Breast Care Shared Care Project

In 2012, The Royal Women's Hospital, the Royal Melbourne Hospital, Western Health, Counterpart and Inner North West Melbourne Medicare Local collaborated in a Breast Cancer Survivorship Program.

The program aim is to improve follow-up care for women who have completed active breast cancer treatment at these hospitals.

The goal was to develop, implement and evaluate a model of survivorship care. This model actively involves women and their GPs, and recognises the specific issues and opportunities that exist at the end of active treatment to support women to live well, such as developing a Follow-Up Care Plan and implementing a shared follow-up care arrangement between the Breast Service and general practice.

This model of care supports better coordinated and more personal health care planning and management. We want all women to feel more educated and empowered about their ongoing health care. This program identifies and addresses a woman's immediate and future needs in terms of her follow-up care, and improves systems that share information between a woman, her GP, other community services and the hospitals in order to improve quality of care.

 Eligible women will:

• have a consultation with a Breast Care Nurse at the end of active breast cancer treatment; and
• have an individualised Follow-Up Care Plan developed at the hospital.

The care plan includes:

• Information on diagnosis, history and treatment
• A health and well-being assessment including referrals (mental health, lifestyle, menopause, sexuality, fertility, etc)
• An individualised timetable of future examinations and investigations
• Recommendations for follow-up care
• Referral and Contacts for different services
• Resources

Women and their GPs receive a copy of the care plan. The woman will be asked to make an appointment with her GP within one month of receiving the care plan in order to discuss ongoing care. This also provides GPs with the opportunity to set up their recall systems and develop team care plans or management plans as appropriate.

If you determine that the patient needs urgent review by the Breast service please contact the Breast Care Nurses on 8345 6896.

GPs with patients involved in the Breast Cancer Shared Care program with Western Health should refer their patients who are 5 years or more post diagnosis, to Western Health Radiology for their annual mammogram. Please note shared care patients will be bulk billed.

To refer:

Complete the form ensuring you include:

1. relevant clinical information relating to the breast cancer
2. all your details in the requesting doctor information to ensure that results are sent to you

Breast Care Nurses at Western Health
Lisa Matar - Breast Care Nurse Consultant
Suzanne Komp - Breast Care Nurse Consultant
Darcie Vogan - Breast Care Nurse Administrative Manager
Phone: 8345 6896
Fax: 8345 0896
BCN@wh.org.au