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Navigating the Transition From Cancer Care to Primary Care: Assistance of a Survivorship Care Plan.

PURPOSE/OBJECTIVES: To examine symptom and quality-of-life (QOL) trajectories in breast cancer and lymphoma survivors enrolled in a survivorship navigation intervention and to explore patient, caregiver, and primary care provider (PCP) satisfaction with receipt of a survivorship care plan (SCP). 
. DESIGN: Prospective, cohort, longitudinal.
. SETTING: The Billings Clinic, an integrated cancer center in Montana. 
. SAMPLE: 67 patients with breast cancer or lymphoma who recently completed cancer treatment, along with 39 of their caregivers and 23 PCPs. 
. METHODS: Data collection at one, thr

Transition to 'Close Care' with a Joint Roadmap for Person-Centered and Integrated Care.

INTRODUCTION: Health and social services face increasing fragmentation and costs, underscoring the need to transition toward more person-centered and integrated care. The Swedish government's 'Close Care' [Nära vård] initiative promotes this transition by encouraging shared regional visions and roadmaps. However, translating a vision into practice remains challenging. This study aimed to explore the experiences of healthcare and social services stakeholders regarding the transition to Close Care, focusing on using a joint roadmap. METHODS: This qualitative study included three focus groups wi

Primary Care Clinician Perspectives on Barriers to Postpartum Transition to Primary Care.

Background: The transition from obstetric to primary care is often suboptimal, particularly for individuals with barriers to accessing care. We aimed to understand experiences of primary care clinicians regarding provision of care and their perceptions of barriers to the transition of care in this critical period. Methods: We conducted focus groups with primary care clinicians recruited from diverse, urban health care settings, including an academic medical center, private practice, and federally qualified health centers. Groups were conducted in person or virtually (December 2019 to February

Patient Perspectives on Transitions of Surgical Care: Examining the Complexities and Interdependencies of Care.

This study examined a thematic network aimed at identifying experiences that influence patients' outcomes (e.g., patients' satisfaction, anxiety, and discharge readiness) in an effort to improve care transitions and reduce patient burden. We drew upon the Sociology and Complexity Science Toolkit to analyze themes derived from 61 semistructured, longitudinal interviews with 20 patients undergoing either a benign or malignant colorectal resection (three interviews per patient over a 30-day after hospital discharge). Thematic interdependencies illustrate how most outcomes of care are significantl

SBAR checklist for the transition of care in nursing in the Pediatric Intensive Care Unit.

OBJECTIVE: To build and validate an instrument based on the SBAR mnemonic for the transition of care in Pediatric Intensive Care Units. METHOD: A methodological study based on Pasquali's framework, developed in three poles (theoretical, empirical, and analytical). Items were drafted via a scoping review (PRISMA-ScR). The instrument underwent content and face validation by 15 experts and semantic analysis by three nursing residents. Agreement was estimated using the CVI and Kappa coefficient (> 0.70). RESULTS: The final version was consolidated into five domains (Identification, Situation, Ba

Defining spine care: a framework for scope, standards, and bidirectional care transitions.

Modern spine care is increasingly fragmented across operative and nonoperative disciplines, with inconsistent terminology, variable procedural standards, and uneven referral thresholds. These limitations can lead to duplicated services, delayed escalation when structural disease is present, premature escalation when operative targets are absent, and prolonged episodes of low-value care. This manuscript presents an implementation-oriented conceptual framework designed to improve transition reliability across the spine-care continuum. The framework was developed through targeted narrative synthe

Transitioning to Palliative Care in an Italian Cardiac Intensive Care Unit Network.

BACKGROUND: Recent data indicate that end-of-life management for patients affected by acute decompensated heart failure in cardiac intensive care units is aggressive, with late or no engagement of palliative care teams. OBJECTIVE: To assess current palliative care and end-of-life practices in a contemporary Italian multicenter registry of patients with cardiogenic shock due to acute decompensated heart failure. METHODS: A survey-based approach was used to collect data on palliative care and end-of-life management practices. The AltShock-2 registry enrolled patients with cardiogenic shock fro

Transitions of care for advanced cancer in post-acute and long-term care.

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… Trust in our medical institutions to ensure basic transitional care competencies, enhanced coordination between PALTC and cancer subspecialties through comprehensive record-keeping, and collaboration with residents and their families will help close the gaps in quality of care faced by this population …

Redefining transition: Self-efficacy in urologic care.

