Having cancer affects more than the patient’s physical condition. It also affects mental health, family life, ability to work, financial planning, social relationships, and faith.
Many patients will encounter problems in one or more of these areas as they transfer from one level of care to another. For example, a patient’s family may have problems obtaining special home equipment or learning to use special equipment. Another patient may have a difficult time accepting the change from anticancer care to symptom relief alone, such as that provided with some types of palliative or hospice care.
Transitional care planning is unique to each cancer patient and family. Transitional care planning helps the patient’s cancer care continue without interruption through different phases of the cancer experience.
Transition means passage from one phase to another. Transitional care planning is the bridge between two phases of care. As the cancer patient’s treatment goals change or the place of care changes, the patient may encounter problems during the transition. Cancer patients will need to make decisions that balance disease status and treatment options with family needs, finances, employment, spiritual or religious beliefs, and quality of life. There may be practical problems such as finding an appropriate rehabilitation center, obtaining special equipment, or paying for needed care. There may be mental health problems such as depression or anxiety.
Transitional care planning helps identify and manage these problems so the transition can go smoothly, without interruption of care. This can reduce stress on the patient and family and improve the patient’s health outcome.
Assessments help identify patients who may have problems during the transition and help determine the kind of support they will need to make the change go smoothly. The assessments may include:
- Complete medical history
- Physical exam
- Test of learning skills
- Tests to determine ability to perform activities of daily living
- Mental health evaluation
- A review of social support available to the patient
- Referral to community resources as needed to assist with issues such as transportation, home care, healthy eating, and medication management.
Assessments help ensure the cancer patient receives the right services at the right times because no one knows what the patient’s needs will be in the future. These are done many times during the patient’s cancer experience, as a routine part of care, especially when the patient moves from one facility to another, such as from hospital to home. Assessments are also done at regular times during the course of the disease, usually at the time of diagnosis, after completing a course of treatment, when there is a relapse, when curative treatment stops, and when treatment is discontinued (end-of-life care begins).
Different types of care are available for different types of needs. Transitional care may include management of the cancer patient’s medical condition and rehabilitation, plus supportive services to ensure basic needs such as comfort, hygiene, safety, and nutrition. It may also include supportive services for educational, social, spiritual, and financial needs. The following is a list of some of the care options that meet the assessed needs of patients during transition:
Place of care
- Nursing home
- Rehabilitation unit or facility
- Patient’s home
- Home of family caregiver
- May be in an inpatient setting specified by the hospice or in the patient’s home.
Health care specialists and other caregivers work as a team, providing services to cancer patients in their homes, clinics, and other settings. These may include the following:
- Physical therapist
- Occupational therapist
- Social worker
- Mental health professional
- Clergy or other religious leader
- Home care aides
Programs that provide care may include the following:
- Bereavement programs
- Community support groups
- Employment counseling agencies
- Home health agencies
- Home infusion agencies
- Hospice programs
- Legal aid organizations
- Palliative care programs
- Pain and symptom management
- Blood transfusions
- Medications that cause blood cells to grow and mature.
- Antibiotics (drugs used to treat infections).
- Treatments that help improve or restore lung function.
- Wound and skin care
The cancer patient may be able to eat normally or may need supplemental nutrition by mouth, by tube-feeding, or by delivery into a vein.
The type of equipment needed, if any, will depend on the cancer patient’s condition. Some commonly needed devices include the following:
- Medical appliances (such as catheters, tubes for drainage, and bags for colostomies).
- Assistive devices (wheelchairs, walkers, special beds and mattresses).
- Pumps to deliver medication into the body.
- Respirators (machines that help the patient breathe).
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