Living with and beyond cancer: The improvement story so far - NHS ...

14 | Living with and beyond cancer: The improvement story so far
Obtaining user’s and clinical teams’
views, and in setting up the lifestyle
management programmes during
scoping, it became evident that
different models of follow-up care
could be used dependant on level of
risk of recurrence and levels of
intervention needed. These would
consist of a combination of:
• Supported self management with self
referral back into system
• Self management with remote
follow-up through telephone clinics
• Self management and face to face
follow-up
• One of the above plus appropriate
surveillance tests.
Client Relations Management
(CRM) system
CRM systems are used by large
companies to track important
information about their customers,
so whenever contact is made with a
customer, they can have all of the
relevant information to hand, and any
actions can be initiated and tracked.
Client Relations Management System
To increase confidence for clinical
teams to move away from a medical
model they needed assurance that
patients would not get lost to follow
up. Equally, proposed changes, would
not impact on identifying recurrence of
cancer in any way.
Therefore an information gathering
process began on how patients in each
tumour group re-presented with
recurrence: surveillance examination,
OPA or self referral and this audit is still
ongoing with results pending.
Additionally we identified that there
wasn’t an information system that
allowed collection of HNA, access to
self management and generally to act
as an alert system if the patient failed
to have the appropriate interactions.
Therefore we are developing a new IT
system, the Client Relations
Management System (CRM), which is
jointly funded by Macmillan and the
Trust’s IM&T department
Having explored whether an ‘off the
shelf’ CRM could be adapted it was felt
that building a system to meet our
needs would be better.
The system will enable:
• Summary of episodes by linking to all
Trust systems This will include
attendance at lifestyle management
events and when HNA has been done
• Diary management of lifestyle
management events indicating when
invites should be sent out to patients
• Holistic needs assessment via Distress
Thermometer recording care plans
and reports to help determine
themes to target Big Clinic topics and
other support needed
• Alert the CNS when the patient has
not had any contact for a year in
order that action can be taken.
Progress and learning so far
• High level of administration for
lifestyle management - will improve
with CRM system
• Benefits have been recognised by
other teams
• Tumour specific sessions provided too
late in patient’s journey therefore
would not be included in future