Advances in pediatric urology have transformed once fatal, congenital anomalies into chronic, manageable conditions, creating a growing population of adults living with childhood-onset urologic disorders. Despite international transition initiatives, most readiness tools emphasize task completion rather than the acquisition of confidence, motivation, and adaptability required for sustained self-management. This review integrates evidence from behavioral science to propose an enhanced, self-efficacy-driven approach to transitional urology. Drawing on established health behavior change models in

A chronic care model for spina bifida transition.

Providing comprehensive transition care for adolescents and young adults with spina bifida (AYASB) requires a structured approach to addressing chronic condition management, self-management, care coordination, and health care navigation that is adaptable to the various levels of cognitive ability, physical function, and family/community environments within the population. This commentary (1) highlights AYASB transition program needs identified in the literature and within a local community, (2) analyzes advantages and limitations of published AYASB transition care models in addressing these ne

The Transitional Experience of Family Caring for Their Child With a Tracheostomy.

UNLABELLED: The purpose of this qualitative study was to describe the family experience of caring for their child with a tracheostomy due to a compromised airway during the transition from hospital to home, and to identify types of support that families request to be successful caregivers. DESIGN AND METHODS: This study used a qualitative descriptive design with focus groups to answer semi-structured interview questions. The investigators followed basic content analysis to interpret descriptive data using three-person consensus. RESULTS: Eighteen family members participated. Four themes emer

Anesthesia Care Transitions and Risk of Postoperative Complications.

BACKGROUND: A patient undergoing surgery may receive anesthesia care from several anesthesia providers. The safety of anesthesia care transitions has not been evaluated. Using unconditional and conditional multivariable logistic regression models, we tested whether the number of attending anesthesiologists involved in an operation was associated with postoperative complications. METHODS: In a cohort of patients undergoing elective colorectal surgical in an academic tertiary care center with a stable anesthesia care team model participating in the American College of Surgeons National Surgical

Organizing safe transitions from intensive care.

Background. Organizing and performing patient transfers in the continuum of care is part of the work of nurses and other staff of a multipro … he categories secure, encourage, and collaborate are strategies used in the three phases of the ICU transitional care process. The main category; a safe, interactive rehabilitation process, illustrated how all strategies were characterized by an intention to create and maintain safety during the process. A three-way interaction was described: between staff and pati …

Homelessness and the transition from foster care to adulthood.

Prior research suggests that homelessness is a significant problem among young people aging out of foster care. However, these studies have not attempted to identify potential risk or protective factors that might affect the likelihood of becoming homeless during the transition to adulthood. This paper uses data from a longitudinal study to examine both the occurrence and predictors of homelessness among a sample of young people from three Midwestern states who recently aged out of foster care.

Transitions of care: An aerodigestive provider assessment survey.

OBJECTIVE: To create, validate, and apply an aerodigestive provider assessment survey. METHODS: A survey assessing provider knowledge and current practice in the transition of patients with chronic aerodigestive disorders from pediatric to adult care was drafted by a multidisciplinary expert panel. Once agreement of the initial survey items was obtained, the survey was distributed to a national multidisciplinary panel of aerodigestive experts for review. Responses from the national panel were systematically quantified and a content validity index (CVI) was calculated. A final survey was devel

An Enhanced Postpartum Transition Program to Primary Care.

Background: Gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP) are risk factors for future cardiovascular disease, yet few individuals receive postpartum care with primary care clinicians (PCP). To facilitate transitions of care to PCPs and improve cardiovascular health monitoring within the first 13 months postpartum, we developed and piloted an enhanced postpartum referral pathway for patients with GDM or HDP. Methods: Eligible patients included those who received perinatal care at a large, urban, academic medical center, experienced GDM or HDP during their mos

Ischemic Stroke Management: Posthospitalization and Transition of Care.

Ischemic stroke is a major cause of morbidity and mortality worldwide. Ischemic stroke and transient ischemic attack exist on a continuum of the same disease process. Ischemic stroke is common, and more than 85% of stroke risk is attributed to modifiable risk factors. The initial management of acute stroke is usually performed in the emergency department and hospital settings. Family physicians have a key role in follow-up, ensuring that a complete diagnostic evaluation has been performed, addressing modifiable risk factors, facilitating rehabilitation, and managing chronic sequelae. Secondary

Case presentation and panel discussion: Transitions in care.

There is evidence that significant quality problems arise as patients transitions in care from one setting to another. Attention to nutrition during transitions of care is important to avoid complication. During the American Society for Parenteral and Enteral Nutrition 2022 preconference course, nutrition during transition of care from pediatric to adult care, from the intensive care unit to the hospital floors and from the hospital to home was addressed.

Transitioning patients with developmental disabilities to adult care.

The pre-visit questionnaire, instructive videos, and Web resources detailed here can help you play a pivotal role in planning, commencing, and solidifying this transition.