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Table 1 Components of the RbCCCMa

From: Optimizing clinical and organizational practice in cancer survivor transitions between specialized oncology and primary care teams: a realist evaluation of multiple case studies

Components

Planned activities

Deliverables

Professional

• Identification of needs (e.g..: continuing education, clinical toolsb, skills development)

• Oncological risk evaluation and multimorbidity (health status)

• Clarification of roles

• Online training modules

• Criteria for referrals between teams

• Identify and develop clinical tools (survivorship care plan)

Organizational

• Development/adaptation of coordination and communication tools

• Consolidation of intra- and inter-team work

• Identify organizational actions for teamwork

• Design effective service corridors

Clientelec

• Development/adaptation of information tools

• Identification of community resources

• Development/adaptation of education for clientele (self-care, symptom management, navigation in health system)

• Paper and web publications

• Survivorship workshop

• Adapted monitoring tools

• Inventory of resource persons

Governance (policy makers, administrators)

• Establishment of normative and legislative aspects related to survival issues

• Establishment/consolidation of a provincial survivorship committee (mandates and responsibilities)

• Recommendations/incentives

• Recognition/clinical time for survivorship care

• Mention of RbCCCM in provincial and national cancer and action plans

  1. aTo be validated in Step I: development of the intervention with the decision–making partners
  2. bOngoing procedures for translating clinical reference tools from the Oncology Nursing Society
  3. cClientele refers to cancer patients and their families