Conception et mise en œuvre d’un programme de transition post-traitement pour les survivants du cancer

Shari Moura, Patricia Nguyen, Aronela Benea, Carol Townsley

Abstract


Contexte : Le programme « After Cancer Treatment Transition » ou ACTT du Women’s College Hospital, à Toronto, est un programme de transition à l’intention des patients, des familles et des professionnels de la santé dont le but est de répondre aux nombreux besoins survenant après le traitement et en phase de survivance. Le présent article décrit l’élaboration et la mise en œuvre systématiques du programme ACTT, plus précisément, le rôle des infirmières en pratique avancée (IPA). 

Conception du programme : La mise en œuvre de l’ACTT requérait la collaboration d’une IPA, d’un omnipraticien en oncologie (OO) et d’une équipe interprofessionnelle. Les concepteurs de l’ACTT ont proposé d’instaurer une structure clinique dans un milieu de soins externes afin de mettre en lien les professionnels de la santé et d’arriver à fournir un suivi post-traitement et des soins continus aux survivants. L’élaboration des lignes directrices post-traitement s’est appuyée sur un consensus d’experts en oncologie, l’avis d’un groupe spécialiste de certains types de cancer, d’autres lignes directrices fondées sur la recherche ou des recommandations sur les pratiques exemplaires. 

Mise en œuvre du programme : Au départ, on s’inquiétait surtout de l’importance de maintenir les soins post-traitement et de répondre aux besoins des survivants. On a donc demandé aux groupes spécialistes et aux équipes interprofessionnelles de fournir leurs commentaires en continu. L’ACTT a établi une approche normalisée pour assurer aux patients une transition sûre et efficace à la fin des soins tertiaires et, en bout de ligne, les aider à obtenir des soins primaires. 

Programme ACTT actuel : L’ACTT fournit des soins post-traitement et des soins aux survivants complets grâce à l’étroite collaboration entre l’OO et l’IPA. Tous deux sont des spécialistes de la prise en charge des effets tardifs ou persistants, de la surveillance et de la prévention du cancer, ainsi que de la satisfaction des besoins psychosociaux avant la transition vers les soins primaires. Le plan de soins aux survivants de l’ACTT est un outil informatif pour les patients et les fournisseurs de soins primaires en vue de continuer les suivis post-traitement. 

Orientations futures : Il est prévu d’étendre le programme ACTT à d’autres types de cancer, d’explorer de nouvelles modalités de soins, d’optimiser le processus de transition et d’analyser en profondeur les résultats rapportés par les patients.


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