Evaluating Long-Term Care Needs in Cancer Survivors: A Case-Mix System-Based Analysis

Evaluating Long-Term Care Needs in Cancer Survivors: A Case-Mix System-Based Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluating Long-Term Care Needs in Cancer Survivors: A Case-Mix System-Based Analysis Hui-wen Po, Ying-Chien Chu, Hui-Chen Tsai, Tzu-Yu Huang, Chung-Yu Chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7325521/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Advancements in cancer diagnosis, screening, and treatment have transformed cancer into a chronic condition, resulting in a growing population of survivors with long-term healthcare needs. Methods This retrospective descriptive study evaluated the discharge planning outcomes of cancer patients managed by discharge-planning nurses in 2024, with a focus on their long-term care (LTC) requirements using the Case-Mix System (CMS). Results Among 207 cancer patients analyzed, discharge outcomes included returning home (68.1%), transfer to LTC facilities (12.6%), transfer to another hospital (0.5%), and death (18.8%). Of the 167 patients who returned home or were transferred to care facilities, 75 (44.9%) applied for government-funded LTC services. Non-application reasons included full independence in activities of daily living (26.1%), ineligibility based on criteria (17.4%), and reliance on family or privately hired caregivers (56.5%). Based on CMS classification, LTC applicants were categorized as having mild (25.3%), moderate (48.0%), or severe disability (26.7%). Mildly disabled patients primarily required home-care support, while those with moderate disabilities had higher needs for combined home-care and respite services. Severely disabled patients showed the greatest reliance on respite care, reflecting substantial caregiver burden. Conclusions These findings underscore the heterogeneous LTC needs among discharged cancer patients and support the utility of the CMS as a comprehensive tool for guiding resource allocation, caregiver support, and policy planning. Cancer Long-Term Care Discharge Planning Case-Mix System (CMS) Disability Levels Caregiver Burden Figures Figure 1 Figure 2 Background Advances in cancer diagnosis, screening, and treatment have transformed cancer from an acute, often fatal illness into a chronic condition, contributing to rising survival rates and longer lifespans [ 1 , 2 ]. This shift has created a growing population of survivors facing long-term complications that extend beyond active treatment, including fatigue, cognitive decline, emotional distress, and reduced physical function [ 3 – 5 ]. Older adults, in particular, encounter heightened long-term care (LTC) needs due to comorbidities, polypharmacy, and functional limitations [ 6 , 7 ]. Despite these increasing demands, healthcare systems remain ill-equipped to provide comprehensive long-term support. Most resources and insurance coverage prioritize acute treatments while overlooking essential services such as home care, rehabilitation, and symptom management [ 1 – 3 ]. As the complexity of survivorship care grows, so does the need for multidimensional assessment tools capable of capturing functional and caregiving needs. Tools like the Holistic Needs Assessment, Geriatric 8, and predictive models have shown promise, yet standardized systems to stratify LTC requirements remain limited [ 7 , 8 ]. To address this gap, the current study adopts a localized adaptation of the Case-Mix System (CMS)—originally developed by the U.S. Centers for Medicare and Medicaid Services—to evaluate post-discharge LTC demands in Taiwanese cancer patients. This Taiwan-implemented CMS classification offers a structured framework to categorize patients by disability severity (mild, moderate, severe), supporting targeted resource planning, personalized care strategies, and improved outcomes for cancer survivors [ 9 ]. Materials and Methods Study Design and Participants This retrospective descriptive study analyzed discharge planning outcomes for cancer patients managed at the National Taiwan University Hospital Yunlin Branch between January and December 2024. Eligible participants were adult patients (≥ 18 years) with a confirmed diagnosis of solid tumors or hematological malignancies who completed acute inpatient care and received structured discharge planning services. Patients discharged against medical advice or lacking critical Case-Mix System (CMS) data were excluded. Cancer types included breast, lung, colorectal, hepatobiliary, hematologic, and other malignancies across stages I–IV (AJCC/UICC). The study was approved by the Institutional Review Board of National Taiwan University Hospital (IRB No. 202505089RIND). Data Sources and Collection Patient data were collected from the hospital’s electronic medical record (EMR) system and the LTC application database maintained by the hospital’s case management center. Collected data included patient demographics, clinical characteristics (cancer diagnosis, treatment modalities), discharge disposition, CMS disability classification, LTC application status, service types received, and documented reasons for not applying. Additional clinical variables such as comorbidities (e.g., diabetes, cardiovascular, neurological disorders) and duration since cancer diagnosis were also extracted to contextualize LTC needs. Role of Discharge-Planning Nurses Discharge-planning nurses at the NTUH Yunlin Branch are specially trained case managers responsible for coordinating pre-discharge assessments and transitional care plans. Their role includes evaluating patients' functional status using standardized tools (including ADL/IADL scales and CMS classification), educating families on LTC options, facilitating applications for government-funded LTC services, and ensuring safe transitions to home or care facilities. They serve as a central liaison among attending physicians, LTC agencies, and families, ensuring continuity of care and timely support services post-discharge. Statistical Analysis Descriptive statistics were utilized to summarize patient demographics, clinical characteristics, discharge outcomes, LTC service utilization, and disability levels classified by the Case-Mix System (CMS). Categorical variables were presented as frequencies and percentages. To strengthen analytical rigor, statistical comparisons of LTC service use among the three CMS disability groups (mild, moderate, severe) were performed using Chi-square tests. In cases where expected cell counts were below five, Fisher's exact tests were applied. Statistical significance was set at a p-value < 0.05. All statistical analyses were conducted using IBM SPSS Statistics software (version 25), facilitating validation of observed service utilization patterns across different disability severity levels. Results This study analyzed the discharge planning of cancer patients managed by discharge-planning nurses in 2024, enrolling a total of 207 cancer patients with discharge outcomes categorized as follows: 141 patients (68.1%) returned home, 26 patients (12.6%) transferred to long-term care facilities, 1 patient (0.5%) transferred to another hospital, and 39 patients (18.8%) deceased. The data indicate that the majority of cancer patients returned home following hospital discharge, highlighting home-based care as the primary mode of care after acute hospital treatment. 