Moura Shari, Nguyen Patricia, Benea Aronela, Townsley Carol
Princess Margaret Cancer Centre - University Health Network, Toronto, Ontario.
Peter Gilgan Centre for Women's Cancers, Women's College Hospital, Toronto, Ontario.
Can Oncol Nurs J. 2022 Feb 1;32(1):3-11. doi: 10.5737/23688076321311. eCollection 2022 Winter.
The After Cancer Treatment Transition (ACTT) program at Women's College Hospital (Toronto) is a transitional follow-up program for patients, their families, and healthcare providers to address the broad range of post-cancer treatment and survivorship needs. This publication describes the systematic development and implementation of the ACTT program, with a focus on the advanced practice nursing (APN) role.
ACTT development required the collaboration of an APN, a general practitioner in oncology (GPO), and an inter-professional team. ACTT developers proposed a clinic structure in an ambulatory setting, linking healthcare professionals to provide post-treatment follow-up and ongoing survivorship care. Post-treatment guidelines were developed based on expert oncologist consensus, cancer site group input, and evidence-informed guidelines or best practice recommendations.
Initial challenges and concerns were rooted in the requirements that post-cancer treatment care was maintained and survivor needs were addressed. Cancer site groups and the inter-professional teams provided continuous feedback on processes and protocols. ACTT established a standard approach to transition patients safely and effectively out of tertiary care and, ultimately, to primary care.
ACTT delivers comprehensive posttreatment and survivorship care through close collaboration between the GPO and APN. Both roles specialize in managing late or persistent effects, cancer surveillance and prevention, and addressing psychosocial needs prior to discharge to primary care. The survivorship care plan provided by ACTT is an informative tool for both patient and primary care provider to continue post-treatment follow-ups.
Next steps for ACTT include expanding to other cancer specialties, exploring new ways to deliver care, optimizing the transition of care, and conducting comprehensive evaluations of patient reported outcomes.
多伦多女子学院医院的癌症治疗后过渡（ACTT）项目是一项针对患者、其家属及医疗服务提供者的过渡性随访项目，旨在满足癌症治疗后及生存期间的广泛需求。本出版物描述了ACTT项目的系统开发与实施，重点介绍了高级实践护理（APN）的角色。
ACTT的开发需要一名APN、一名肿瘤全科医生（GPO）以及一个跨专业团队的协作。ACTT开发者提出了一种门诊环境下的诊所结构，将医疗专业人员联系起来，以提供治疗后随访及持续的生存护理。治疗后指南是基于肿瘤专家共识、癌症部位小组的意见以及循证指南或最佳实践建议制定的。
最初的挑战和担忧源于维持癌症治疗后护理以及满足幸存者需求的要求。癌症部位小组和跨专业团队对流程和方案提供了持续反馈。ACTT建立了一种标准方法，以安全、有效地将患者从三级护理过渡到最终的初级护理。
当前的ACTT项目：ACTT通过GPO和APN之间的密切协作提供全面的治疗后及生存护理。这两个角色都专门负责管理晚期或持续性影响、癌症监测与预防，以及在转至初级护理前满足心理社会需求。ACTT提供的生存护理计划是患者和初级护理提供者继续进行治疗后随访的信息工具。
ACTT的下一步包括扩展到其他癌症专科、探索提供护理的新方法、优化护理过渡，以及对患者报告的结果进行全面评估。
