Coordinating Seamless Transitions Across Care Settings

Topics: Efficiency, Performance Improvement, Quality, Care Coordination, Methodologies, Oncology, Service Lines, Collaborative Relationships, Physician Issues

By reading this study, members will learn how to:

  • Use data to identify and prioritize care transition challenges
  • Engage patients and providers in smoothing care transitions
  • Collaborate with the emergency department to improve communication and patient care
  • Ensure continuity between inpatient and outpatient cancer care
  • Develop ongoing hospice relationships to better meet patients’ care needs and goals
  • Start the conversation on patient transitions

  • Use our discussion guide to identify which transitions are most problematic for your organization and develop strategies with your team to work toward smoother patient transitions. Download the guide.

Executive Summary

Cancer providers have long been sheltered from payment reforms and budgetary pressures, but cancer care coordination is quickly coming into the spotlight as providers assume more accountability for costs and quality. 

To improve care, curb unnecessary spending, and increase patient and provider satisfaction, cancer providers must work to smooth patients’ care transitions. This study provides 21 best practices for looking inward and reaching outward to improve patient transitions.


Cross-continuum collaboration critical

Transitions are especially critical within oncology, where patients are highly vulnerable and routinely move across care settings. Cancer centers can take some steps on their own to identify and address transition problems, but they will also need to reach out to other entities to establish communication channels and set expectations for patient care.


Look inward to find transition opportunities

The first step toward improvement is scrutinizing the cancer program’s processes to understand potential problems. Upon identifying problem areas, some programs are engaging those at the center of care provision—patients and providers— in coordination efforts. 

We’ve seen that simply educating patients about what to expect at various sites of care can improve many transitions.

Signaling another opportunity, Oncology Roundtable survey data reveals that 54% of cancer programs that work with independent oncologists experience challenges coordinating transitions to and from their offices. One organization overcame this issue by launching a collaborative, cross-site effort to map patient flow and care coordination responsibilities.


Forge relationships outside the cancer center

Transitions can be particularly rough and disjointed as cancer patients move among the emergency department, hospital inpatient units, and hospice. 

Cancer centers must find ways to align more closely with providers in these settings to help them better manage cancer patients’ needs—continuity that improves patient care, decreases no-show rates, and increases patient satisfaction.

How are the best programs safeguarding these transitions? Some are establishing two-way communication channels, essential for ensuring care continuity and preventing patients from falling through the cracks. 

Others are developing cross-site protocols, such as guidelines to support ED triage decision making. The most intensive and highly coordinated efforts, meanwhile, cultivate a transitions-oriented culture.

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