1. Utilization of Government-Funded Long-Term Care (LTC) Services Among the 167 cancer patients who returned home or transferred to care facilities, 75 (44.9%) applied for government-funded long-term care (LTC) services, indicating a substantial need for supportive LTC resources among cancer patients and their families post-discharge. The most common diagnosis category is hepatobiliary & pancreas (22.7%), followed by lower digestive tract (18.7%), head and neck (12.0%), and respiratory track (10.7%). Detailed cancer diagnosis categories among patients who applied for LTC services are summarized in Supplementary Table 1. In the ADL assessment, 16.0% of individuals (n = 12) were classified as totally dependent. The largest proportion fell into the severely dependent category (ADL score: 21–60), accounting for 41.3% (n = 31), followed by those with moderate dependence (ADL score: 61–90, n = 20, 26.7%). Mild dependence (ADL score: 91–100) was the least common, observed in 12 individuals (16.0%) (Fig. 1 A). In contrast, the IADL assessment showed the highest concentration in the 4-item category, with 37 participants (49.3%) able to independently perform four instrumental activities, suggesting a moderate level of functional independence. Fewer individuals were distributed across the remaining categories (1–3 and 5–8 items) (Fig. 1 B). These findings indicate that although many individuals require considerable support with basic daily functions, most still retain the capacity to manage a limited range of more complex, instrumental tasks. Analysis was conducted on 10 types of cancer diagnoses, and no statistically significant differences were observed in ADL, IADL, length of hospital stay, discharge disposition, or CMS classification across cancer types. However, when comparing average hospital stay between tumor types, patients with hematologic malignancies had a significantly longer hospitalization (mean: 68.20 ± 53.92 days) compared to those with solid tumors (mean: 29.42 ± 24.64 days), with a statistically significant difference (p = 0.03). Most individuals are cared for by family members (57.3%), while 17.3% rely on hired caregivers. Nearly half of the individuals (49.3%) are dependent in 4 IADL areas, and 14.7% are dependent in all 8 areas, indicating significant challenges in independent community living. Of the 92 patients who did not apply for LTC services, 24 (26.1%) were fully independent in Activities of Daily Living (ADL), 16 (17.4%) did not meet eligibility criteria (age below 65 without recognized disability), and the remaining 52 (56.5%) relied on family caregiving, privately hired 24-hour caregivers, or felt that available services did not align with their needs. This analysis underscores that, beyond eligibility constraints and sufficient self-care capabilities, family caregiving resources or privately hired care arrangements significantly influenced patients' decisions not to utilize government LTC services. 2. Analysis of LTC Needs by CMS (Case-Mix System) Levels This study utilized the CMS classification system (Centers for Medicare and Medicaid Services) to better understand the LTC needs of cancer patients based on their functional limitations after discharge. LTC applicants were classified by the Case-Mix System (CMS), including mild disability (levels 2–3, 25.3%), moderate disability (levels 4–6, 48%), and severe disability (levels 7–8, 26.7%) (Table 1 ). These findings indicate that patients with moderate disability (CMS 4–6) were the largest group among LTC applicants, followed by those with severe disability (CMS 7–8) and mild disability (CMS 2–3), respectively. Table 1 Distribution of Participants by Case-Mix System (CMS) Disability Level CMS Level Mild disability (Levels 2–3) Moderate disability (Levels 4–6) Severe disability (Levels 7–8) Total Number (%) 19 (25.3%) 36 (48.0%) 20 (26.7%) 75 3. LTC Services Requested by Patients at Different CMS Levels The detailed breakdown of LTC services requested by cancer patients according to their CMS classification is summarized below: Patients with mild disability (CMS levels 2–3) primarily requested home-care services such as bathing assistance, meal preparation, housekeeping, and support in social activities; they generally maintained considerable independence, partly relying on family caregivers with occasional respite support. Patients with moderate disability (CMS levels 4–6) exhibited significantly higher demands for home-care (77.8%) and respite services (72.2%) due to their reduced self-care capacity and increased caregiver burden, alongside greater dependency on transportation for medical follow-ups (36.1%), reflecting mobility limitations and the need for external support (Table 2 ). Table 2 Utilization of Long-Term Care (LTC) Services by Case-Mix System (CMS) Disability Levels LTC Service Type CMS Levels 2–3 (N = 19) CMS Levels 4–6 (N = 36) CMS Levels 7–8 (N = 20) Home care 11 (57.9%) 28 (77.8%) 5 (25.0%) Assistive devices 4 (21.1%) 7 (19.4%) 0 (0%) Home-based rehabilitation 0 (0%) 1 (2.8%) 3 (15.0%) Respite care 8 (42.1%) 26 (72.2%) 18 (90.0%) Transportation services 4 (21.1%) 13 (36.1%) 6 (30.0%) Barrier-free modifications 1 (5.3%) 2 (5.6%) 0 (0%) Patients with severe disability (CMS levels 7–8), fully dependent in activities of daily living, demonstrated the highest need for respite care (90.0%) due to substantial caregiving stress, with some patients also utilizing home-based rehabilitation services to address ongoing therapeutic needs despite their severe functional limitations (Fig. 2 ). Discussion This study provides a comprehensive analysis of cancer patients' long-term care (LTC) needs after hospital discharge, highlighting the relationship between disability levels, as classified by the Case-Mix System (CMS), and the demand for specific LTC services. The findings align with existing literature indicating that cancer has evolved from an acute, life-threatening illness to a chronic condition requiring ongoing healthcare support. As treatments