Care Coordination in the Older Adult with Cancer (CCOAC). C.B Steer 1,, J.P.Donnelly 2,J O’Connor 2. R.J.Myers 2, C.R.Underhill 1, R.W.Eek 1,K. A. Clarke 1, C.E.Packer 2 Border Medical Oncology, Wodonga, VIC, Australia 1, Hume Regional Integrated Cancer Service, VIC, Australia 2, This project is an initiative of Cancer Australia funded by the Australian Government. Background The aim of this project was to improve care coordination and access to supportive care options for people over 70 years of age with a cancer diagnosis, and to develop a system for routine supportive care screening of these patients. As the median age of patients at the first diagnosis of cancer in Australia is 67 years, the majority of patients can be considered elderly. The CCOAC project sought to investigate the feasibility of the routine screening of patients over the age of 70 in a regional community setting using the “Adelaide screening tool”. Screening vs Assessment Model The CCOAC tool (a revision of the ‘Adelaide Tool’) was provided to patients, who then completed it at home. This tool is a composite of validated screening tools. Domains include comorbidities, medications, IADLs, social supports, cognition, vision and hearing, distress & pain scales and caregiver’s concerns. The Cancer Care Coordinator then phoned every patient to clarify supportive care risks Where a risk was identified patients were referred to a community or aged care service for further assessment and referral. Some simple interventions were provided on the phone e.g. practical information and reassurance The carer was also interviewed The process was based in the Victorian Service Coordination Framework to ensure consistency with the broader aged care and community sector Conclusions  The model is feasible, accessible and provides a clear message that it makes a positive difference to a patient’s cancer journey  The project developed a model which linked patients to appropriate assessment by aged care and community services  It is possible to use existing community based resources not previously accessed by oncology services on a routine basis  The needs of carers must be addressed concurrently with the supportive care needs of patients, particularly for this age cohort  Engaging GPs within this model is problematic and reflects this issue in the health sector more broadly  Health literacy, and the assumptions made about health literacy of this patient cohort, has an impact on the type of support sought and/or accepted, and needs to be further addressed  Ongoing and effective change management and relationship building is key to sustainability of this model. The Cancer Care Coordinator position is consequently a critical component For further information in relation to this project please contact Jenny Donnelly or Jenny O’Connor 91 patients participated in this pilot (50 males/41 females) 91 baseline screens were completed 39x4 week screens were completed 25 x8 week screens were completed Age range 70 – 94 (median = 77) years Average time of follow up phone call = 20 minutes There was no identified process for direct referral to a GP from the CCC Patients who reported the process was a positive experience = 99% Results Screening is a brief process for identifying the risk of having supportive care needs. Assessment is a more in-depth process that confirms the presence of supportive care needs. (Dept of Health, Vic, Supportive Care guide) Results NumberPercentage Patients receiving an intervention 5762% Where the patient considered the phone call itself to be beneficial 6967% Patients requiring a referral 2730% Total referrals all destinations 34 Referrals to HACC assessment (Home & Community Care) 67% Referrals to community allied health 78% Referral to Carer organisation 89% Patients identifying feeling depressed 3943% Patients where memory was an issue 89% Patients unable to identify their tumour stream/illness 4145%