Aims:
As cancer survival continues to improve, health systems face increasing demand to provide coordinated survivorship care beyond acute treatment settings. Community-based multidisciplinary care offers an opportunity to address the ongoing physical, psychological, and supportive care needs of cancer survivors while reducing reliance on hospital services. This presentation aims to share lessons learned from implementing hospital-to-community survivorship referral pathways and provides practical strategies to support the integration of personalised multidisciplinary care across healthcare settings.
Methods:
Drawing on experiences implementing survivorship referral pathways across multiple hospital oncology services and community health organisations, this presentation will examine the key components required to establish and sustain integrated models of care. Particular focus will be given to pathway design, stakeholder engagement, referral processes, partnership development, communication systems, and the care coordination role in facilitating transitions between acute and community settings. Reflections from implementation experiences will be used to identify barriers, enablers, and practical considerations for embedding pathways into routine practice.
Key implementation lessons:
Implementation demonstrated that hospital to community referral pathways can be successfully established within existing service structures. Critical success factors included dedicated coordination roles, clinical leadership, workforce development, effective communication, and shared commitment to integrated survivorship care. Experiences across sites also identified key system, workforce and organisational considerations that require attention to support pathway sustainability. The referral pathway strengthened care coordination and facilitated access to personalised multidisciplinary allied health support for cancer survivors.
Conclusions:
Hospital-to-community referral pathways offer a practical approach to integrating personalised multidisciplinary care beyond acute treatment settings. Lessons learned from implementation highlight the importance of dedicated care coordination, strong partnerships, workforce capability, and effective communication in establishing sustainable pathways across healthcare settings. These insights provide practical guidance for health services seeking to strengthen care coordination, improve access to supportive care, and embed community-based survivorship care within existing health systems.