Excellent Practices
Multidisciplinarity, Clinical Pathways and My-Care Plan
Practice Category: Multidisciplinarity
Centre: Karolinska Institute and University Hospital
Berit Sunde
Nurse Director Cancer Theme
berit.sunde@regionstockholm.se
Challenge addressed by the practice
Multidisciplinary care is embedded in clinical practice through structured collaboration across health professionals, ensuring coordinated care planning, timely decision-making, and reduced duplication of assessments. This approach enables holistic, integrated care that addresses the patient’s medical, psychosocial, and supportive needs.
These principles are operationalised through My Care Plan and the assigned contact nurse. My Care Plan provides each patient with a personalised, structured care pathway outlining treatments, timelines, and relevant information. The contact nurse serves as the patient’s primary point of contact, coordinating and providing continuous practical and emotional support throughout the care process. Together, these practices ensure transparency, shared decision-making, continuity, and seamless collaboration across the multidisciplinary team.
Solution
The implementation of My Care Plan and the Contact Nurse role is a key part of Swedish cancer care, based on the National Cancer Strategy and Regional Cancer Center (RCC) guidelines. At Karolinska CCC, these practices are fully integrated into the clinical pathway and have improved both patient experience and care quality.
My Care Plan gives each patient a personal overview of their cancer journey, including examinations, treatments, timelines, and relevant information. It is available digitally and on paper and is mainly used by contact nurses. The care plan supports clear communication, patient involvement, and shared decision-making.
The Contact Nurse is the patient’s main point of contact and ensures continuity and coordination between different care providers. The role includes updating the care plan, monitoring waiting times, and offering psychosocial and practical support.
Examples of what we measure:
- Percentage of patients with a documented My Care Plan
- Patient-reported sense of security and access to care (PREM)
Impact
This practice has shown clear and documented benefits for cancer care and patient outcomes. Patients feel better informed and more actively involved in decisions about their treatment, which increases empowerment, trust, and confidence in care. Clear and predictable care pathways, supported by My Care Plan and the Contact Nurse role, improve continuity of care and reduce uncertainty and stress throughout the cancer journey. Communication between patients and care teams is strengthened through digital tools that enable two-way dialogue and timely information sharing. Shared decision-making is supported through the joint development of the care plan, promoting patient autonomy and partnership in care. Accessibility and continuity are ensured by having a clear and consistent point of contact in the care team. Patients’ physical, social, and existential needs are systematically assessed and addressed using PROMs (Patient Reported Outcome Measures) tools such as Hälsoskattningen, enabling early identification of needs and more person-centred care.
Critical success factors
Several factors were critical for the successful implementation of My Care Plan and the Contact Nurse role. A clear national and regional framework, based on the Swedish Cancer Strategy and RCC guidelines, created a shared direction and common goals. Strong involvement of contact nurses was essential, as they have main responsibility for using, updating, and following up the care plan together with the patient. The structured but flexible design of My Care Plan made it easy to adapt to individual patient needs while still supporting standardised care pathways. Availability in both digital and paper formats ensured accessibility for all patients. Continuous focus on patient involvement and shared decision-making strengthened trust and engagement. Finally, regular use of patient-reported measures supported systematic follow-up of needs and outcomes, helping teams to see the value of the practice and sustain its use over time.
Next steps
The next step is to further standardise and develop the Contact Nurse role across Cancer Theme, in line with national guidelines, to ensure equal, high-quality, and person-centred care throughout the cancer pathway. Continued training and clearer role descriptions will strengthen coordination and follow- up. A key development is to integrate Hälsoskattningen more clearly as a structured part of cancer rehabilitation, supporting systematic assessment of physical, social, and existential needs. Future evaluations will focus on patient-reported outcomes, continuity of care, and how well rehabilitation needs are identified and addressed over time.