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Care Coordination Screening and Triage

Illawarra Shoalhaven Local Health District
Project Added:
6 October 2015
Last updated:
21 October 2015

Care Coordination Screening and Triage


This project implemented a screening and triage tool within the outpatient cancer service at Illawarra Shoalhaven Local Health District (ISLHD), to improve the care coordination of patients during their treatment journey. 


To improve the social, psychological and physical condition of cancer patients during their treatment journey.


  • Provides the right care at the right time to the patient.
  • Empowers the patient through their treatment journey.
  • Provides effective and efficient care coordination service with existing resources and financial constraints.

Project status


Project start: January 2014
Project finish: July 2015


Implementation - The initiative is ready for implementation, is currently being implemented, piloted or tested.


In recent years, support resources such as clinical nurse coordinators and allied health professionals have not increased in line with the expansion of cancer services across ISLHD. In addition, data suggests that the clinical activity of patients attending the service for referral and treatment has increased since the expansion of the service.

ISLHD receives funding from the Cancer Institute NSW, to support the provision of care coordination within cancer services. The key performance indicators developed to support this funding includes a requirement that all patients who receive the service are screened using a validated screening tool, however it does not specify the type of screening tool that must be used.

A patient survey was completed by all patients who completed treatment within ISLHD cancer centres during November and December 2014. The results indicated there were opportunities for improvement in relation to the planning, delivery and coordination of patient care. This would enable the service to meet patient needs in a timely manner and allow the service to meet the key performance indicators set by Cancer Institute NSW.


  • Workshops were held with clinical nurse coordinators and allied health professionals, to identify the care coordination tasks undertaken with their role.
  • A screening and triage working group developed and implemented patient and staff surveys to how care coordination could be streamlined within the service. Results from these surveys found that:
    • patients felt regular assessment and monitoring by staff could be improved
    • staff felt their biggest concern was providing the right information to the patient at the right time
    • staff felt there was a lot of duplication, contradiction and gaps in care coordination, as they were not aware who should be doing what task and when
    • patients felt psychosocial support could have been better, including coping with financial aspects of treatment and lifestyle factors that were not addressed by staff
    • staff felt they did not manage and coordinate treatment as well as they could, while patients thought the overall coordination of their care and treatment was done very well.
  • A literature review was undertaken to assess the use of screening tools across the US, UK and Australia. This provided the team with an understanding of which tools appeared to be more user-friendly and produced identifiable outcomes.
  • The [US] National Comprehensive Cancer Network Version 2. 2014 Distress Thermometer and Problem List screening tool was implemented as a pilot in two areas of the service, to assess useability and measure outcomes. This tool was selected due to its ease of use and ability to easily identify problems and concerns when used by healthcare professionals and patients.
  • An education package and procedure guide was developed to support the pilot implementation of the screening and triage tool throughout the wider service.

Implementation site

Outpatient Cancer Services, ISLHD


  • Post-implementation surveys indicated that the tool was easy to use by patients and nursing staff and only took 5-10 minutes to complete. Nursing staff felt the tool acted as a prompt to address problems or concerns that may not have otherwise been discussed with the patient.
  • There was a correlation between the number of patients with a higher distress score and those with a higher number of problems identified on the tool. The tool allowed staff to refer patients to the appropriate health professional at the time of screening.
  • All patients were seen or contacted with a matter of 48 hours of the healthcare professional receiving the referral. Nurses who had concerns about a patient rang the healthcare professional directly for immediate advice or consultation.
  • A detailed analysis of the results from the pilot project is currently underway.
  • It was recognised that clinical nurse consultants undertake and manage a significant proportion of patient care coordination. The challenge was ensuring that this became everyone’s responsibility, not just one group of staff.
  • An in-depth understanding of the quality improvement process was required to implement this project.
  • We identified the importance of being open to understanding problems from a multidisciplinary health professional perspective.
  • Managing a multidisciplinary project team and the dynamics that come with this was a challenge, particularly in relation to communication, negotiation and leadership skills.
  • The initial aim and objective was focused on patient assessments across the service, which was not logistically feasible. We decided to change the project in the research stages of the project, as we captured data that suggested the introduction of a screening tool across two areas of the service would be more useful, practical and conducive to positive change.


Nicola Ryan
Nurse Manager, Cancer Services
Illawarra Shoalhaven Local Health District
Phone: 02 4222 5773

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