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Transitional Care Planning

Special Considerations

Caring for a patient at home can increase the physical and emotional burdens on the patient's caregivers.

The stress and responsibility of in-home care can be hard on family relationships and should be carefully considered. Day-to-day routines may change for everyone. Many families have trouble getting used to the role changes that result. Patients and families may be referred to counseling to help them with these issues.

Pain control is a key factor in successful home care. Pain medications are given to help patients feel better and are often a part of cancer care. Controlling the patient's symptoms, especially pain, can make things easier on both the patient and the caregivers. It is important that the family and caregivers understand the use of pain control medications and other treatments that keep the patient comfortable.

See the following PDQ summaries for more information:

If home care is to be considered, the following factors and others will be assessed:

This assessment will help determine if care at home is a workable option for the patient.

Transitional care planning will help the patient explore ways to pay for services and care needed.

Medical insurance, Medicare, veteran's benefits, and/or Medicaid may pay some of a patient's medical expenses. These have limits to their coverage, however, and patients may need to find other ways to pay for costs not covered. The costs of home care, for example, are usually covered only under certain conditions and for a limited time.

Transitional care planning will include referrals to community resources that can help the patient plan for treatment costs not met by insurance. Social service agencies may be available to help with certain care needs. Some organizations lend medical equipment (such as wheelchairs and hospital beds), provide short-term assistance with a nursing aid or housekeeper, or provide transportation to and from the doctor’s office or clinic.

For more information about financial resources, contact the National Cancer Information Service (CIS) at 1-800-4-CANCER. The CIS offices have information about cancer-related services and resources that are available in different parts of the country.

Transitional care may include employment counseling for the patient.

People with cancer often want to get back to work. Their jobs give them not only an income but also a sense of routine. Some people feel well enough to work while they are having treatment. Others need to wait until their treatments are over. Patients who have disabilities or other special needs after treatment may not be able to return to their old jobs at all.

Referrals can be made to services that help the patient with job-related issues. These services may include employment counseling, education and skills training, and help in obtaining and using assistive technology and tools.

If a patient does return to work, coworkers may not know what to say or may not know if the patient wants to talk about the cancer. Education of the patient's coworkers about the cancer can help ease this transition.

Advance directives need to move with the patient.

During transitions in care, the patient's advance directives, health care proxy form, and durable power of attorney document need to be given to the appropriate caregivers. This step will ensure that the patient's wishes are known through all disease stages and places of care. (See the Legal Assessment section for information about these forms.)