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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