Transitional Care: Methods and Processes for Transitioning Older Adults With Cancer in a Postacute Setting

Area of Science:

• Geriatric oncology
• Healthcare delivery systems
• Patient transitions

Background:

• Transitional care aims to improve patient movement between healthcare settings.
• Current models face challenges with rising costs and suboptimal patient outcomes.
• Effective transitional care strategies are crucial for healthcare system efficiency.

Purpose of the Study:

• Examine challenges for older adults with cancer transitioning to skilled nursing facilities.
• Assess continuity of care from hospital to skilled nursing facility.
• Explore clinical difficulties in post-acute care for this population.

Main Methods:

• Conducted literature searches in CINAHL®, Ovid, PubMed, and Google Scholar.
• Focused on transitional care models for older adults with cancer.
• Reviewed studies on post-acute care and care continuity.

Main Results:

• Successful transitional care models emphasize effective communication.
• Interprofessional team approaches are vital for successful transitions.
• Nurse navigators facilitate medical treatment and care plan execution.

Conclusions:

• Communication and team-based care are key to successful transitional care.
• Addressing clinical difficulties in post-acute settings is essential.
• Optimizing care transitions can improve outcomes for older adults with cancer.