Table 2.

Enablers, barriers and strategies for improvement in the continuity and coordination of care within and between the PHC and cancer treating tertiary hospital as identified by study participants, displayed in IPCHS categories.

WHO IPCHS identified primary drivers of continuity and coordination of care	Enablers	Barriers	Strategies for improving continuity and coordination of care
Interpersonal continuity (refers to patients’ experiencing continuity in their trusted therapeutic relationships, care provided based on identified personal and cultural needs provided by a central provider) [26,41].	Continued relationships and trust Patient follow-up and provision of holistic care General practitioner (GP) as central point	Staff workload resulting in minimum time for patients (hospital setting) Limited staff knowledge to provide adequate care	Education/Upskilling of staff. PHC staff – education on diagnosed cancers, treatment and management. Hospital staff – education on health and hospital associated needs of Indigenous patients. Patient centred care. Aboriginal Liaison Officer (ALO) providing cultural support and care prior to patient presentation to hospital based on patient-identified needs, use of translators as required Collaborative practices and proactive attitudes/practices, peer support amongst care providers within and between sectors
Longitudinal continuity (refers to patients seeing the same professional over multiple episodes of care, ensuring strategies are in place for care to be connected, and availability of a patient support network) [26,41].	Proactive approach to patients care Patient navigator Patient support to access services	Systems and processes resulting in barriers to care e.g. organisation protocols resulting in a lot of paperwork and time delays)	Practical support for patients to access care (for example, transport, accommodation, care coordinators/navigators Collaborative practices across settings to plan patient’s post-discharge care and follow-up prior to hospital discharge Sharing of electronic patient records across hospital and PHC sites Seeing the same care navigator/coordinator through the cancer journey across settings to deliver care continuity Simpler protocols around release of patient information documents for treating PHC services to obtain copies of patient hospital records to be able to provide care continuity and quality follow-up care at the PHC end
Flexible continuity (refers to the ability to adjust care and treatment plans in response to patients changing individual needs across time [26].	Flexible care delivery (e.g. telehealth) ‘Drop-in’ clinics Extension of clinic hours (PHC) Longer GP/specialist patient consultations Visiting specialists/allied health professionals at PHC setting	Rigid hospital appointment schedules/times Transport and parking costs (hospital setting) Short hospital consultation times with specialists Lengthy waiting times before seeing specialist (hospital setting)	Care flexibility (especially at the hospital) and consideration of individual patient needs when scheduling appointments (for example, travel distance), in care delivery (such as telehealth options), availability of outside business hours clinics to access allied health staff, practical considerations (for example, parking costs, public transport). More consideration for appointment flexibility for patients living outside urban areas More time allocated for specialists’ consultations Active follow-up of patients who are unable to attend scheduled appointments Patient support (help with self-management strategies and to prioritise health as needed) Timely and improved communication pathways between services Keeping patients informed whilst waiting to be seen in hospital
Informational continuity (refers to the provision of timely and comprehensive information in relation to patient care needs) [26].	Timely communication and information exchange Use of technology	Limited communication & coordination/teamwork within hospital Delayed communication and information exchange on patient treatment/condition Ineffective administrative/system processes (such as some PHC having difficulty accessing paperwork)	Sharing of patient electronic records across settings in real time Timely, frequent and ongoing communication and more use of telephone calls, case conferences between services, specialists providing updates to GP after every hospital specialist appointment (not only for changes and/or to discuss concerns) Name and contact details of a contactable medical staff member as point of contact on all discharge summaries Patient information – ensuring patients are aware they can access both hospital and PHC care services after hospital discharge Streamlined administrative processes and paperwork (for example, streamlined release of patient information consent forms)
Cross-boundary team continuity (refers to effective collaborations among professionals in all care settings) [26].	Collaborative partnerships, teamwork and good relationships within and external to the organisation Care management plans	Working in silos Lack of clarity between PHC and hospital staff on who’s providing the follow-up care Lack of streamlined services and system processes	Working together, good relationships and follow-up care. Hospital providing discharge summaries and/or paperwork to PHC in timely manner, shared patient management care plans, developing communication protocols between services, more collaboration across multidisciplinary teams in hospitals Shared patient electronic records across services in real time Clarity around professional roles and responsibilities (for example, role of ALO and social worker at the hospital) and clarity between hospital and PHC staff on post discharge follow-up care (who is doing what) Communication/engagement with PHC such as copying GP in relevant communications with specialists, referrals, keeping PHC in the loop Prompt follow-up of positive test results and communication with GP and relevant professionals Hospital admission notifications and treatment updates to PHC while patient is hospitalised (with patient consent) Streamlined administrative processes Designated site contact person at the PHC and hospital is provided to services as a point of contact for any patient and care related enquires