The results of this investigation made it possible to assess the quality of care transitions from the perspective of cancer patients discharged from hospital. Sociodemographic and clinical characteristics were also identified and compared to CTM-15 factor scores. Our key findings indicated poor scores for the care plan and assured preferences CTM factors highlighting the need for improvement. The overall average of the CTM was satisfactory. Similar values were obtained in others studies conducted in Brazil [16,8] indicating moderate quality in care transitions at the time of hospital discharge.
Our results corroborate with international data, as pointed out by the first Alberta´s Home to Hospital to Home Transitions Guideline, which indicates near 30 per cent of patients in Alberta experience a gap in care during their transition from hospital to home. To address this gap, the provincial government launched the guideline targeting a standard approach to transitions, which enables the understanding of care transition processes from all involved in a transition. Above all, improvement in patient outcomes, experience and satisfaction are expected. Also, the approach will bring provider satisfaction and enable a collaborative team attitude to providing patient-centered care [12].
In our study, among factors of the CTM, preparation for self-management obtained a satisfactory average. Self-management of your health condition is influenced by the understanding or not of the information provided by health professionals, as well as the attention given to clarifying the patient or family’s questions. This is an important component of care transitions that requires commitment from both, professionals and patient/family to avoid insecurity and uncertainties regarding the necessary care after discharge [5].
The literature also highlights that the patient's place of hospitalization is associated with the preparation for self-management of health after hospital discharge. A previous study [16] showed that patients hospitalized in clinical inpatient units evaluated this factor better, due to the availability of professionals and greater opportunities to prepare the patient for discharge. Furthermore, professionals see discharge planning as part of their work. However, for patients that remain several days in emergency department due to lack of hospital beds, aspects of care transitions become more complex, and a lower score can be attributed to insufficient time of health care providers to prepare the patient and family to be discharged. Overcrowding and excessive work overload also impact health care providers’ time. Cancer patients in our study were all from clinical and surgical inpatient units, which may explain the higher CTM-15 score regarding their perception of feeling better prepared to manage their health condition.
Aspects related to the CTM-15 factor, understanding of medications, was also evaluated in another study with patients with chronic disease [16], and was found to have the lowest average score of all CTM-15 factors. In contrast, the current study demonstrated that this factor was positively evaluated by cancer patients, with the highest average found among all factors of the CTM-15. This result corroborates with the literature, where adherence to medication is considered a priority by patients. In general, patients tend to value medication management more as compared to other health behaviors, such as exercise and diet after hospital discharge [7]. Studies have identified that the implementation of care protocols for medications based on scientific evidence that aim to avoid the occurrence of adverse events and maintain patient safety, are indispensable in all health institutions, as they improve care, organize health services, with the establishment of flows, and are imperative in improving the quality of care provided to the patient. In addition, having a routine review of medications and care plans by the interprofessional team helps to identify issues and the need for improvements in education for the patient and family [18]. Thus, information about medications, their use, dosage, and side effects are paramount for patients [19].
The factors of the CTM-15, care plan and assured preferences, were assessed as unsatisfactory by cancer patients. These results require strategies to overcome this gap in this study location. Similar results have also been reported in other surveys [16, 20].
Ensuring preferences in relation to the care process of cancer patients is paramount when making care decisions post-discharge. Considering these preferences is necessary to plan actions to provide patient-centered care. Therefore, including these individuals in the preparation of a care plan, where individual preferences and needs are taken into account, tends to minimize fragmented care and optimize discharge planning [16, 21].
Our study showed that the care plan was not prioritized in the care of cancer patients. However, a well-designed and individualized care plan would provide continuity of care, in addition to enabling an adequate care transition between the different health services in which this patient was receiving care. However, gaps and disarticulation in the health system in Brazil causes the lack of referrals and monitoring of health concerns and treatment [8]. Another Brazilian study observed that, through telephone contact between hospital nurses and primary health care nurses, for example, communication between services was strengthened and, consequently, the continuity of care for patients improved [22].
Ideally, advanced care planning, which can start at the time of hospitalization or even as an outpatient, guarantees an individualized care plan that includes patient/family preferences, instructions on medications, social support for access to health services, symptom warning signs and clinical monitoring. This makes the objectives of care clear and precise between the patient and health services, and between health care providers [5, 23]. Therefore, it is imperative that health institutions aim to promote adequate and safe care transitions for their patients. Ideally, through strategies aimed at health education and self-care planning, involving patients and health professionals in developing an individualized care plan that considers medication reconciliation and treatment adherence can result in reduced hospital readmissions [5].
The profile of the cancer patient identified in our research corroborates findings from other Brazilian studies, with a predominance of males, white people, with low education, over 50 years of age and stage III cancer diagnosis [24, 25]. Also, we identified a higher prevalence of patients with neoplasms of the digestive system (64%). Malignant neoplasms of the digestive tract occur frequently in the population and are practically incurable once spread throughout the body, since the late development of symptoms is a hallmark of this type of cancer. This is reflected in diagnoses in more advanced stages [25] and requires hospitalization for treatment. Still, the sociodemographic variables did not present statistically significant association with the CTM-15 score, converging with a study carried out in Israel with cancer patients, which also found no significant difference between groups [9].
Patients with primary cancer showed a statistically significant difference in the assured preferences factor of the CTM-15 (p = 0.044), when compared to the average of patients with secondary cancer. The other clinical variables did not show statistical differences related to the CTM-15 factors. Other studies carried out using CTM-15 in cancer patients that compared the groups also found no statistical difference [7, 9-11, 20]. Due to the lack of large studies with oncology patients and CTM measures, it is not possible to point out possible or potentially associated factors that could be addressed to explore possibilities for strengthening care transitions from hospital to community in this group of patients.
Cancer is a chronic condition, with psychological and physical changes, requiring complex and long-term care with the participation of multidisciplinary health professionals. Above this, oncology patients require access to the necessary drugs and equipment, and it is necessary that they, like their family, are fully attended to, through the provision of health education and the involvement of the patient and family in the preparation for self-management in health and social support [26]. Continuity of care is essential and requires connection with all points of the health care system to facilitate effective and comprehensive care aimed at treating health problems.
Care transitions are considered a complex process that requires coordination and communication between the people involved, using clinical protocols, in addition to the organization and integration across the entire health care system. Thus, effective care transitions still challenge the integration and continuity of care for all patients, but particularly for cancer patients, as found in this study.
Clinical implications
Our key findings indicated poor scores for the CTM factors of care plan and assured preferences, highlighting the need for improvement. Further studies are needed to understand the reasons why the secured preferences factor and the care plan have lower scores, which in practice make it difficult to provide or even prevent patient-centered care.
Study limitations
As limitations of the study, we highlight the cross-sectional design, in addition to the inclusion of only cancer patients admitted to a single hospital. Still, the results are important, as this is the first study conducted in Brazil with this profile of patients. From the analysis of these results, we suggest carrying out further research, applying mixed methods, for example, to try to understand, in depth, the reasons why the patients’ preferences and the care plan did not receive appropriate attention from professionals, which hinders or may even prevent patient-centered care. Furthermore, qualitative perspectives from patients and families could also be helpful.