Due to improvements in cancer screening and treatment, the cancer journey often lasts many years for survivors who routinely manage cancer-related side-effects and sometimes complex medication regimes. Cancer management occurs within person-specific and system complexity requiring individuals to often self-manage and cope with cancer and comorbidities at home. An integrated model of care may address the reality of patient complexity and comorbidity in the context of cancer as a chronic condition. This model of care incorporates self-management support and care planning into supportive care delivered during outpatient cancer treatment.

Most self-management support and care planning studies have shown improvement in chronic care outcomes and evidence is needed for the acceptability, feasibility and utility of this approach in the context of cancer care. This mixed method study utilised descriptive interviews and focus groups to explore the acceptability, feasibility and timing of integrating self-management and care planning support into outpatient cancer treatment. A longitudinal outcomes pilot transplanted The Flinders Program from primary care into the secondary care setting to support self-management, care planning and care coordination.

An integrated model of cancer care is presented that incorporates self-management support and care planning into outpatient cancer treatment. An intervention protocol was developed and implemented to support colorectal cancer survivors receiving outpatient treatment in Wellington, New Zealand. Process and outcome evaluations are expected to indicate the value of a large-scale trial of The Flinders Program for improving the experience of cancer survivorship across New Zealand.