advance and survival rates improve, a growing population of cancer survivors faces persistent physical, cognitive, psychological, and social challenges that necessitate LTC services. Our study shows that nearly half of discharged cancer patients required government-funded LTC services, reflecting a widespread need for structured caregiving support in this population [ 10 ]. This is consistent with previous studies reporting high rates of functional impairment and dependency among cancer survivors, especially older adults who often experience polypharmacy, physical limitations, and caregiver burden [ 11 ]. Among patients who did not seek government LTC services, the main reasons included sufficient functional independence, ineligibility due to age or disability criteria, and reliance on private or family-based care. These findings suggest that eligibility constraints and the availability of informal caregiving significantly influence LTC utilization, a trend also noted in prior research [ 12 ]. Monitoring these patients is essential to prevent unrecognized caregiver strain and unmet care needs. CMS-based disability classification revealed distinct LTC service utilization patterns. Mildly disabled patients primarily used basic home-care services, reflecting preserved autonomy and lower caregiver burden. Moderately disabled patients required more combined home-care and respite services, indicating increased caregiving demands and reduced self-care capacity. Severely disabled patients predominantly used respite care due to near-total dependency, consistent with studies linking greater disability with higher LTC needs [ 13 ]. These findings underscore the value of standardized, multidimensional assessment tools like CMS for guiding targeted interventions and resource allocation. The study also highlights systemic gaps in healthcare and LTC resource allocation, which often prioritize acute treatment over long-term supportive care. This aligns with previous findings on inadequate professional training, limited insurance coverage, and systemic unpreparedness for managing long-term survivorship care [ 14 ]. Future strategies should include enhancing education for healthcare providers and families, increasing awareness of available LTC resources, and advocating for policy reforms to ensure more comprehensive and accessible support [ 15 ]. Larger-scale, longitudinal studies are recommended to assess caregiver burden, patient quality of life, and the long-term outcomes of various LTC interventions. Several limitations should be noted. Accurate CMS classification depended on comprehensive discharge assessments, and inconsistent documentation—especially in complex cases—may have led to misclassification. The retrospective design limited control over data completeness and quality. Additionally, the study did not statistically adjust for confounding factors such as cancer type, stage, treatment, or comorbidities, although these were descriptively documented. Future prospective studies should incorporate statistical controls or subgroup analyses to clarify these influences [ 8 , 13 ]. Clinically, integrating CMS into discharge planning can support early identification of LTC needs and timely referrals. Regular post-discharge follow-up may further assist caregivers and identify unmet needs [ 1 , 3 , 11 , 14 ]. CMS classification can also guide structured, needs-based assessments at discharge, enabling tailored care planning based on disability severity. This approach supports prioritization of high-burden cases for intensive services while optimizing resource allocation for those with lower needs. The findings also have implications for workforce development and education. Training programs can incorporate CMS-guided care planning to enhance provider competence in identifying and addressing LTC needs. Additionally, these insights can inform the development of decision aids—such as checklists, educational materials, and digital tools—to help families navigate LTC options and eligibility, promoting shared decision-making and care continuity. Future research should include longitudinal cohort studies to track changes in LTC needs, caregiver burden, and patient quality of life over time. Integrating qualitative methods, such as interviews and focus groups, can further enrich understanding of the lived experiences of patients and caregivers, offering deeper insights into service adequacy, satisfaction, and barriers to access [ 4 , 9 ]. Conclusion This study underscores the value of the Case-Mix System (CMS) as a scalable and practical tool for identifying long-term care (LTC) needs at hospital discharge. Incorporating CMS classification into discharge planning enables early functional assessment, stratifies patients by disability severity, and facilitates timely referrals—particularly for patients with moderate to severe impairments who require home care or respite services. Early CMS-based assessment supports proactive LTC application, reducing delays in care, caregiver burden, and potential readmissions. As a decision-support tool, it also informs resource allocation and service prioritization, enhancing the efficiency of transitional care planning. Beyond discharge, structured post-discharge follow-up is critical. Periodic reassessment of patient function and caregiver stress—through multidisciplinary outreach such as nurse-led calls, telehealth check-ins, or home visits—ensures that care plans remain responsive to changing needs and are embedded within survivorship pathways. To strengthen implementation, CMS-based assessment protocols can be integrated into electronic health records to support clinical workflows. Additionally, targeted training for healthcare providers and caregivers—focusing on CMS interpretation, LTC eligibility, and service coordination—can facilitate shared decision-making and care continuity. Tools such as digital checklists, coordination apps, and eligibility guides tailored to CMS levels may further streamline planning and improve access. These strategies help bridge the gap between acute care and community-based LTC, fostering a more coordinated, responsive, and patient-centered approach to cancer survivorship. Abbreviations · ADL: Activities of Daily Living · AJCC: American Joint Committee on Cancer · CMS: Case-Mix System · EMR: Electronic Medical Record · IADL: Instrumental Activities of Daily Living · LTC: Long-Term Care · UICC: Union for International Cancer Control Declarations Ethics approval and consent to participate This study was approved by the Institutional Review Board (IRB) of National Taiwan University Hospital (IRB No. 202505089RIND) and conducted in accordance with the Declaration of