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Transitional Care Planning

What Is Transitional Care Planning?

Transitional care planning helps the patient’s cancer care continue without interruption through different phases of the cancer experience.

Transition means passage from one phase to another. Transitional care planning is the bridge between two phases of care. As the cancer patient's treatment goals change or the place of care changes, the patient may encounter problems during the transition. Patients will need to make decisions that balance disease status and treatment options with family needs, finances, employment, spiritual or religious beliefs, and quality of life. There may be practical problems such as finding an appropriate rehabilitation center, obtaining special equipment, or paying for needed care. There may be mental health problems such as depression or anxiety. Transitional care planning helps identify and manage these problems so the transition can go smoothly, without interruption of care. This can reduce stress on the patient and family and improve the patient’s health outcome.

See the following PDQ summaries for more information:

Transitional care planning may include support and education for the patient and family and referral to resources. Ideally, it involves a team approach by the patient's health care providers. It is important that there be close communication between members of the team and that this communication include the patient and family.

Goals of cancer care may change as the disease changes.

Each type of cancer requires different care and the goals of a patient’s treatment may change as his or her disease gets better or worse. Cancer care may include any of the following:

Transitional care planning can help the patient and family with medical, practical, and emotional issues that arise as they adjust to these different levels and goals of care.

A patient may receive care in several different settings during the course of the illness.

Most of the care received by people with cancer is provided in places other than a hospital. The place where the patient receives treatment may change several times during the course of the illness. Patients may go from receiving care in a hospital or as an outpatient to receiving care at home, in a nursing home, at a rehabilitation center (a place for special training, such as help in regaining strength or movement), or from a hospice team for end-of-life care. When a patient moves from one place of care to another, the process of planning for the move is often called discharge planning. This may involve a case manager who acts on the patient's behalf when dealing with the hospital, visiting nurses, health care companies, rehabilitation facilities, nursing homes, and other groups that provide the care needed. The case manager is a link to resources and services in the community and can arrange for the provision of services, including patient and family education and referrals.