharge planning. Referrals are also made to the palliative care consult team, physiotherapy, social work, occupational therapy and the dietitian. Clinical support and other services Some clinicians do not do any formal psychosocial assessments using a specific screening tool. However, psychosocial questions are asked and referrals are made to the breast care nurse, social work, psychiatry and psychology. The breast care nurse receives referrals from consultants on an ad hoc basis and sees patients at both Cabrini Malvern and Cabrini Brighton. The breast care nurse accesses patient information and records statistical information regarding her treatment in the computerised patient administration system. Care and treatment is documented on a paper system, with a specifically designed medical record form being placed in the patient s medical record. Chemotherapy nurses and breast care nurses undertake specific post graduate courses to qualify for their role. Follow-up Surgery Patients have post-surgical and ongoing follow-up in the surgeon s private rooms. Radiation oncology Follow-up is conducted by the treating radiation oncologist. Some factors which may impact on follow-up are: o type of patient o type of cancer o geographic proximity to treating radiation oncology centre o number and type of other doctors/consultants involved in care. Surgery After surgical follow-up, the patient proceeds to their next therapy or is scheduled for ongoing follow-up. Radiation oncology After radiotherapy follow-up, the patient proceeds to their next therapy or is scheduled for ongoing follow-up. Medical oncology Patients are followed up at the medical oncologist s private rooms. The patient receives ongoing follow-up with the medical oncologist 3 monthly for 2 years, 6 monthly up to 5 years and 12 monthly after that. Medical oncology After chemotherapy follow-up, the patient proceeds to their next therapy or has ongoing follow-up as required. Determine & implement treatment program for recurrence Surgery / radiation oncology / medical oncology If the patient has a recurrence, it will be detected by either their GP or at the follow-up appointments with the breast surgeon or medical oncologist. The GP then refers the patient back to the breast surgeon and the patient enters the system as they did at the beginning of their journey. Surgery / radiation oncology / medical oncology If there is disease recurrence the patient s case is presented at the Breast Cancer Multidisciplinary Team Meeting for discussion and a decision about their treatment. See Multidisciplinary Team Meeting above. 8.
End of life care Management of end of life issues are facilitated by Palliative Care Consult Team. Palliative care There are 2 palliative care liaison nurses who coordinate palliative care services at Cabrini Malvern. Nurses from the DOU and the breast care nurse also organise palliative care for their patients when required. Inpatient palliative care commences on the ward. Patients are later transferred to the 22 bed Cabrini Prahran inpatient facility or to Cabrini Community Palliative Care for home based Palliative care. Patients requiring long term palliative care can be transferred out of Cabrini Prahran palliative care to other facilities, such as Calvary Health Care Bethlehem. Other services available include o GP o RDNS o Eastern Palliative Care o South Eastern Palliative Care o Peninsula Hospice o Nursing homes. 9.
3. Summary of issues comments and improvements Issues Issues raised 2005 Issues raised 2009 N/A. There is no PET scanner at Cabrini Health. The Breast Care Nurse needs a clinical database (that provides the capacity to record patient recommendations and advice), which interfaces with the Cabrini Health Patient Administration System. There are no lymphoedema services at Cabrini Health. There is no backfill for the Breast Care Nurse. Access to additional dietitians is required. Patient transport between Cabrini Health and the external Radiation Oncology services requires improvement. Medical oncologists would like to access radiological imaging, pathology results and patient histories on line between health services. Provision of maps to guide patients to external services would be helpful to the patients. Improvement s N/A Improvements to service Office Use Only Version 1.0 Author: HD Date: 20/04/2010 Reviewer: JC File Path G:\smics_mapping\Service Mapping 200809\Cabrini\Reports\Breast Cabrini Health 20100420v1.0.doc 10.