Helsinki. Due to the retrospective nature of the study, the requirement for written informed consent was waived by the IRB. Consent for publication Not applicable. Availability of data and materials All data generated or analysed during this study are included in this published article and its supplementary information file. Competing interests The authors declare that they have no competing interests. Funding No funding was received to support this research. Authors' contributions HWP wrote the main manuscript text and preliminary data analysis. YCC, HCT, and TYH conducted data collection. CYC designed and supervised the study, and revised the manuscript. All authors reviewed the manuscript. Clinical trial number: not applicable. Acknowledgements We would like to express our gratitude to the Cancer Registry of the Oncology Center at National Taiwan University Hospital Yunlin Branch for their assistance in providing the data used in this study. References Lin CC. When Cancer Care Becomes a Long-term Care Issue: Are We Ready? Cancer Nurs. 2017 Sep/Oct;40(5):341–342. Gopal DP, de Rooij BH, Ezendam NP, Taylor SJ. Delivering long-term cancer care in primary care. Br J Gen Pract. 2020;70(694):226–227. Rubinstein EB, Miller WL, Hudson SV, Howard J, O'Malley D, Tsui J, Lee HS, Bator A, Crabtree BF. Cancer Survivorship Care in Advanced Primary Care Practices: A Qualitative Study of Challenges and Opportunities. JAMA Intern Med. 2017;177(12):1726–1732 Schmidt ME, Goldschmidt S, Hermann S, Steindorf K. Late effects, long-term problems and unmet needs of cancer survivors. Int J Cancer. 2022;151(8):1280–1290. Stamp E, Clarke G, Wright P, Velikova G, Crossfield SSR, Zucker K, McInerney C, Bojke C, Martin A, Baxter P, Woroncow B, Wilson D, Warrington L, Absolom K, Burke D, Stables GI, Mitra A, Hutson R, Glaser AW, Hall G. Collection of cancer Patient Reported Outcome Measures (PROMS) to link with primary and secondary electronic care records to understand and improve long term cancer outcomes: A protocol paper. PLoS One. 2022;17(4):e0266804. doi: 10.1371/journal.pone.0266804 . Villani ER, Fusco D, Franza L, Onder G, Bernabei R, Colloca GF. Characteristics of patients with cancer in European long-term care facilities. Aging Clin Exp Res. 2022;34(3):671–678. Depoorter V, Vanschoenbeek K, Decoster L, Silversmit G, Debruyne PR, De Groof I, Bron D, Cornélis F, Luce S, Focan C, Verschaeve V, Debugne G, Langenaeken C, Van Den Bulck H, Goeminne JC, Teurfs W, Jerusalem G, Schrijvers D, Petit B, Rasschaert M, Praet JP, Vandenborre K, Milisen K, Flamaing J, Kenis C, Verdoodt F, Wildiers H. Long-term health-care utilisation in older patients with cancer and the association with the Geriatric 8 screening tool: a retrospective analysis using linked clinical and population-based data in Belgium. Lancet Healthy Longev. 2023;4(7):e326-e336. Chien SC, Chang YH, Yen CM, Chen YE, Liu CC, Hsiao YP, Yang PY, Lin HM, Lu XH, Wu IC, Hsu CC, Chiou HY, Chung RH. Predicting Long-Term Care Service Demands for Cancer Patients: A Machine Learning Approach. Cancers (Basel). 2023;15(18):4598. Tsui J, Hudson SV, Rubinstein EB, Howard J, Hicks E, Kieber-Emmons A, Bator A, Lee HS, Ferrante J, Crabtree BF. A mixed-methods analysis of the capacity of the Patient-Centered Medical Home to implement care coordination services for cancer survivors. Transl Behav Med. 2018;8(3):319–327. Lin WC, Tsao CJ. Information needs of family caregivers of terminal cancer patients in Taiwan. Am J Hosp Palliat Care. 2004 Nov-Dec;21(6):438–44. Kadambi S, Loh KP, Dunne R, Magnuson A, Maggiore R, Zittel J, Flannery M, Inglis J, Gilmore N, Mohamed M, Ramsdale E, Mohile S. Older adults with cancer and their caregivers - current landscape and future directions for clinical care. Nat Rev Clin Oncol. 2020;17(12):742–755. Yoo BK, Bhattacharya J, McDonald KM, Garber AM. Impacts of informal caregiver availability on long-term care expenditures in OECD countries. Health Serv Res. 2004;39(6 Pt 2):1971–92. Zhou M, Zha F, Liu F, Zhou J, Liu X, Li J, Yang Q, Zhang Z, Xiong F, Hou D, Weng H, Wang Y. Long-term care status for the elderly with different levels of physical ability: a cross-sectional survey in first-tier cities of China. BMC Health Serv Res. 2023;23(1):953. Dulko D, Pace CM, Dittus KL, Sprague BL, Pollack LA, Hawkins NA, Geller BM. Barriers and facilitators to implementing cancer survivorship care plans. Oncol Nurs Forum. 2013;40(6):575–80. Liu D. Addressing healthcare disparities in long-term care: challenges and strategies. Managing Quality and Safety in Long-Term Care. 2024. Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable1.docx Supplementary Table 1. Distribution of Cancer Diagnosis Categories Among Patients Applying for Long-Term Care Services Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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14:59:57","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":72497,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7325521/v1/61effee0a7406448c2fd772f.html"},{"id":93243695,"identity":"5b4dc3e4-f13f-48ef-9a0a-933839bda3d5","added_by":"auto","created_at":"2025-10-10 14:59:57","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":152369,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of Functional Dependence Among Participants Assessed by Activities of Daily Living (ADL) scores and Instrumental Activities of Daily Living (IADL) scores\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(A) Bar chart showing the distribution of Activities of Daily Living (ADL) scores. The majority of individuals were categorized as having severe dependence (n = 31), followed by moderate dependence (n = 20), while few participants were fully independent or mildly dependent. (B) Bar chart illustrating the distribution of Instrumental Activities of Daily Living (IADL) scores based on the number of items performed independently. Most individuals were capable of performing 4 items (n = 37), indicating a moderate level of instrumental functioning, while fewer participants achieved full independence (8 items) or demonstrated minimal capability (1–2 items).\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7325521/v1/64383ace43d2c289fb5cf51a.jpeg"},{"id":93243697,"identity":"3a0b9fdb-6dbd-4e2b-9236-0a95c3ccbe5b","added_by":"auto","created_at":"2025-10-10 14:59:57","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":225870,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eUtilization Rates of Long-Term Care (LTC) Services by Case-Mix System (CMS) Disability Levels.