Draft: Triage and management of referrals to Cancer Nurse Coordinator Triage Presentation Action Outcome category 1 Confirmed diagnosis Comprehensive assessment Requires psycho-social support Liaise with MDM to identify a coordinated plan of care AND/OR Act as first point of contact Has complex care coordination needs Lead role in facilitating care Has poor understanding of Patient care is focused on symptom treatment trajectory management, information and supportive care Nurse Coordinator acts as primary nurse Recognise barriers in care and opportunities to progress service development 2 High suspicion of cancer or Comprehensive assessment confirmed diagnosis Liaise with MDM to identify a Requires psycho-social support coordinated plan of care AND/OR Patient care is focused on support and information Has complex care coordination needs Manage transition between treatment services Clear treatment pathway identified Referral to support services Engaged with HCP at key points on treatment trajectory Recognise barriers in care and opportunities to progress service development 3 Confirmed cancer diagnosis Review referral and patient information Single modality treatment Liaise with treatment teams as Psychosocial needs are met necessary Does not meet DHB criteria for Signpost availability of information complex care coordination and education materials Engaged with established treatment Update patient records as required team Maintain data 4 High suspicion of cancer Review referral and patient information Psychosocial needs met Liaise with treatment team as Does not meet DHB criteria for necessary, eg, GP, MDM complex coordination Update patient records as required Patient has clear understanding of the diagnostic pathway Maintain data
Draft: Triage and management of referrals to Cancer Nurse Coordinator Triage category Presentation Action Outcome 1 Confirmed diagnosis Requires psycho-social support AND/OR Has complex care coordination needs Has poor understanding of treatment trajectory Nurse Coordinator acts as primary nurse Comprehensive assessment Liaise with MDM to identify a coordinated plan of care Act as first point of contact Lead role in facilitating care Patient care is focused on symptom management, information and supportive care Recognise barriers in care and opportunities to progress service development 2 High suspicion of cancer or confirmed diagnosis Requires psycho-social support AND/OR Has complex care coordination needs Clear treatment pathway identified Engaged with HCP at key points on treatment trajectory Comprehensive assessment Liaise with MDM to identify a coordinated plan of care Patient care is focused on support and information Manage transition between treatment services Referral to support services Recognise barriers in care and opportunities to progress service development 3 Confirmed cancer diagnosis Single modality treatment Psychosocial needs are met Does not meet DHB criteria for complex care coordination Engaged with established treatment team Review referral and patient information Liaise with treatment teams as necessary Signpost availability of information and education materials Update patient records as required Maintain data 4 High suspicion of cancer Psychosocial needs met Does not meet DHB criteria for complex coordination Patient has clear understanding of the diagnostic pathway Review referral and patient information Liaise with treatment team as necessary, eg, GP, MDM Update patient records as required Maintain data
evaluation-of-cancer-nurse-coordinator-initiative-annual-report-oct14_0.docx