“…Despite numerous efforts put forth to better coordinate care and services for cancer patients, significant shortcomings remain at several levels, specifically in terms of hospital discharge planning, transfers within the same facility, transfers from one facility to another, and transition to the home (ISQ, 2014). The resources available also pose difficulties in terms of support and communication between professionals, at the screening and medical workup stages, during news of the diagnosis, treatment and palliative care (Ganz, Casillas, & Hahn, 2008;Garderet, Olivier, Najman, & Gorin, 2006;Hewitt & Simone, 1999;ISQ, 2014;Kantsiper et al, 2009). These problems are cause for concern given the high number of transitions and discharge plans cancer patients (inpatient and outpatient) experience during the care process (Burge, Lawson, & Critchley, 2005) and the impact they can have on health and well-being (Comité consultatif concernant les hospitalisations évitables, 2011; Davidson, Moore, MacMillan, & Wiens, 2004;Davies & Batehup, 2011).…”