\u003c/strong\u003e Bar chart illustrating the percentage of participants utilizing various LTC services, stratified by CMS disability levels. CMS Levels 2–3 represent mild disability (blue), Levels 4–6 moderate disability (orange), and Levels 7–8 severe disability (green). Respite care showed the highest overall utilization, particularly among those with severe disability (90.0%). Home care usage was most prominent in the moderate disability group (77.8%). In contrast, assistive devices and barrier-free modifications were minimally used across all groups, and home-based rehabilitation was more common in the severely disabled group.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7325521/v1/1e721822868c7aaefeb0f710.jpeg"},{"id":98776206,"identity":"6b1a5e25-7181-469c-bc01-8e471bb057e0","added_by":"auto","created_at":"2025-12-22 12:22:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1114333,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7325521/v1/fea6085b-fe86-4c49-98a2-4b4c4ad5053f.pdf"},{"id":93243694,"identity":"4496ef60-c7f0-4997-aa10-bc47dba2ebec","added_by":"auto","created_at":"2025-10-10 14:59:57","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15706,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary Table 1. Distribution of Cancer Diagnosis Categories Among Patients Applying for Long-Term Care Services\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7325521/v1/b637cff63fddb62401905ce4.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluating Long-Term Care Needs in Cancer Survivors: A Case-Mix System-Based Analysis","fulltext":[{"header":"Background","content":"\u003cp\u003eAdvances in cancer diagnosis, screening, and treatment have transformed cancer from an acute, often fatal illness into a chronic condition, contributing to rising survival rates and longer lifespans [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This shift has created a growing population of survivors facing long-term complications that extend beyond active treatment, including fatigue, cognitive decline, emotional distress, and reduced physical function [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Older adults, in particular, encounter heightened long-term care (LTC) needs due to comorbidities, polypharmacy, and functional limitations [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite these increasing demands, healthcare systems remain ill-equipped to provide comprehensive long-term support. Most resources and insurance coverage prioritize acute treatments while overlooking essential services such as home care, rehabilitation, and symptom management [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. As the complexity of survivorship care grows, so does the need for multidimensional assessment tools capable of capturing functional and caregiving needs. Tools like the Holistic Needs Assessment, Geriatric 8, and predictive models have shown promise, yet standardized systems to stratify LTC requirements remain limited [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo address this gap, the current study adopts a localized adaptation of the Case-Mix System (CMS)\u0026mdash;originally developed by the U.S. Centers for Medicare and Medicaid Services\u0026mdash;to evaluate post-discharge LTC demands in Taiwanese cancer patients. This Taiwan-implemented CMS classification offers a structured framework to categorize patients by disability severity (mild, moderate, severe), supporting targeted resource planning, personalized care strategies, and improved outcomes for cancer survivors [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Participants\u003c/h2\u003e\u003cp\u003eThis retrospective descriptive study analyzed discharge planning outcomes for cancer patients managed at the National Taiwan University Hospital Yunlin Branch between January and December 2024. Eligible participants were adult patients (\u0026ge;\u0026thinsp;18 years) with a confirmed diagnosis of solid tumors or hematological malignancies who completed acute inpatient care and received structured discharge planning services. Patients discharged against medical advice or lacking critical Case-Mix System (CMS) data were excluded. Cancer types included breast, lung, colorectal, hepatobiliary, hematologic, and other malignancies across stages I\u0026ndash;IV (AJCC/UICC). The study was approved by the Institutional Review Board of National Taiwan University Hospital (IRB No. 202505089RIND).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Sources and Collection\u003c/h3\u003e\n\u003cp\u003ePatient data were collected from the hospital\u0026rsquo;s electronic medical record (EMR) system and the LTC application database maintained by the hospital\u0026rsquo;s case management center. Collected data included patient demographics, clinical characteristics (cancer diagnosis, treatment modalities), discharge disposition, CMS disability classification, LTC application status, service types received, and documented reasons for not applying. Additional clinical variables such as comorbidities (e.g., diabetes, cardiovascular, neurological disorders) and duration since cancer diagnosis were also extracted to contextualize LTC needs.\u003c/p\u003e\n\u003ch3\u003eRole of Discharge-Planning Nurses\u003c/h3\u003e\n\u003cp\u003eDischarge-planning nurses at the NTUH Yunlin Branch are specially trained case managers responsible for coordinating pre-discharge assessments and transitional care plans. Their role includes evaluating patients' functional status using standardized tools (including ADL/IADL scales and CMS classification), educating families on LTC options, facilitating applications for government-funded LTC services, and ensuring safe transitions to home or care facilities. They serve as a central liaison among attending physicians, LTC agencies, and families, ensuring continuity of care and timely support services post-discharge.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics were utilized to summarize patient demographics, clinical characteristics, discharge outcomes, LTC service utilization, and disability levels classified by the Case-Mix System (CMS). Categorical variables were presented as frequencies and percentages. To strengthen analytical rigor, statistical comparisons of LTC service use among the three CMS disability groups (mild, moderate, severe) were performed using Chi-square tests. In cases where expected cell counts were below five, Fisher's exact tests were applied. Statistical significance was set at a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. All statistical analyses were conducted using IBM SPSS Statistics software (version 25), facilitating validation of observed service utilization patterns across different disability severity levels.