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A Guide to Transitional Care Management for Aging Adults with Cancer

Aging adults diagnosed with cancer face unique challenges that require specialized care and support. Transitional care management plays a crucial role in ensuring a smooth transition between different healthcare settings, such as hospital to home or from active treatment to survivorship. LifeSpan CM provides a comprehensive guide to transitional care management for aging adults with cancer, highlighting key considerations and strategies to enhance their overall well-being in part of what we offer with Case Management.

1. Collaborative Care Planning

Transitional care management begins with collaborative care planning involving healthcare providers, patients, and their caregivers. This includes discussions about treatment options, potential side effects, and long-term care needs. Involving a multidisciplinary team ensures comprehensive and personalized care for the aging adult. Care Managers, Case Managers, and other health providers should know the patient and family well enough that they understand their values to guide treatment choices.

2. Clear Communication

Effective communication is vital throughout the transitional care process. Clear and concise information about the cancer diagnosis, treatment plan, medication management, and self-care instructions should be provided to the patient and their caregivers. Open lines of communication between the healthcare team and the patient’s primary care physician are crucial for coordinated care.

3. Medication Management

Medication management plays a critical role in transitional care for aging adults with cancer. Ensure that all medications, including those prescribed during treatment, are reviewed and reconciled to prevent any potential interactions or duplications. Provide detailed instructions on medication administration, potential side effects, and the importance of adherence.

4. Emotional Support

Cancer diagnosis and treatment can have a profound impact on the emotional well-being of aging adults. Transitional care management should prioritize emotional support, including counseling services, support groups, and access to mental health professionals. Providing resources and information on coping mechanisms and stress reduction techniques can be invaluable.

5. Survivorship Planning

For aging adults transitioning from active cancer treatment to survivorship, survivorship planning becomes crucial. This involves developing a personalized survivorship care plan that includes recommendations for follow-up visits, screening schedules, and management of long-term side effects. Encourage the patient to maintain a healthy lifestyle, including regular exercise, balanced nutrition, and smoking cessation.


6. Home Care and Safety

Ensure that the patient’s home environment is safe and supportive for their recovery. Assess their home for potential hazards, such as trip and fall risks, and make necessary modifications. Consider home care services to provide assistance with daily activities, medication management, and symptom monitoring.


7. Caregiver Support

Aging adults with cancer often rely on the support of their caregivers. It is essential to include caregiver education and support as part of transitional care management. Provide resources, education, and respite care options to help caregivers manage their responsibilities effectively.


8. Palliative and Hospice Care

For aging adults with advanced cancer, palliative and hospice care may be necessary. Transitional care management should include discussions about these options and ensure the patient and their caregivers have access to these supportive services. Addressing pain management, symptom control, and emotional support are essential during this phase.


Transitional care management plays a vital role in supporting aging adults with cancer throughout their treatment journey. By implementing collaborative care planning, clear communication, and monitoring the case as the loved one goes through these transitions, we can improve the overall well-being and quality of life for aging adults with cancer. By addressing their unique needs, we can help them navigate the challenges associated with cancer treatment and ensure a smooth transition between healthcare settings, ultimately enhancing their overall care for the families and patients.