What is transitional care?

The importance of transitions: The course of treatment for cancer can be long and difficult, with many changes in disease state and in treatments. As these changes occur, the needs of the patient and the patient’s family or caregivers also change. For example, the patient may move from hospital care to home care, or from home care to hospice care. In other situations, the patient may shift frequently between home care and hospital care, or may require care at a rehabilitation facility or a nursing home. Whatever the case may be, it is important that the patient’s (and family’s) needs remain the primary consideration and that each transition occurs as smoothly as possible to ensure continuity of care.

What to consider in planning: Ideally, a nurse will develop a comprehensive care plan addressing every aspect of the patient’s life that will be affected by the forthcoming transition. This plan should include a detailed assessment of the following:

• The patient’s current physical status





• Specific needs of the patient and family if the patient is cared for at home





• The patient’s and family’s emotional and psychological adjustment





• Requirements for extra support at home





• Transferring records and other information with the patient if health care providers change





• Financial issues, such as insurance coverage, the patient’s ability to work, and how the costs of care will be covered





• Spiritual needs of the patient and family





• Legal issues, such as advance directives, a living will, health care proxy, durable power of attorney, and do-not-resuscitate (DNR) orders
  

The patient (or the patient’s caregivers) should receive all legal documents, which should accompany the patient through different stages of care. This helps ensure that the patient’s wishes are respected during all stages of care.

Who does the planning: Many people may be involved in planning for transitional care, depending on the needs of the patient and family. Those involved might include the patient and patient’s family or caregivers, the patient’s doctors and primary nurse, a social worker, psychologist or other mental health professional, advocacy or support personnel from community agencies or cancer support organizations, pastoral counselor or other spiritual adviser, physical therapist, and occupational therapist.

Services available: A variety of services are available, depending on the needs of the patient and family and on available local resources. For example, patients may require specific services, such as visiting nurses, housekeeping or cleaning services, medical equipment and supply services, a home infusion agency, financial or legal consultation, transportation services for medical appointments, counseling, spiritual care, employment services that can help with employment transitions or skills retraining, special services to enable the patient to return to school, and other community services that can assist with various needs, such as home meal delivery and errands.

Other patients may be transferred to a hospice, to a nursing home, or to a rehabilitation center. Many of these facilities provide a social worker, nurse, or other personnel to help the patient and family adjust to the new surroundings, to access needed services, and to ensure that the patient’s medical care (including medication) is coordinated among previous and current care providers.

Transition to the patient’s or caregiver’s home: In this case, health care staff are advised to assess the following aspects of home care:

• Issues of safety and access (stairs, bathing facilities, and the like) that may require modification (ramps, handle bars, lifts)





• If special equipment (hospital beds, medical devices) will be required in the home





• If the home can physically accommodate such equipment





• If the patient or caregiver is able to operate the equipment





• If the patient or caregiver will require physical help (such as with the patient’s hygiene or personal care)





• If the patient or caregiver understands and can safely give medications





• If the patient or caregiver can handle the emotional stress of home care





• If the patient or caregiver understands pain control and how to manage symptoms of pain.

The person performing this assessment (for example, an occupational therapist, social worker, or home health nurse) can then work with the patient and appropriate staff to ensure the patient’s needs are met.

Bibliography

Abrahm, Janet L. A Physician's Guide to Pain and Symptom Management in Cancer Patients. 3rd ed. Baltimore: Johns Hopkins UP, 2014. Print.

Bellenir, Karen, ed. Cancer Survivorship Sourcebook. Detroit: Omnigraphics, 2007. Print.

Brennan, James. Cancer in Context: A Practical Guide to Supportive Care. New York: Oxford UP, 2004. Print.

Bucher, Julia A., Peter S. Houts, and Terri Ades, eds. Complete Guide to Family Caregiving: The Essential Guide to Cancer Caregiving at Home. 2nd ed. Atlanta: Amer. Cancer Soc., 2011. Print.

Houts, Peter, ed. Home Care Guide for Cancer. Philadelphia: Amer. College of Physicians, 1994. Print.

Stern, Theodore, and Mikkael Sekeres. Facing Cancer: A Complete Guide for People with Cancer, Their Families, and Caregivers. New York: McGraw, 2004. Print.

Talley, Ronda C., Ruth McCorkle, and Walter F. Baile, eds. Cancer Caregiving in the United States: Research, Practice, Policy. New York: Springer, 2012. Print.