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis study analyzed the discharge planning of cancer patients managed by discharge-planning nurses in 2024, enrolling a total of 207 cancer patients with discharge outcomes categorized as follows: 141 patients (68.1%) returned home, 26 patients (12.6%) transferred to long-term care facilities, 1 patient (0.5%) transferred to another hospital, and 39 patients (18.8%) deceased. The data indicate that the majority of cancer patients returned home following hospital discharge, highlighting home-based care as the primary mode of care after acute hospital treatment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Utilization of Government-Funded Long-Term Care (LTC) Services\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 167 cancer patients who returned home or transferred to care facilities, 75 (44.9%) applied for government-funded long-term care (LTC) services, indicating a substantial need for supportive LTC resources among cancer patients and their families post-discharge. The most common diagnosis category is hepatobiliary \u0026amp; pancreas (22.7%), followed by lower digestive tract (18.7%), head and neck (12.0%), and respiratory track (10.7%). Detailed cancer diagnosis categories among patients who applied for LTC services are summarized in Supplementary Table\u0026nbsp;1. In the ADL assessment, 16.0% of individuals (n\u0026thinsp;=\u0026thinsp;12) were classified as totally dependent. The largest proportion fell into the severely dependent category (ADL score: 21\u0026ndash;60), accounting for 41.3% (n\u0026thinsp;=\u0026thinsp;31), followed by those with moderate dependence (ADL score: 61\u0026ndash;90, n\u0026thinsp;=\u0026thinsp;20, 26.7%). Mild dependence (ADL score: 91\u0026ndash;100) was the least common, observed in 12 individuals (16.0%) (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eA). In contrast, the IADL assessment showed the highest concentration in the 4-item category, with 37 participants (49.3%) able to independently perform four instrumental activities, suggesting a moderate level of functional independence. Fewer individuals were distributed across the remaining categories (1\u0026ndash;3 and 5\u0026ndash;8 items) (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eB). These findings indicate that although many individuals require considerable support with basic daily functions, most still retain the capacity to manage a limited range of more complex, instrumental tasks.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnalysis was conducted on 10 types of cancer diagnoses, and no statistically significant differences were observed in ADL, IADL, length of hospital stay, discharge disposition, or CMS classification across cancer types. However, when comparing average hospital stay between tumor types, patients with hematologic malignancies had a significantly longer hospitalization (mean: 68.20\u0026thinsp;\u0026plusmn;\u0026thinsp;53.92 days) compared to those with solid tumors (mean: 29.42\u0026thinsp;\u0026plusmn;\u0026thinsp;24.64 days), with a statistically significant difference (p\u0026thinsp;=\u0026thinsp;0.03).\u003c/p\u003e\n\u003cp\u003eMost individuals are cared for by family members (57.3%), while 17.3% rely on hired caregivers. Nearly half of the individuals (49.3%) are dependent in 4 IADL areas, and 14.7% are dependent in all 8 areas, indicating significant challenges in independent community living. Of the 92 patients who did not apply for LTC services, 24 (26.1%) were fully independent in Activities of Daily Living (ADL), 16 (17.4%) did not meet eligibility criteria (age below 65 without recognized disability), and the remaining 52 (56.5%) relied on family caregiving, privately hired 24-hour caregivers, or felt that available services did not align with their needs. This analysis underscores that, beyond eligibility constraints and sufficient self-care capabilities, family caregiving resources or privately hired care arrangements significantly influenced patients' decisions not to utilize government LTC services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Analysis of LTC Needs by CMS (Case-Mix System) Levels\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study utilized the CMS classification system (Centers for Medicare and Medicaid Services) to better understand the LTC needs of cancer patients based on their functional limitations after discharge. LTC applicants were classified by the Case-Mix System (CMS), including mild disability (levels 2\u0026ndash;3, 25.3%), moderate disability (levels 4\u0026ndash;6, 48%), and severe disability (levels 7\u0026ndash;8, 26.7%) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). These findings indicate that patients with moderate disability (CMS 4\u0026ndash;6) were the largest group among LTC applicants, followed by those with severe disability (CMS 7\u0026ndash;8) and mild disability (CMS 2\u0026ndash;3), respectively.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDistribution of Participants by Case-Mix System (CMS) Disability Level\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCMS Level\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMild disability (Levels 2\u0026ndash;3)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eModerate disability (Levels 4\u0026ndash;6)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSevere disability (Levels 7\u0026ndash;8)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNumber (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19 (25.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36 (48.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20 (26.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e75\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e3. LTC Services Requested by Patients at Different CMS Levels\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe detailed breakdown of LTC services requested by cancer patients according to their CMS classification is summarized below: Patients with mild disability (CMS levels 2\u0026ndash;3) primarily requested home-care services such as bathing assistance, meal preparation, housekeeping, and support in social activities; they generally maintained considerable independence, partly relying on family caregivers with occasional respite support. Patients with moderate disability (CMS levels 4\u0026ndash;6) exhibited significantly higher demands for home-care (77.8%) and respite services (72.2%) due to their reduced self-care capacity and increased caregiver burden, alongside greater dependency on transportation for medical follow-ups (36.1%), reflecting mobility limitations and the need for external support (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eUtilization of Long-Term Care (LTC) Services by Case-Mix System (CMS) Disability Levels\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eLTC Service Type\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCMS Levels 2\u0026ndash;3 (N\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCMS Levels 4\u0026ndash;6 (N\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCMS Levels 7\u0026ndash;8 (N\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHome care\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e11 (57.