Building insights into the implementation of an integrated cancer care model using risk-stratified pathways: a multi-stakeholder deliberation analysis

Introduction Risk-stratified pathways are promoted by leading cancer institutions as a model of integrated care to improve cancer survivor’s follow-up. According to the level of risk clinical integration requires to support self-management and to facilitate timely access to primary or specialized cancer care as needed. However, implementation presents considerable challenges. Our deliberative multi-stakeholder consultation aims to inventory and address the issues from the different point of view of cancer survivors, cancer specialists and other cancer team members, primary care providers, managers and researchers. Methods Our consultation embodies three key elements from the Nose to Tail Tool (NTT) (Gupta et al. 2016).  . The NTT is a step-by-step planning process intended to aid in the successful development, implementation and scaling up of health innovations through a deliberative process. Three steps were performed: (i) identifying a common definition of the problem, (ii) determining prerequisites to translate risk-stratified pathways into practice, (iii) establishing a list of resources needed for pilot testing a new stratified-risk model of integrated care in two regional cancer network in Quebec (Canada). The process includes small group deliberations and plenary discussion with all participants using video conference. Content analysis of both deliberations and observations was performed. Results All participants highlighted the need for “risk-stratified pathways concept” clarification, and required operational definition of each level of risk. Pre-requisites should be in place before pilot testing: (1) more effective communication and coordination mechanisms between cancer teams and primary care providers, and additional training on: (2) survivorship care and risk assessment, (3) impact on workflow, (4) implication for survivors' participation in risk self-monitoring. Additionally, management of risk evolution, resources, and legal consequences need to be addressed. Discussion Our empirical results align with Rainbow Model of Integrated Care (Valentijn, 2016). Translating risk-stratified pathways into practice goes beyond clinical integration and requires alignment between functional (eg. Training) and organizational integration (eg. Communication and coordination mechanisms between cancer teams and primary care providers). Conclusions Although stakeholders were from two different geographic regions in Quebec, main issues were similar. Deliberative processes strengthen the next pilot testing by building recognition of common values, shared engagement, and by providing a comprehensive understanding of potential issues. Lessons learned Multi-stakeholder deliberation may be a starting point for national program expecting to implement effective risk-stratified models of integrated care. The new insights also revealed challenges in the applicability of best practices promoted by leading institutions. Limitations Policy-makers were not participant in the deliberation to avoid potential power issues. This may be a limit knowing that the feasibility of new models of cancer care depends on how health systems are funded and arranged, and potentially varies between countries. Suggestions for future research Multi-stakeholder deliberation may be given more consideration in planning risk-stratified model of integrated care considering the interdependency of various actors (patients, care providers, managers and policy-makers) having potential competing interests, and the multiple dimensions of integration.