Creating a Transitional Care Plan
When you are diagnosed with lung cancer and start receiving treatments, you begin to realize the many changes that are happening in your life. As your health status and treatment plans change, the care you receive will also change. During these periods of change, you may have problems moving from one phase into the next. Your healthcare team should help you move between phases by working with you to create a transitional care plan.
Transitional care planning will help you find a healthy balance between your disease and the rest of your life. While you have treatments, doctor’s appointments, and days when you are not feeling your best, your family, finances, and job situation will continue to move on. You may become depressed or anxious about these issues that you just simply cannot manage right now. Transitional care planning can help you identify and manage these problems to minimize the impact on your treatment and healing process. Your healthcare team will help educate and support you and your family by providing support and referrals to resources that you may need during your care.
As your lung cancer gets better or worse, your treatment goals will change. During active treatment, you may be receiving chemotherapy, radiation, surgery, some combination therapy, or a new, experimental treatment. You will also be receiving supportive care to treat symptoms of the lung cancer and side effects from your treatments. Palliative therapy will be given to improve the quality of your life at any time in your cancer journey or to make you comfortable at the end of your life. Because each of these types of care are different, your transitional care plan can help you and your family adjust by helping with the day-to-day issues, medical problems, and emotional issues that will arise in each phase. And because you are a unique person, your transitional care plan will also be unique. Your healthcare team will do many assessments to determine what care is needed to make the changes you experience go smoothly.
Transitional care planning will help you find a healthy balance between your disease and the rest of your life.
Some kind of assessment will be done at every contact with your healthcare team. Your oncologist will examine you, the nurse will ask about side effects, general health status, appetite, and any issues you may be having in your life. The social worker and the financial counselor will help you with any issues you might be having in your employment or financial life. As your treatments change, your team will help to identify any new needs or stresses you or your family might have. Here are some examples of the different types of assessments your healthcare team may perform:
♦ Physical Assessment
Throughout your treatment, but especially when you are diagnosed with lung cancer, when you are receiving treatments, or when there is a change in your treatment, you will receive regular physical assessments by various members of your healthcare team. In general, your doctors and nurses will be primarily responsible for your physical assessment. In addition to asking you questions about your symptoms and quality of life, the healthcare team will usually do a hands-on exam.
♦ Care Setting Assessment
During your treatments, you may receive treatment in many different care settings. Some of your care may occur in the hospital, but you may also receive care in an outpatient cancer center, your home, a nursing home, or a rehabilitation center. As your care moves from one setting to another, your healthcare team will help you plan for this change in care setting. New team members may become involved in your care. As you move from one care setting to another, your team will assess your needs and the physical arrangements in the new setting. If the team determines that you need medical equipment or assistive devices to help you move around, they will help you find those services.
♦ Support Systems Assessment
Your healthcare team will do a full assessment of your support systems – those people and groups around you who are willing to help you during your illness. If you have young children or elderly parents that you care for, your team will help you determine how roles and relationships might change during your treatments. It is sometimes very hard to ask for help. However, this is one time when you will need people around you who care about you and are willing to help.
Depending on your needs, your healthcare team may also provide spiritual and mental health, nutrition, legal, financial, and other types of assessments. These assessments may not be done at every visit, but will certainly be done when there are changes in your health status or treatment plan. The goal of transitional care planning is to make the transitions between different types of care as seamless as possible so that your cancer care may continue without interruptions through all phases of your cancer experience.
Reprinted with permission from The Bonnie J. Addario Lung Cancer Foundation, lungcancerfoundation.org.
This article was published in Coping® with Cancer magazine, July/August 2017.