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e28 (77.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e5 (25.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAssistive devices\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e4 (21.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e7 (19.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHome-based rehabilitation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e1 (2.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e3 (15.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRespite care\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e8 (42.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e26 (72.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e18 (90.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTransportation services\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e4 (21.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e13 (36.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e6 (30.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBarrier-free modifications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e1 (5.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2 (5.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003ePatients with severe disability (CMS levels 7\u0026ndash;8), fully dependent in activities of daily living, demonstrated the highest need for respite care (90.0%) due to substantial caregiving stress, with some patients also utilizing home-based rehabilitation services to address ongoing therapeutic needs despite their severe functional limitations (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e This study provides a comprehensive analysis of cancer patients' long-term care (LTC) needs after hospital discharge, highlighting the relationship between disability levels, as classified by the Case-Mix System (CMS), and the demand for specific LTC services. The findings align with existing literature indicating that cancer has evolved from an acute, life-threatening illness to a chronic condition requiring ongoing healthcare support. As treatments advance and survival rates improve, a growing population of cancer survivors faces persistent physical, cognitive, psychological, and social challenges that necessitate LTC services. Our study shows that nearly half of discharged cancer patients required government-funded LTC services, reflecting a widespread need for structured caregiving support in this population [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This is consistent with previous studies reporting high rates of functional impairment and dependency among cancer survivors, especially older adults who often experience polypharmacy, physical limitations, and caregiver burden [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Among patients who did not seek government LTC services, the main reasons included sufficient functional independence, ineligibility due to age or disability criteria, and reliance on private or family-based care. These findings suggest that eligibility constraints and the availability of informal caregiving significantly influence LTC utilization, a trend also noted in prior research [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Monitoring these patients is essential to prevent unrecognized caregiver strain and unmet care needs.\u003c/p\u003e\u003cp\u003eCMS-based disability classification revealed distinct LTC service utilization patterns. Mildly disabled patients primarily used basic home-care services, reflecting preserved autonomy and lower caregiver burden. Moderately disabled patients required more combined home-care and respite services, indicating increased caregiving demands and reduced self-care capacity. Severely disabled patients predominantly used respite care due to near-total dependency, consistent with studies linking greater disability with higher LTC needs [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These findings underscore the value of standardized, multidimensional assessment tools like CMS for guiding targeted interventions and resource allocation. The study also highlights systemic gaps in healthcare and LTC resource allocation, which often prioritize acute treatment over long-term supportive care. This aligns with previous findings on inadequate professional training, limited insurance coverage, and systemic unpreparedness for managing long-term survivorship care [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Future strategies should include enhancing education for healthcare providers and families, increasing awareness of available LTC resources, and advocating for policy reforms to ensure more comprehensive and accessible support [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Larger-scale, longitudinal studies are recommended to assess caregiver burden, patient quality of life, and the long-term outcomes of various LTC interventions.\u003c/p\u003e\u003cp\u003eSeveral limitations should be noted. Accurate CMS classification depended on comprehensive discharge assessments, and inconsistent documentation\u0026mdash;especially in complex cases\u0026mdash;may have led to misclassification. The retrospective design limited control over data completeness and quality. Additionally, the study did not statistically adjust for confounding factors such as cancer type, stage, treatment, or comorbidities, although these were descriptively documented. Future prospective studies should incorporate statistical controls or subgroup analyses to clarify these influences [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eClinically, integrating CMS into discharge planning can support early identification of LTC needs and timely referrals. Regular post-discharge follow-up may further assist caregivers and identify unmet needs [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. CMS classification can also guide structured, needs-based assessments at discharge, enabling tailored care planning based on disability severity. This approach supports prioritization of high-burden cases for intensive services while optimizing resource allocation for those with lower needs. The findings also have implications for workforce development and