Care Transition From the Perspectives of Oncological Patients and the Multiprofessional Care Team

BackgroundIntegration into the health system is essential for safe care and efficient use of resources.ObjectivesThe aims of this study were to analyze the transition of care from the perspective of adult patients with neoplasia of the digestive tract and the multiprofessional care team, identify factors that influence the transition of care, and, collectively with professionals, create actions to improve the transition of care at the study site.MethodsThe Care Transitions Measure-15 was administered in a mixed methods study, with a QUAN -> QUAL sequential explanatory approach. The principles of deliberative dialogue were used as a knowledge translation strategy, and data integration was carried out.ResultsThe average score of the Care Transitions Measure-15 considered satisfactory was 74.3. The care plan factor had an unsatisfactory score of 66. Strategies to improve the care transition were listed by the focus group participants, such as supplementary care protocol for patients with neoplasms of the digestive tract, and providing a single discharge plan containing all information relevant to the treatment and continuity of patient care.ConclusionThe low score for the care plan factor indicates weakness in the care transition.Implications for PracticeThe integrated analysis results indicated that the care transition can be improved by an educational process during discharge planning, implementation of protocols for patients with neoplasia of the digestive tract, and identification of a reference caregiver to help patients navigate the healthcare system.