Patient care management

Patient care is organized as an integrated pathway consisting of successive stages.

1. Patient Reception and Care Pathway Identification

At the initial consultation, the suspected or confirmed cancer diagnosis, clinical priority, and available medical documentation are assessed. The patient is then referred to the appropriate clinical unit and multidisciplinary team and enrolled in the relevant Diagnostic, Therapeutic and Care Pathway.

2. Assignment of a Case Manager

The patient is assigned a dedicated nurse case manager, who serves as the key point of coordination between the patient, their family, and the various healthcare professionals involved.

In particular, the case manager:

• facilitates the collection and completion of medical documentation;
• organizes the different stages of the care pathway;
• coordinates appointments, diagnostic tests, and treatments;
• prepares the patient’s case for multidisciplinary discussion;
• provides information and guidance;
• identifies care, psychological, and social needs;
• monitors progress along the care pathway and flags any issues or critical concerns;
• supports transitions between hospital care, home care, community-based services, rehabilitation, palliative care, and hospice care;
• maintains continuity and coordination throughout follow-up.

The case manager network is coordinated by a supervisory professional who ensures organizational consistency across the different care pathways, collaboration among Multidisciplinary Teams (MDTs), continuity of care between hospital and community-based services, and the professional development of healthcare staff.

3. Diagnostic Work-up and Staging

The necessary diagnostic investigations are scheduled in accordance with the relevant Diagnostic, Therapeutic and Care Pathway (PDTA) and may include diagnostic imaging, endoscopy, biopsy, histopathological examination, molecular and genetic testing, and specialist assessments.

The aim is to ensure that all the information required to make an appropriate treatment decision is available, while avoiding unnecessary duplication of tests and delays.

4. Shared Decision-Making on the Care Plan

The multidisciplinary team’s recommendations are communicated to the patient in clear and understandable language. The available treatment options, expected benefits, potential risks, and impact on quality of life are discussed with the patient to support shared decision-making.

5. Treatment Delivery and Monitoring

The case manager coordinates the scheduling of the planned interventions, including surgery, systemic therapy, radiotherapy, interventional procedures, or combined treatments. Throughout the care pathway, treatment outcomes and any complications are monitored, together with the patient’s nutritional, psychological, rehabilitation, social, and palliative care needs.

6. Follow-up and Continuity of Care

At the end of active treatment, a personalized follow-up plan is established, specifying the required clinical assessments and diagnostic tests, their recommended timing, and any symptoms that may require earlier reassessment.

When necessary, the Cancer Centre coordinates care with the patient’s General Practitioner (GP), community-based healthcare services, home care services, rehabilitation, pain management, palliative care, or hospice care, ensuring seamless continuity of care.