Making it happen
The team achieved an improved model of follow up care for prostate cancer patients by:
- Undertaking Holistic Needs Assessments and care plan reviews at key points in the pathway, allowing for individual patient needs to be identified and addressed.
- Stratifying patients to an appropriate pathway, so that their individual clinical needs are met.
- Providing treatment summaries, which give GPs and patients asuccinct record of their diagnosis, treatments, potential side effects and contact details for where they can get additional support.
- Offering information and advice on health and wellbeing pre and post-treatment through Living-well events (more information below) and signposting to local support services, to increase men’s ability to self-manage.
- Improving access to clinical and non-clinical support services, ensuring men can access the services they need to live with and beyond their diagnosis and treatment.
- Ensuring that patients on a self-management pathway continue to be remotely monitored by the specialist team reducing the need for face-to-face follow-up.
- Providing information about prostate cancer and the project/pathway to GPs through meetings, such as Survivorship Network meetings, and local GP events, to increase awareness of prostate cancer, this project, and the range of services they can refer patients.
The team ran Living-well days four times are year for four and a half hours. The agenda consists of speakers such as dieticians, physiotherapists, erectile dysfunction specialists, clinical health psychologists, urologists and the Macmillan 1 to 1 support team. The aim was to empower patients to better understand their disease and support the self-management process.
The Living-well course led on from the Living-well day. Patients could self-refer on the day if they felt it would be of benefit to them. The course consisted of five weekly sessions of two and a half hours, followed by a three month follow-up session. They were run by a psychologist, CNS and patient tutor. These sessions were interactive, covering topics including setting short-term and long-term goals that support recovery and survivorship, as well as information on relaxation, managing fear and anxiety, communication and relationships, PSA and Gleason and sign posting so patients know where to access more information or support.