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Transitional Care Planning (PDQ®)

  • Last Modified: 11/19/2013

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Transitional Care Planning Assessments



An assessment collects information that helps the health care team identify and manage problems a patient may have in adjusting to a change in care.

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 patient and family. 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 a complete medical history; a physical exam; a test of learning skills; tests to determine ability to perform activities of daily living; a mental health evaluation; a review of social support available to the patient; and referral to community resources as needed to assist with issues such as transportation, home care, healthy eating, and medication management.

Assessments are done many times during the patient's cancer experience, as a routine part of care.

Assessments are done when the patient moves from one facility to another, such as from hospital to home. They 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). The patient may feel added emotional stress at these times. Regular assessments can identify these and other causes of distress in the patient, such as job loss or the death or illness of a patient's loved one or caretaker. (See the PDQ summary on Grief, Bereavement, and Coping With Loss for more information.)

Because no one knows what the patient’s needs will be in the future, assessments are done many times during the cancer experience as a routine part of care. This is helps ensure the patient receives the right services at the right times.

All members of the patient’s health care team are involved in the assessment process.

In planning for a change in cancer care, doctors, nurses, and other members of the patient’s health care team will consider all the areas of a patient’s life that may be affected. The following professionals may each conduct different parts of the transitional care planning assessment:

The following types of assessments will be done for transitional care planning:

Physical assessment

A physical assessment will look at the patient's general health, treatment plan, and changes in disease status, including the following factors:

See the following PDQ summaries for more information:

Family and home assessment

Factors such as the patient's age and living arrangements may affect how easily a change in level of care can be accomplished. The assessment will look at the following:

  • Age of the patient and family members.
  • Living arrangements.
  • Whether the patient has a spouse or children.
  • Level of education of the patient and family.
  • Language spoken in the home.
  • Cultural beliefs and practices.
  • Whether family and friends are able to help during treatment.
  • The age and floor plan of the home. Will medical equipment (such as a hospital bed, oxygen tank, or portable monitor) fit in the bedroom, if needed, and is wiring adequate? Can a person in a wheelchair move through the house easily?

Mental health assessment

Change can be a stressful time for both the patient and family. The nature of the relationship between the patient and his or her family and others helps determine the kinds of services the family may need to cope with the transition. The following questions may be asked:

  • How do the patient and family feel about the cancer, the treatment, and the treatment goals? Sometimes patients develop serious problems such as depression or anxiety. Family members also may need help dealing with their feelings. These problems are often treatable. The doctor or health care professional can make referrals to a support group, counselor, or mental health care worker.
  • What beliefs and values are important to the patient and do they affect the patient’s treatment decisions?
  • How has the family coped with stress and crisis in the past? This may be helpful in predicting how they will react to the stress caused by the changes in the patient's treatment.
  • Are there problems in the home that are unrelated to the cancer but may affect how well the patient and family can handle the change?
  • Are there current or past mental health problems in the family?
  • Has there been physical or sexual abuse in the patient's past?
  • In the case of a patient considering home care, does the patient or any family member smoke or use drugs or alcohol? Smoking is not safe around oxygen equipment. Family members responsible for giving the patient medicines or other care must be clear-headed and not under the influence of any substance that could affect their ability to provide care in the prescribed way.

See the following PDQ summaries for more information:

Social assessment

Doctors and other health care professionals can provide referrals to supportive services available to the patient. A review of the kinds of social services already available to the patient will be done:

  • What kind of support is available in the home and community? How will the patient travel to medical appointments or other places? Who can the patient call on for help if necessary? Where the patient lives may affect what services are available and how the patient can get to appointments. Referrals can be made to local providers of services such as home nursing, food and medication delivery, and transportation to and from treatment centers.
  • Does the patient understand hospice care and palliative care and know about available programs in the community? (See the PDQ summary on Last Days of Life for more information.)
  • Before home care is considered, the availability of in-home help must be determined. Is there someone at home who can help the patient or will outside help be needed?
  • Will the primary caregiver have anyone to help with the caregiving duties and make it possible to take time off?
  • How will the change affect the patient’s ability to work?
  • Does the patient have insurance coverage (group coverage from a job, Medicare, Medicaid, veteran’s benefits, or other)?
  • What are the patient’s financial resources? How will the cost of care be paid?

Spiritual assessment

Knowing the role that religion and spirituality play in the patient's life help the health care team understand how these beliefs may affect the patient's transition to a new level of care. A spiritual assessment may include the following questions:

  • Does the patient consider himself or herself to be a spiritual person?

  • What is the importance of religion to the patient?

  • Is the cancer or its treatment causing spiritual distress?

  • Is support available from the patient’s religious group? Many patients find visits from members of their religious group valuable. A patient may want to talk to a spiritual advisor (for example, a priest, rabbi, or minister) during treatment.

Most hospitals, especially larger ones, employ hospital chaplains who are trained to work with medical patients and their families. Hospital chaplains are trained to be sensitive to a range of religious and spiritual beliefs and concerns.

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

Legal assessment

Advance directives and other legal documents can help doctors and family members make decisions about treatment should the patient become unable to communicate his or her wishes. The patient may be asked if he or she has prepared any of the following documents:

  • Advance directive: A general term for different types of documents that state what an individual's wishes are concerning certain medical treatments when the patient can no longer communicate those wishes. The patient may declare the wish to be given all possible treatments that are medically appropriate, only some treatments, or no treatment at all. Advance directives are most effective when the patient and doctor talk about the decisions made by the patient and make plans to ensure the directives are followed.
  • Health care proxy (HCP): A document in which the patient identifies a person (called a proxy) to make medical decisions if the patient becomes unable to do so. The form may not need to be notarized, but it must be witnessed by two other people. The patient does not have to state specific decisions about individual treatments, only that the proxy may make medical decisions for him or her. HCP is also known as durable power of attorney for health care (DPOAHC) or medical power of attorney (MPOA).
  • Living will: A living will is a legal document in which a person states that they want certain life-saving medical treatments to be either withheld or withdrawn under certain circumstances. A living will is a type of advance directive. Living wills are not legal in all states.
  • Durable power of attorney: A document in which the patient names another person to make legal decisions for him or her.
  • Do Not Resuscitate (DNR) order: A document in which the patient instructs doctors not to perform cardiopulmonary resuscitation (restart the heart) at the moment of death, so that the natural process of dying occurs. A DNR order may be medically appropriate when cardiopulmonary resuscitation is not likely to save the patient's life.