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Optimal Care Pathways Implementation

Optimal Cancer Care Pathways aim to improve patient outcomes by facilitating consistent, safe, high quality and evidence-based care.  They can be used by health services and professionals as a tool to identify gaps in current cancer services and inform quality improvement initiatives across all aspects of the care pathway.

Details regarding current SMICS OCP related projects can be found below:

Aboriginal and Torres Strait Islander Project: (COMPLETED)

A co-planned, co-designed and co-delivered educational program for cancer services and Aboriginal health workers to support the workforce to deliver culturally competent cancer services.

Project Lead: Jenny Thresher

Brain Project:

Based on the recommendations from the Victorian Brain Tumour Summit, areas of investigation for SMICS include:

  • improving coordination of care between metro/regional services for patients repatriated for post-surgery treatment and care. SMICS is working with Gippsland ICS to explore referral pathways.

  • access to early palliative care planning.

Project Leads: Anna Maciejewska, Tracey Bucki

OCP implementaion
Improving Equity
Improving Equity
MDM Quality: Establishment of MDM Governance Group:

MDM Governance structures are being established and supported at Monash Health, Peninsula Health, and Alfred Health to monitor and improve MDM quality.

Project Leads: 

 Geraldine Largey (Monash Health)

 Anna Maciejewska (Peninsula Health)

 Jenny Thresher (Alfred Health)

Care of the older person with cancer:


SMICS and Hume Regional Integrated Cancer Service (HRICS) have developed the VICS Care of the Older Person with Cancer Toolkit to assist health services and ICS improve the care of the older person with cancer.

The toolkit provides information to help identify and address existing barriers, examples of existing geriatric oncology services and key resources including how-to guides, education opportunities and patient resources.

Project Lead:   Tracey Bucki

Wellbeing & Support
Supportive Care: Living with Cancer Education Program (Mandarin):

Cancer Council Victoria, Monash Health and SMICS collaborated to adapt the Living with Cancer Education Program (LWCEP) to encompass Chinese culture and the Mandarin language. Interpreters from Monash Health and consumers assisted and informed the development of the Mandarin LWCEP. Delivery of the program is on hold until COVID restrictions allow.

Project Lead: Jessica Delaney

Accessing cancer care equitably using Support Services (ACCESS) project:

SMICS is supporting the Cancer Council Victoria to implement the ACCESS project to improve access to supportive care for people affected by cancer in Southern Melbourne. The project aims to support acute and primary health services respond to the increased demand for supportive care screening, psych-oncology and practical support during the COVID-19 recovery.

Visit the Cancer Council Victoria for more information about the project and support services available.

Project Leads:  Jessica Delaney, Tracey Bucki

Supportive Care Refresh Project:

The aim of the Supportive Care Refresh project is to ensure people affected by cancer have equitable access to timely and appropriate supportive care throughout the care pathway by supporting health services to: build workforce capacity to identify and address supportive care needs; integrate supportive care screening, assessment and referral into routine practice; strengthen referral pathways and linkages to services; and assist people to self-manage supportive care needs using the resources.

Project Lead: Jessica Delaney

The Victorian Statewide Collaboration to Improve Cancer Survivorship Care:

VICS has partnered with the Australian Cancer Survivorship Centre (ACSC) to improve survivorship care across Victoria. The project aims to improve survivorship care by supporting health services to implement survivorship care policies; models of care; and by building capability and capacity in survivorship care.  
Co-design workshops are planned for early 2023 to enable improved, more consistent implementation of survivorship care plans and needs assessment tools across the state.

Project Leads:  Jessica Delaney, Tracey Bucki

Workforce Development
Virtual training program for Metastatic Breast Care Nurses:

The McGrath Foundation, Monash Health, Monash University and SMICS is piloting an innovative training program to upskill McGrath breast care nurses caring for people with metastatic breast cancer. In an Australian first, breast care nurses are participating in virtual training at the Monash Cancer Centre via a telepresence robot. The program is being evaluated to assess the effectiveness of remote learning using telepresence technology. 

Project Lead: Jessica Delaney

SMICS workforce development
COVID-19 Response
VCCN COVID- 19 Cancer Network Support:

SMICS staff provide significant program management support to the Victorian COVID-19 Cancer Network (VCCN) Taskforce and expert working groups.

The VCCN was established in March 2020 by the VCCC alliance and Monash Partners Comprehensive Cancer Consortium (MPCCC) in response to the challenges involved with managing cancer care amid the COVID-19 global health crisis. It aims to provide support and advice to clinicians and health care services treating patients with cancer during the COVID-19 pandemic.

SMICS completed projects
Completed Projects
Completed 2022

Cancer Nurse Coordinator Community of Practice
Project Lead: Jenny Thresher

Following identification of the professional and supportive needs of Monash Health cancer nurse coordinators, a community of practice was developed and implemented incorporating an education and well-being program. The impact of participation on stress, burnout, resilience, job satisfaction and mindfulness was measured and documented via an evidenced based research methodology.

Patient Information Brochure for Bowel Surgery Preparation

Project Lead: Tracey Bucki

An easy English patient information brochure has been developed and translated into six additional languages to support the introduction of the Monash Health Enhanced Recovery After Surgery (ERAS) Colorectal Pathway at Dandenong Hospital. The resource will provide surgical preparation information to approximately 190 patients treated for bowel cancer per year.

