F2-a - Providing a seamless transition of care (shared care model) for colorectal cancer survivors within an urban family health team

2. Continuous care: ensuring seamless transitions for patients across the continuum of care

  • Date: Friday, September 20, 2019
  • Concurrent Session F
  • Time: 12:00pm-12:45pm

  • Room: Pier 8
  • Style: Presentation (information provided to audience, with opportunity for audience to ask question)
  • Focus: Practical (e.g. Presentation on how to implement programs and/or practices in the team environment)
  • Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Representatives of stakeholder/partner organizations

Learning Objectives

  1. Describe a seamless transition of care program “Colorectal Cancer Survivorship Program” (CSP) within a family health team setting
  2. Describe a shared care model (primary, community & tertiary level) through a logic model for cancer survivors to ensure continuity of care 
  3. Gain an understanding of cancer survivorship care needs 
  4. Gain an understanding of community resources for cancer survivors


The ground-breaking 2018 report from the Canadian Partnership Against Cancer concluded that many cancer survivors experience significant and often debilitating physical and emotional side effects from their cancer treatment. As a Nurse Practitioner (NP) within a Colorectal Cancer Survivorship Program (CSP) at the North York Family Health Team (NYFHT), I was driven to address this timely and pertinent topic. CSP is a collaborative program with North York General Hospital & North York Family Health Team (NYFHT). These patients are referred to the primary care setting to address their care needs from a shared care approach to ensure continuity of care.    CSP provides medical surveillance and addresses short and long term side effects of cancer treatment within an interdisciplinary team (nurse practitioner, specialists, social worker, dieticians, pharmacists, family doctors and community resources). Patients are seamlessly transitioned to the tertiary care specialist if a cancer recurrence is detected.    According to the above study, 10 % of cancer survivors in Ontario identify their primary care provider (family doctor/nurse practitioner) as the one in charge of their cancer survivorship care. With more, cancer survivors being transitioned to primary care providers, it’s imperative that primary care providers become more aware of the cancer care needs and work collaboratively within an interdisciplinary team to best meet cancer survivors care needs.      CSP utilizes an evidence-based assessment tool to prioritize cancer survivorship needs. This is called a distress scale (Red flags, ESAS & The Canadian Problem List). The priority care needs of cancer survivors are multifactorial (psychosocial & physical) but not limited to distress (anxiety/depression), cancer related fatigue and bowel care. CSP is in the process of implementing an online evidence-based assessment tool, developed by Cancer Care Ontario (CCO) in conjunction with the Canadian Partnership Against Cancer, to address these particular care needs (www.cancercareontario.ca/en/symptom-management).     Lastly, a logic model has been developed to encourage a “shift from a disease centred to person centred cancer care approach.” It emphasizes a comprehensive approach that engages the patients/families, specialists, primary care & allied health care providers and community resources to best meet the needs of cancer survivors.


  • Helen Frederickson, NP-PHC, MN, Nurse Practitioner, North York Family Health Team 


  • Jessica Lau NP, Nurse Practitioner, North York FHT    
  • Dr. Danny Robson, MD (Medical Oncology- NYGH)
  • Maria Timofeeva, DNP, Nurse Practitioner (Women's College Hospital)
  • Susan Griffis,RN, MN,  Executive Director, North York Family Health Team
  • Aronela Benea, CNS, Cancer Survivorship, Women's College Hospital
  • Shima Davati, RD, North York Family Health Team