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Transitional Care Planning (PDQ®)

Health Professional Version
Last Modified: 04/09/2014


Transitional care can be defined as care that is required to facilitate a shift from one disease stage and/or place of care to another. For example, as a disease progresses, a patient may proceed through phases of illness that require vastly different levels of emphasis in the goals of care and, consequently, in the nature of care delivery. An individual may have a disease that is amenable to curative therapy; the major goal of therapy may focus on this. Alternatively, another stage of cancer may be more amenable to an intense focus on palliation. In many cases, a balance between curative therapy and palliation is the goal. For increasing numbers of individuals, challenging transitions also occur from illness to health. Transitions also occur with movement from one level of care to another, such as from inpatient acute care to subacute care, nursing home, rehabilitation facility, home care, or hospice care. The process of planning for these transitions is frequently referred to as discharge planning because it implies a release from one facility to another. Transitions may occur on an outpatient basis when the patient no longer benefits from tumor-directed therapy and would benefit from a hospice or palliative care referral made directly by the outpatient staff. Nonetheless, discharge planning must embrace the concept of the continuum of care, or care will become fragmented. The site of care is dictated by disease stage and/or associated comorbid factors that complicate oncologic treatment, by patient or family values and goals of care, and by fiscal or other factors associated with access to care. All transitions necessitate some degree of change. A change, whether viewed as positive or negative, generates stress for the patient, family, and staff. Protocols for these transitions should be developed with the goal of minimizing stress and ensuring good patient care.

Optimal and successful transitions can be ensured through an integrated, seamless relationship between inpatient and outpatient care. Outpatient care is broadly defined to include home care, rehabilitation units or centers, skilled nursing facilities, nursing homes, and hospice care. Discharge planning can be improved through a coordinated systems approach, which may place a community liaison nurse and/or social worker as intermediaries among the hospital, major home health care companies, rehabilitation facilities, nursing homes, and other supportive care resources.[1] A coordinator of the diverse array of health care professionals is imperative, and communication between the professionals is most important. Often, it is the person with the illness or his or her family who carries information from one member of the health care team to another. As an illness becomes more burdensome and complex, a formalized and defined mechanism that is clear to all team members is imperative. Underpinning the approach to patient care should be a biopsychosocial model that assumes that illness is not only a biological phenomenon but also a psychological and social one.[2] In addition, and most importantly, this model must underpin transitions through varying goals of care and foci of treatment.

Routine and comprehensive biopsychosocial evaluation performed by a trained member of the health care team, preferably a medical social worker or a clinical nurse specialist, should complement the physician’s efforts to begin the planning of a strategy of care. For the assessment of the overall goals of care, it is imperative that the treating clinician be cognizant of the need to guide the patient through the varying options for care based on the balance between disease status, treatment possibilities, functional status, patient and family goals, and their interpretation of quality-of-life parameters. Ideally, the assessment of transitional needs should be performed at the time of admission to any inpatient facility and at critical points during the course of disease, including diagnosis, completion of curative treatment protocols, relapse, and terminal phase. It is essential that this assessment be routine because many changes will occur over time in the patient’s and family’s goals of care, and in the family’s willingness and ability to care for the patient. Reassessment is essential for successful home care, medical compliance, and stress management.[3] Routine re-evaluations of the patient and family biopsychosocial status need to be part of the management process in both inpatient and ambulatory care.

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

  2. McDaniel S, Hepworth J, Dogerty W: A new prescription for family health care. Family Therapy Networker 17 (1): 18-29, 1993. 

  3. Beck-Friis B, Strang P: The organization of hospital-based home care for terminally ill cancer patients: the Motala model. Palliat Med 7 (2): 93-100, 1993.  [PUBMED Abstract]