Telehealth nurse-led survivorship clinic enhancing outcomes for colorectal cancer patients

Southern Melbourne

The SMICS‑supported Telehealth Nurse‑Led Survivorship Clinic (TNLSC) for stage I and II colorectal cancer (CRC) survivors, established at Monash Health in June 2025, is now complete.

The TNLSC aimed to meet the growing demand for accessible, patient‑centred survivorship care for individuals transitioning from active cancer treatment to long‑term follow‑up care.

Keep reading for more information about this project.

 

Project background

Colorectal cancer (CRC) was the third most prevalent cancer in Victoria, representing 9.4% of all newly diagnosed cases in 2024. CRC survivors often face a wide range of physical (e.g. fatigue, gastrointestinal issues), emotional, and practical challenges following initial treatment and during subsequent follow‑up care. A crucial component of effective cancer management is the provision of high‑quality, well‑structured survivorship care that addresses these challenges.

SMICS aimed to help enhance the survivorship care for early-stage CRC patients by supporting the establishment of a TNLSC at Monash Health.

 

About the TNLSC

The TNLSC was led by a dedicated Clinical Nurse Consultant (CNC) with specialised expertise in colorectal cancer care. It operated alongside the weekly CRC surgery clinic, with TNLSC appointments alternating with surgical reviews.

The TNLSC supported patients by:

  • Survivor‑Centred Care: Establishing an integrated and coordinated care model that effectively met and addressed the identified health needs of early‑stage CRC survivors.
  • Optimised Access to Care: Improving access to follow‑up care by providing services closer to home.
  • Comprehensive Care Coordination: Providing specialised post‑treatment care coordination through a dedicated intervention nurse who addressed the complex, multifaceted supportive care needs of CRC survivors.
  • Referral Facilitation: Ensuring necessary referrals were made during TNLSC appointments to address the specific needs identified by the patient.
  • Patient Education: Educating survivors about self‑management, lifestyle changes, and disease prevention, and providing effective management strategies and access to reliable resources to empower them to actively participate in their care.

Project outcomes

Over a six‑month period, the TNLSC successfully supported 57 CRC survivors, demonstrating operational feasibility and the capacity of nurse‑led telehealth to manage growing caseloads without compromising care quality.

Key outcomes of TNLSC participation

  • 94% (57 of 61) of eligible patients were enrolled in the TNLSC
  • 100%  (N=57) of participants completed a validated distress thermometer and problem list assessment
  • 7% (4 of 57) of participants were referred internally and a further 7% were referred externally to address their identified needs
  • GPs were kept informed with 97% (55 of 57) of patient GPs receiving a copy of their patients completed survivorship care plan
  • Access to care was timely, with a median wait time of 7 days (IQR 5.0–29.0) from referral to the initial TNLSC appoitment
  • All respondents (100%, n=37) reported satisfaction with their TNLSC consultation
  • Eighty‑one percent (30/37) of respondents said the specialist nurse introduced them to reliable information sources they could use to support themselves.

The healthcare team that participated in the project reported that the TNLSC represents a viable, sustainable, and scalable model for meeting increasing survivorship care demands.

The TNLSC has now been embedded into routine CRC practice at Monash Health.

For more information about this project, or to discuss an idea for a similar project within a SMICS member health service, please contact: SMICS Program Manager, Seleena Sherwell 

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