Table 3 Summary of implementation outcomes

Implementation

Workforce

Employed clinical staff:

1 Senior physiotherapist (20hr/wk)

1 Mid-level physiotherapist (19.5hr/wk)

Support staff:

1 senior research physiotherapist

Service operation

Resources: physiotherapy gym with existing equipment

Average wait time to the first appointment: 20 days (range 0–99)

Average time taken for first appointment: 51 min (SD 7)

Service access: 4d/wk (Mon-Thur)

Attendance option: 1x or 2x/wk (Ihr/session)

Clinician to patient ration (per group class): 1:4

Service promotion: Within and outside health facility (e.g., flyer, poster, newsletter) with the aid of the organization’s communications officer

Referral mechanism: Direct verbal referral (i.e., in-person, telephone); use of centralized email address (i.e., by including patient name/contact details); self-referralClinicians were encouraged to have a brief conversation on exercise with patients prior to referrals.

Transition plan: Patients were referred to community-based rehab, existing sub-acute multidisciplinary Cancer rehab, home-based rehab, and occupational therapy

Workforce: 4 AEPs including consultants (AEPs were separate to the patient core care team)

Service operation: Independent of the cancer center: patient triage and integrated medical record were lacking

Resources: Provided by ECU

Service access: 3days/wk; 2hrs/session with lack of co-ordination between gym and treatment times

Service promotion: Not reported

Referral mechanismPathway: direct verbal referrals from clinicians; self-referralReferrals were made only when oncologists remembered and had the time

Workforce: 5 physiotherapists (I clinical director and 4 staff physiotherapists) + 3 kinesiologists with training and experience in oncology

Service operation: Independent of the cancer center

Resources: Provided by Hope and Care

Service promotion: Presentations on the values of exercise interventions to various departments

Referral mechanism: well-defined patient triage and referral pathwaysSources include oncologists, allied health workers, self-referral, other sources including wellness centers

Transition plan: Home-based exercise program, wellness center

Workforce: Physiotherapy: 21/31 programs; Exercise Physiology: 20/31 programs

Service promotion: Exercise fliers, letters to GPs, community awareness programs

Service structure: outpatient programs:

2x/wk for 8 wks; inpatient programs:

2x/day for the duration of inpatient stay (approximately 2 weeks)

Early morning sessions were less practical and received the lowest patient attendance

Developing flexible and rolling program is critical to enhancing practicality

Referral mechanism

Patient feedback to their primary doctors was a key driver of more referrals from doctors

Transition plan: Home-based exercise program, community groups

Cost

Funding: External service improvement grant

Cost to patient: no cost

Health service

Staffing, e.g., payment of salaries: AUD $160,916

Consumables:

Mobile phone costs (AUD $180; $30 per month)Printing of assessment forms and home exercise programs (5 pages per patient x 73 patients @ 0.66 c /page) (AUD $2)

Total Cost: AUD $161,098

Cost to health service per patient: AUD $1,104

Funding: ECU research grant

Cost to patient: no cost

Operational cost was covered through a research grant

Funding: Private donations

Funding sources: public = 14; private = 17

Reach/Penetration

~10% of patients treated in the cancer center (i.e., 155 referrals including self-referrals)

12% (i.e., 237 out of 1963 patients that received cancer treatment over a 50-month period)

Average annual reach = 10-14%

1635 patients over a 5-year evaluation period, with an average of 5.8 follow-up visits

31 eligible programs identified from 46 public hospitals/cancer centers and 39 private hospitals/centers across 6 out of 8 states/territories

Service uptake

46 staff made 148 referrals over the 6 months evaluation period: medical: n = 32, 22%; nurses: n = 53, 36%; allied health: n = 63, 43%

Facilitators of service utilization: Service visibility, convenience, building rapport, accessibility, timing, and staff experience

Number of oncologists with at least 1 patient attending Co-LEC = 11/11

Sources of referrals: oncologists = 21%; nurses = 20%

Referrals were largely from oncologists (35%) and nurses (36%) (e.g., over a 2-month referral period)

Referral sources: oncologists (28/31 programs); allied health clinicians (21/31 programs)

Poor knowledge among doctors on the role of exercise in cancer management was a major limiting factor

Acceptability

44% (52* out of eligible 119 patients)

Refused referrals: n = 67, 43% [Reasons: not interested (n = 17), unsure (n = 16), unwell/treatment related (n = 3), work (n = 2), location/parking (n = 2), home-based exercise (21) other (n = 6)]

No. of refusals after 1st session: n = 2 (reason: readmission = 1)

Compliance: 38 patients elected for 2x/wk with 56% completing 7/16 sessions; 14 patients elected for 1x/wk with 40% completing 3/8 sessions

Missed sessions were due to:

Refusal (25%)

Unwell due to treatment (23%)

Drop out: n = 20; 38% (Reasons: COVID-19 restrictions; hospital readmission, disease progression)

27% (i.e., 64 out of 237 referrals over a 50 month)

Common reason for non-service utilization was lack of awareness of its availability

71% compliance (over 3 years) in a sample of 41 patients with multiple myeloma (81% had bone lesion) on active treatment

Dropouts: Increased with the incidence of skeletal-related events, including pathologic fracture, spinal cord compression, and radiation for stabilization of bone lesions

Overall, annual enrolment per program:

10-70 patients; 2000 survivors per year across Australia

Satisfaction

n = 57^#, 100%)

Access (timing, facility, location): n = 46, 81%

Willingness to recommend others to participate during treatment: n = 57, 100%

Feeling of improved overall health/wellbeing: n = 56, 98%

Sources of dissatisfaction

Difficulties with access: n = 6, 8%

Difficulties were largely due to lack of parking space

Social value: n = 11 out of 61 patients

Improved treatment experience: 12 out of 61 patients

Positivity: 24/61 patients

Staff experience/professionalism: 17/61 patients

Sources of dissatisfaction

Lack of coordination between treatment and gym times: 33/51 patients

Parking issues: 5/51 patients

Lack of transition plan at the end of the program: 4/51 patients

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Patient cantered: programs addressed individual patient needs and goals

Programs increased opportunities for social support

Sources of dissatisfaction

Program timing (attendance were lowest for early morning sessions)

Parking issues

Travel distances particularly for metropolitan centers

Fidelity

Exercise service was implemented by clinicians with 5.5 years oncology-specific experience and prior cancer-specific training in acute and community cancer settings. A steering committee comprising a consumer, clinical directors, physiotherapy manager and a community partner ensured service implementation

Program staff and other hospital physiotherapists received three 1hr education sessions on cancer and rehabilitation

Medical, nursing, and allied health staff received 3 presentations to provide updates throughout program implementation

Service implementation was spearheaded by 3 AEPs with experience in exercise oncology

Continuous staff mentoring and education

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Sustainability

Philanthropic funds were sought to pay staff salaries to sustain the program beyond the pilot period

Funding: Direct clinical operational cost was covered by ECU and GenesisCare to support service continuation at the end of the feasibility phase

Structural adjustments (mainly due to inadequate funds):

Operational hours reduced to 2hrs/wk (1hr/2days/wk)

Eligibility was rescinded for patients receiving chemotherapy alone

Service duration was reduced to 3 months for all patients regardless of treatment duration

Challenges

Communication gap between ECU and GenesisCare

Financial model was lacking— Co-LEC was not generating revenue

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