Improving the Transition From Inpatient to Outpatient Care in Oncology

The transition of patients from inpatient to outpatient care is a critical yet complex part of the oncology care process. A recent survey conducted by Targeted Oncology^TM sheds light on how this transition is managed in different settings.

In an effort to further understand these practices, Cristina Gasparetto, MD, cellular therapy specialist, hematologic oncologist, hematologist (Malignant), stem cell transplant specialist at Duke University School of Medicine, shared valuable insights based on her experience. She offers a comprehensive picture of the challenges, best practices, and areas for improvement in this vital aspect of patient care.

Current Transition Processes

In the survey, oncologists were asked about their satisfaction with the current process of transitioning patients from inpatient to outpatient care. Many of the responders expressed satisfaction, particularly those from larger practices. Gasparetto emphasized the difference between large academic centers and smaller or solo practices.

“In my clinic, we have everything set in place. When a patient comes from the inpatient unit to the outpatient, we notify the team, schedule the appointment, and labs. Everything is coordinated before the discharge, so it is easy. But in the community, it is different. Where do they place their patients?” she explained, highlighting the challenges smaller practices face in managing transitions due to limited resources.

This was echoed by the survey respondents (Figure 1) as a total of 47.73% of people who responded worked in practices with 3 to 10 physicians, and 34.09% were part of practices with more than 10 physicians. The size of the practice appeared to influence the approach to care transitions, with larger practices having more structured and standardized processes in place.

Survey responses also showed that oncologists tend to rely on several criteria when deciding whether a patient is ready for transition from inpatient to outpatient care (Figure 2). Some of these include improved vital signs (65.91%), controlled symptoms (77.27%), completion of a specific treatment cycle (61.36%), and patient education on follow-up care (61.36%).

Gasparetto offered an in-depth perspective on this decision-making process, saying that “it depends on the situation...Can the patient come every day to the clinic for antibiotics? Can they afford lodging if they live 2 hours away?”

She also emphasized the importance of assessing the patient's social situation, as well as having a caregiver at home prior to making the decision to discharge. She notes this to be especially true for complex cases like transplants.

Involvement of the Primary Care Physician (PCP)

Another important aspect of care transitions is communication with the patient’s primary care physician (PCP). While 36.36% of survey respondents reported always involving the PCP, Gasparetto explained why this is less common in oncology practices (Figure 3).

“In oncology, we are so specialized, and we often do not involve the PCP directly...it is more about the referral oncologist. The PCP is not involved in the transition because they are not actively managing cancer care. Sometimes we want the patient to go back to the PCP for other health issues, but they are often reluctant,” she noted.

This represents a broader challenge in cancer care, as PCPs are often excluded from direct cancer management, leaving oncologists to handle the majority of the patient’s needs. This finding was reflected in the survey, where a significant portion of oncologists prefer direct communication with referring oncologists, rather than involving the PCP.

Key Resources to Allow for Successful Transitions

There were several tools identified in the survey that help facilitate smoother transitions, including standardized transition protocols (54.55%), electronic health record information sharing (68.18%), patient education materials (43.18%), and nurse navigators or care coordinators (63.64%; Figure 4).

Gasparetto highlighted the importance of patient education, particularly at her institution, where patients receive detailed discharge instructions.

“We do discharge classes, provide patients with written information, and a number to call with questions. That’s very helpful, especially for immunocompromised patients who need to know what to do and what not to do,” she explained.

Challenges in Coordinating Care Transitions

Insights from both the survey answers and Gasparetto showcased several key challenges in coordinating care transitions. According to the survey respondents, issues regarding insurance, patient understanding of their disease, scheduling difficulties, and patient non-compliance are often observed. Gasparetto added another significant concern: socioeconomic factors.

“One of the biggest challenges is if the patient does not have the social support needed for a safe transition. If a patient is debilitated and doesn’t have a caregiver, they cannot go home,” she said, showing the complexities involved in ensuring patients have the necessary support systems in place before transitioning to outpatient care.

Additionally, respondents highlighted the issue of insufficient resources, such as limited inpatient beds and home healthcare options. Gasparetto pointed out that there are often challenges in coordinating care for patients who need long-term care or rehabilitation but do not require intensive inpatient care.

“It is not so easy. We need to have more housing or resources close to the hospital for patients who aren’t ready to go home but don’t need intensive care,” she suggested.

Improving Communication and Patient Education

Effective communication with patients is crucial during the transition (Figure 5). Nearly two-thirds (63.64%) of survey respondents noted the importance of involving nurse navigators and using patient education materials. Gasparetto agreed that education is essential, adding that specialized pharmacists are integral to ensuring patients understand their treatment regimens.

“We have our pharmacy team meet with patients to go over medications and potential side effects. We also give them a calendar to track their medication schedule,” she said, highlighting how integrated support systems can improve patient comprehension and reduce errors.

Access to Inpatient Bed Information

Interestingly, 40.91% of survey respondents indicated they do not have access to real-time information about available inpatient beds (Figure 6). Gasparetto shared his experience with this challenge, explaining that even at a large academic center like Duke, overcapacity and the difficulty of managing inpatient resources remains an issue.

“It’s not surprising. We are often at overcapacity. We try to avoid transferring patients to different floors, but it’s a problem. We don’t always know when a bed will be available,” she noted.

Conclusions

The survey shows a complex landscape in the transition from inpatient to outpatient oncology care. While larger practices benefit from more infrastructure and resources, smaller practices face greater challenges in ensuring a smooth transition. Oncologists recognize the importance of standardized protocols, effective communication, and robust support systems to ensure that patients receive continuous, high-quality care. However, challenges such as socioeconomic factors, insurance issues, and resource limitations continue to impact the process.

According to Gasparetto, improving care transitions depends on addressing the diverse needs of patients and leveraging available resources efficiently.

“The challenges vary depending on the setting,” he said, underscoring the importance of tailored solutions to meet the unique needs of different patient populations. With ongoing efforts to improve coordination, communication, and support, the transition from inpatient to outpatient care can become more seamless, ultimately improving patient outcomes,” she shared.