Transforming Prostate Cancer Follow-Up Care: The Crucial Role of Patient Support Workers in Stratified Self-Managed Follow up

Prostate cancer patients in post-treatment follow-up, stand to benefit from a more patient-centred, accessible and community-centric healthcare approach. Stratified Self-Managed Follow-up (SSMFU) pathways aim to adopt a standardised approach nationally to stratified follow-up care after cancer treatment with a more personalised approach for patients. Patients undergo necessary tests and scans without the need for routine follow-up clinic appointments, with access back into the hospital if needed. Collaboration with service providers was pivotal in designing the SSMFU pathway. The NCCP along with service providers, the Cancer Patient Advisory Committee, and patient representatives, worked collaboratively to develop components of care and processes for the SSMFU pathway. Additionally, we introduced new Patient Support Worker (PSW) posts, working with service providers to establish a standard role description and core competency requirements. This co-design process emphasized the importance of the PSW operating within their scope. The PSW post was introduced as a patient-facing role, working as part of the healthcare team to ensure the safe follow-up of patients, and acting as a central point of contact and co-ordinator of care for the patient and the clinical team. The PSW contributes to patient education, empowering them to actively participate in their follow-up. Their role involves creating a comprehensive directory of community support services to signpost patients appropriately. The role of PSW has facilitated the introduction of a standardised Holistic Needs Assessment (HNA) process for patients on the pathway. This process helps to tailor personalised discussions with patients and enhances the quality of their care. Over 200 prostate cancer patients have enrolled in the pathway, with healthcare teams expressing satisfaction and advocating for the pathways expansion to further hospital sites. The critical enabler in this process, the PSW empowers patients self-manage and access community services, thereby reducing unnecessary hospital visits and relieving demand on acute hospitals. A modelling-based calculation based on NCCP Follow-up surveillance guidelines for prostate cancer, estimates potential savings of over 1,880 follow-up hospital visits for these 200 patients over a five-year period. An important element of the PSW role is the safe remote patient monitoring, addressing a gap where the healthcare team often lacks sufficient resources and time. Initial feedback indicates that patients are more open about their concerns through the relationship with the PSW by completing the HNA. The emphasis is on meeting the psychosocial needs of patients as they move into the survivorship phase of their cancer journey. This shift acknowledges the unique contributions of the PSW in addressing prostate patients' psychosocial and functional support requirements. Furthermore, there is an acknowledgment of the more efficient utilization of resources through community services. This is achieved by directing patients to available services in their communities, enhancing overall resource management. Next steps: Our ongoing experience with SSMFU and PSWs in the acute hospital setting highlights patient empowerment and community engagement. Continual refinement based on feedback is integral, with a focus on monitoring and evaluating the PSW's success and utilising patient experience as a benchmark. Plans include extending the pathway to additional hospital sites.