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Transitional Care Planning (PDQ®)

Health Professional Version
Last Modified: 04/09/2014

Comprehensive Biopsychosocial Assessment

Successful discharge planning and planning for transitions begin with an adequate biopsychosocial assessment of the patient and family.[1] This assessment should recognize patients who need help as well as those who are not getting enough help.[2,3] The following areas require assessment:

  1. Physiological:
    • Type of cancer.[4]
    • Functional status.
    • Symptom profile.
    • Disease stage.
    • Disease status (new diagnosis, recurrent, progressive, or remission).
    • Smoking status. (Refer to the PDQ summary on Smoking in Cancer Care for more information.)
    • Nutrition status. (Refer to the PDQ summary on Nutrition in Cancer Care for more information.)
    • Metastasis.
    • Impact of current treatment.
    • Treatment options for the future.
    • Impairment, disability, and/or handicap; or functional independence.

  2. Demographics of patient and caregiver:
    • Age, marital status, parental status, and education/occupation.[4]
    • Sex.[5]
    • Length of hospital stay.[6]
    • Primary language.
    • Cultural background; relevant beliefs and practices.
    • Physical barriers to community/home re-entry (e.g., does the patient live alone? does the patient or family have other responsibilities?).

  3. Psychological:
    • Motivation (including that of family).

    • Other beliefs, values, and cultural systems.[7] (Refer to the PDQ summary on Spirituality in Cancer Care for more information.)

    • Pre-illness family stability.[8]

    • Communication patterns within the family and with the health care team and community.

    • Patient and family perception of illness.

    • Patient and family perception of quality of life.

    • Patient and family fears and concerns about the future, and mechanisms for dealing with these issues. (Refer to the PDQ summary on Adjustment to Cancer: Anxiety and Distress for more information.)

    • History of coping patterns with previous stressful events and crisis management. (Refer to the PDQ summary on Post-traumatic Stress Disorder for more information.)

    • Patient and family life cycle position.

    • Significant family history:
      • Medical and psychiatric illnesses.
      • Health behaviors (e.g., alcohol abuse, drug abuse, history of physical abuse, history of sexual abuse, smoking practices, and sexual practices).

    • History of health and mental health use patterns.

    • Patient and family visions and goals of therapy.

  4. Spiritual:
    • Spiritual beliefs or sense of spirituality.

    • Spiritual distress and spiritual issues.

    • Religious affiliation and level of importance.

    • Religious beliefs and practices as they bear on management of the illness and its treatment.

    • Involvement of members of the religious community, or degree of social support available through the religious community.

    (Refer to the PDQ summary on Spirituality in Cancer Care for more information.)

  5. Social:
    • Knowledge of available support systems (nuclear and extended family, friends, community, and spiritual networks); knowledge of the skills, strengths, and weaknesses of these systems and individuals within them; and the ability to access the systems.

    • Knowledge about hospice care (open-access hospice).

    • Knowledge about palliative care.

    • Support system abilities to provide physical assistance when needed (e.g., transfers, wound care, bladder or bowel care, and lifting).

    • Employment history and flexibility of employment.

    • Insurance assessment, including coverage for the following:
      • Medications (prescription plans).
      • Medical equipment.
      • Skilled home care.
      • Postacute care.
      • Hospice care. (Refer to the PDQ summary on Last Days of Life for more information.)

    • Financial assessment.

    • Transportation availability.

    • Accessibility of home for medical equipment.

    • Handicap access to home.

    • Knowledge and use of community resources.

    • Support system for primary caregiver, including the following:
      • Availability of other individuals who can share the burden of care.
      • Availability of respite for the primary caregiver.

  6. Legal and advance directives:
    • Will preparation or update, and estate planning.

    • Living will.

    • Durable power of attorney for health care (also known as medical power of attorney or health care proxy).

    • Legally defined surrogate.

    • Guardianship for dependent children.

    • Resuscitation status: inpatient Do Not Resuscitate (DNR) and outpatient or community DNR orders.

    • End-of-life care preferences (e.g., hydration, antibiotics, sedation for refractory symptoms, enteral or parenteral nutrition). (Refer to the PDQ summary on Last Days of Life for more information.)

  1. King C: Five steps to improving assessment skills. Home HealthCare Consultant 4 (10): 42-54, 1997. 

  2. Mor V, Allen SM, Siegel K, et al.: Determinants of need and unmet need among cancer patients residing at home. Health Serv Res 27 (3): 337-60, 1992.  [PUBMED Abstract]

  3. Curry C, Cossich T, Matthews JP, et al.: Uptake of psychosocial referrals in an outpatient cancer setting: improving service accessibility via the referral process. Support Care Cancer 10 (7): 549-55, 2002.  [PUBMED Abstract]

  4. Costantini M, Camoirano E, Madeddu L, et al.: Palliative home care and place of death among cancer patients: a population-based study. Palliat Med 7 (4): 323-31, 1993.  [PUBMED Abstract]

  5. Allen SM: Gender differences in spousal caregiving and unmet need for care. J Gerontol 49 (4): S187-95, 1994.  [PUBMED Abstract]

  6. Yost LS, McCorkle R, Buhler-Wilkerson K, et al.: Determinants of subsequent home health care nursing service use by hospitalized patients with cancer. Cancer 72 (11): 3304-12, 1993.  [PUBMED Abstract]

  7. Taylor EJ, Ferrell BR, Grant M, et al.: Managing cancer pain at home: the decisions and ethical conflicts of patients, family caregivers, and homecare nurses. Oncol Nurs Forum 20 (6): 919-27, 1993.  [PUBMED Abstract]

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