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Transitional Care Planning (PDQ®)

  • Last Modified: 04/09/2014

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Overview

Nearly 90% of all cancer care is delivered in outpatient settings.[1] This places increased responsibility on the patient and family [2] and requires a coordinated approach by the health care system. While health care continues to increase in complexity, regulatory and fiscal pressures have become more restrictive.[3] Optimal care is now dependent on careful planning across different care settings to ensure a continuum of care. Patients now move across numerous care settings during treatment (e.g., the transition from being an inpatient at a hospital to being an outpatient in need of home care). Key components to successful outpatient and home care treatment of patients with cancer are a coordinated team for delivery of health care, an involved and committed patient and/or family, and the availability of ongoing support and education for the patient and family. (Throughout this section, the broad term family has been used to refer to individuals who are closely bonded socially to the patient. The nature of close relationships varies widely, and some people who are considered family may not be next of kin or immediate relatives. In the home care setting, these individuals are frequently caregivers for the ill person.) Not only is the delivery of care at risk if care is fragmented, but the demands of illness may place families at risk for job loss and economic hardship as they struggle to care for their family members at home.[4] The planning for and delivery of home care services to patients and their families are often fragmented. The most vulnerable of those experiencing cancer—such as those with a low income, urban-dwelling minorities,[5] and those in a rural setting—may be at a higher risk of experiencing fragmented care.[6]

A team approach to the care of patients and their families is optimal to meet their needs, which frequently are unrecognized and complex.[7] Depending on the diagnosis, disease stage, level of nursing care required, and a variety of psychosocial factors, patient needs range from low technology to high technology and from low intensity of support to high intensity of support. Care needs are dictated by medical and biologic factors and by demographics, setting (urban vs. rural), and psychosocial factors. Thus, care needs are unique to each patient and family. However, the delivery of care for those in transition and for those in need of assessment, planning, and ongoing management is challenging and time consuming and may become unsystematic and haphazard.

In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly from information related to adults. When specific information about the care of children is available, it is summarized under its own heading.

References
  1. Haylock PJ: Home care for the person with cancer. Home Healthc Nurse 11 (5): 16-28, 1993 Sep-Oct.  [PUBMED Abstract]

  2. Given BA, Given CW: Family home care for individuals with cancer. Oncology (Huntingt) 8 (5): 77-83; discussion 86-8, 93, 1994.  [PUBMED Abstract]

  3. Wolfe LC: A model system. Integration of services for cancer treatment. Cancer 72 (11 Suppl): 3525-30, 1993.  [PUBMED Abstract]

  4. Muurinen JM: The economics of informal care. Labor market effects in the National Hospice Study. Med Care 24 (11): 1007-17, 1986.  [PUBMED Abstract]

  5. O'Hare PA, Malone D, Lusk E, et al.: Unmet needs of black patients with cancer posthospitalization: a descriptive study. Oncol Nurs Forum 20 (4): 659-64, 1993.  [PUBMED Abstract]

  6. Buehler JA, Lee HJ: Exploration of home care resources for rural families with cancer. Cancer Nurs 15 (4): 299-308, 1992.  [PUBMED Abstract]

  7. Glajchen M: The emerging role and needs of family caregivers in cancer care. J Support Oncol 2 (2): 145-55, 2004 Mar-Apr.  [PUBMED Abstract]