Shared follow-up for women with low-risk endometrial cancer in general practice

Project Leads: Tracey Bucki, Jessica Delaney

Women with low-risk endometrial cancer have a reduced risk of cancer recurrence but still require monitoring after treatment. SMICS supported the Gynae-Oncology Department at Monash Health to develop a procedure that facilitates shared follow-up care for low-risk women in general practice. Where appropriate, women will be discharged to their nominated GP for follow-up care with rapid access to specialists at Monash Health if required. For more information see the attached report and Cancer Australia’s guide for shared follow-up care of women with low risk endometrial cancer.

COVID-19 Responses

Code Brown Support 

SMICS staff provided support and assistance to health care services treating patients with cancer during the COVID-19 pandemic.

Telehealth Support
Project Leads:  Jessica Delaney, Jenny Thresher 

To reduce the risk of exposing vulnerable patients and healthcare workers to COVID-19, SMICS supported oncology outpatient clinics to implement a telehealth service delivery model using the Health Direct platform. The level and type of support varied between health services, but included process mapping, documenting procedures, developing scripts to support telehealth bookings, rescheduling appointments and helping patients who required additional support accessing telehealth services. Rapid uptake of telehealth ensured continuity of care for people affected by cancer throughout the pandemic.

Prostate Resource Flyer
Project Leads:  Tracey Bucki, Anna Maciejewski 

To support access for patients to appropriate information and support at diagnosis, VICS engaged with health professionals, consumers, Prostate Cancer Foundation Australia and Cancer Council Victoria. Four resources have been identified as the ‘gold standard’ to be given to newly diagnosed prostate cancer patients.  This will help avoid the variation in information provided to newly diagnosed prostate patients across Victoria, as identified at the last Prostate Tumour Summit. The resources include: the PCFA booklet Prostate cancer: a guide for newly diagnosed men; Cancer Council’s Understanding prostate cancer and Guides to best cancer care – prostate cancer; and the ‘A Common Path’ video developed by North Eastern Melbourne Integrated Cancer Service.

Completed 2021

Advance Care Planning at Alfred Health and Peninsula Health

Project Lead: Geraldine Largey

SMICS supported the development and pilot implementation of an Advance Care Planning (ACP) Workbook Project at Alfred Health and Peninsula Health between February 2021 and October 2021. The aim of the project was to promote greater participation by oncology multidisciplinary practitioners in ACP activities.

Monash Health Virtual Nurse-led Clinic

Project Lead: Geraldine Largey

SMICS supported establishing and piloting a Telehealth Cancer Support Nurse Review Clinic (TCSN-RC) at Monash Health to enhance current oncology service provision. The TCSN-RC operated on demand from Monday to Friday during business hours. It provided a service for cancer patients from all Monash sites and was led by four experienced oncology nurses distinctively positioned to provide accurate and timely assessment, triage, education, support, and intervention to optimise management of poorly controlled treatment related symptoms at home.

Pancreatic Cancer Resectability Project

Project Lead: Anna Maciejewska

SMICS in partnership with North Eastern Melbourne Integrated Cancer Service (NEMICS) engaged key stakeholders to adopt the ‘International consensus on definition and criteria of borderline resectable pancreatic ductal adenocarcinoma 2017.’ A newly developed synoptic report is currently being piloted by MDTs at Alfred and Austin Health.

Lung Project

Project Lead: Geraldine Largey

SMICS collaborated with local clinicians to develop agreed solutions to data identified variations in the surgical pathway at Peninsula Health. In the six-month pilot implementation period, median time from date of referral to date of diagnosis, and date of referral to date of first curative intent surgery improved by 26% and 3% respectively. 

Palliative Care Project at Monash Health

Project Lead: Geraldine Largey

In October 2020, Monash Health established a pilot Palliative Care Virtual Clinic (PCVC) to enable virtual palliative care consultation of outpatients attending oncology clinics, whether these were being delivered face to face or by video consult via health direct or telephone. SMICS supported the interim six-month evaluation of this project. Results have been withheld pending finalisation of the project and potential publication. 

MDM Quality: QOOL VIC Implementation at Peninsula Health​

Project Leads: Anna Maciejewska, Jenny Thresher

SMICS has assisted Peninsula Health in implementing the Queensland Oncology On-Line-Victoria (QOOL-VIC) application for all oncology multi-disciplinary meetings. QOOL-VIC assists meeting preparation, and documentation and communication of essential clinical information such as diagnosis, cancer stage and recommended treatment plans.

Symptom Urgent Review Clinics

Project Lead: Nell Sproule

A number of Symptom Urgent Review Clinics (SURCs) have been implemented across Victoria to support patients experiencing systemic anti-cancer therapy (SACT) side effects. In 2020, SMICS provided over $300,000 in grant funding to establish SURCs at Alfred Health, Peninsula Health and Cabrini Health.


The Victorian Integrated Cancer Services are supported by the Victorian Government 

© 2023 Southern Melbourne Integrated Cancer Service

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The Victorian Government acknowledges Aboriginal and Torres Strait Islander people as the Traditional Custodians of the land and acknowledges and pays respect to their Elders, past, present and emerging.

We are committed to safe and inclusive work places, policies and services for people of LGBTIQ+ communities and their families.

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