Harold C. Simmons Comprehensive Cancer Center
Transitional Care Coordination
We understand that being treated for cancer can be difficult and confusing. This is particularly true when treatment is provided in multiple locations such as outpatient clinics, inpatient hospital rooms, a skilled nursing facility, a rehabilitation hospital, or even at home. At the Harold C. Simmons Comprehensive Cancer Center, we know that successful coordination of care requires detailed planning across these many different treatment locations.
Moving between care settings, such as from a hospital admission to home, is referred to as “transitions in care.” Oncology transitional care coordinators are medical social workers who work with a patient’s oncology team to ensure seamless transitions in care while providing emotional support for patients and families during a stressful time.
When to Contact a Transitional Care Coordinator
The good news is that patients don’t need to contact a transitional care coordinator. We come to patients when they are admitted to our hospital. The transitional care coordinators are part of the cancer care team and work with patients and families as needed to make sure that all aspects of their cancer care are coordinated and seamless.
The transitional care coordinator assists patients and their families by:
- Assisting the inpatient oncology medical team in determining a discharge plan that complements the oncology treatment plan
- Facilitating communication between the outpatient physician and the inpatient medical team
- Giving them one person to contact if they need answers to questions
- Helping them deal with the emotional aspects of care transitions
- Helping them identify community resources that can help
- Providing ongoing assistance following discharge until they see their outpatient oncologist