education. Training programs can incorporate CMS-guided care planning to enhance provider competence in identifying and addressing LTC needs. Additionally, these insights can inform the development of decision aids\u0026mdash;such as checklists, educational materials, and digital tools\u0026mdash;to help families navigate LTC options and eligibility, promoting shared decision-making and care continuity. Future research should include longitudinal cohort studies to track changes in LTC needs, caregiver burden, and patient quality of life over time. Integrating qualitative methods, such as interviews and focus groups, can further enrich understanding of the lived experiences of patients and caregivers, offering deeper insights into service adequacy, satisfaction, and barriers to access [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study underscores the value of the Case-Mix System (CMS) as a scalable and practical tool for identifying long-term care (LTC) needs at hospital discharge. Incorporating CMS classification into discharge planning enables early functional assessment, stratifies patients by disability severity, and facilitates timely referrals\u0026mdash;particularly for patients with moderate to severe impairments who require home care or respite services. Early CMS-based assessment supports proactive LTC application, reducing delays in care, caregiver burden, and potential readmissions. As a decision-support tool, it also informs resource allocation and service prioritization, enhancing the efficiency of transitional care planning. Beyond discharge, structured post-discharge follow-up is critical. Periodic reassessment of patient function and caregiver stress\u0026mdash;through multidisciplinary outreach such as nurse-led calls, telehealth check-ins, or home visits\u0026mdash;ensures that care plans remain responsive to changing needs and are embedded within survivorship pathways.\u003c/p\u003e\u003cp\u003eTo strengthen implementation, CMS-based assessment protocols can be integrated into electronic health records to support clinical workflows. Additionally, targeted training for healthcare providers and caregivers\u0026mdash;focusing on CMS interpretation, LTC eligibility, and service coordination\u0026mdash;can facilitate shared decision-making and care continuity. Tools such as digital checklists, coordination apps, and eligibility guides tailored to CMS levels may further streamline planning and improve access. These strategies help bridge the gap between acute care and community-based LTC, fostering a more coordinated, responsive, and patient-centered approach to cancer survivorship.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e·\u0026nbsp; ADL: Activities of Daily Living\u003c/p\u003e\n\u003cp\u003e·\u0026nbsp; AJCC: American Joint Committee on Cancer\u003c/p\u003e\n\u003cp\u003e·\u0026nbsp; CMS: Case-Mix System\u003c/p\u003e\n\u003cp\u003e·\u0026nbsp; EMR: Electronic Medical Record\u003c/p\u003e\n\u003cp\u003e·\u0026nbsp; IADL: Instrumental Activities of Daily Living\u003c/p\u003e\n\u003cp\u003e·\u0026nbsp; LTC: Long-Term Care\u003c/p\u003e\n\u003cp\u003e· \u0026nbsp;UICC: Union for International Cancer Control\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board (IRB) of National Taiwan University Hospital (IRB No. 202505089RIND) and conducted in accordance with the Declaration of Helsinki. Due to the retrospective nature of the study, the requirement for written informed consent was waived by the IRB.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article and its supplementary information file.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNo funding was received to support this research.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHWP wrote the main manuscript text and preliminary data analysis. YCC, HCT, and TYH conducted data collection. CYC designed and supervised the study, and revised the manuscript. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our gratitude to the Cancer Registry of the Oncology Center at National Taiwan University Hospital Yunlin Branch for their assistance in providing the data used in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLin CC. When Cancer Care Becomes a Long-term Care Issue: Are We Ready? Cancer Nurs. 2017 Sep/Oct;40(5):341\u0026ndash;342.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGopal DP, de Rooij BH, Ezendam NP, Taylor SJ. Delivering long-term cancer care in primary care. Br J Gen Pract. 2020;70(694):226\u0026ndash;227.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRubinstein EB, Miller WL, Hudson SV, Howard J, O'Malley D, Tsui J, Lee HS, Bator A, Crabtree BF. Cancer Survivorship Care in Advanced Primary Care Practices: A Qualitative Study of Challenges and Opportunities. JAMA Intern Med. 2017;177(12):1726\u0026ndash;1732\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchmidt ME, Goldschmidt S, Hermann S, Steindorf K. Late effects, long-term problems and unmet needs of cancer survivors. Int J Cancer. 2022;151(8):1280\u0026ndash;1290.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStamp E, Clarke G, Wright P, Velikova G, Crossfield SSR, Zucker K, McInerney C, Bojke C, Martin A, Baxter P, Woroncow B, Wilson D, Warrington L, Absolom K, Burke D, Stables GI, Mitra A, Hutson R, Glaser AW, Hall G. Collection of cancer Patient Reported Outcome Measures (PROMS) to link with primary and secondary electronic care records to understand and improve long term cancer outcomes: A protocol paper. PLoS One. 2022;17(4):e0266804. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0266804\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0266804\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVillani ER, Fusco D, Franza L, Onder G, Bernabei R, Colloca GF. Characteristics of patients with cancer in European long-term care facilities. Aging Clin Exp Res. 2022;34(3):671\u0026ndash;678.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDepoorter V, Vanschoenbeek K, Decoster L, Silversmit G, Debruyne PR, De Groof I, Bron D, Corn\u0026eacute;lis F, Luce S, Focan C, Verschaeve V, Debugne G, Langenaeken C, Van Den Bulck H, Goeminne JC, Teurfs W, Jerusalem G, Schrijvers D, Petit B, Rasschaert M, Praet JP, Vandenborre K, Milisen K, Flamaing J, Kenis C, Verdoodt F, Wildiers H. Long-term health-care utilisation in older patients with cancer and the association with the Geriatric 8 screening tool: a retrospective analysis using linked clinical and population-based data in Belgium. Lancet Healthy Longev. 2023;4(7):e326-e336.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChien SC, Chang YH, Yen CM, Chen YE, Liu CC, Hsiao YP, Yang PY, Lin HM, Lu XH, Wu IC, Hsu CC, Chiou HY, Chung RH. Predicting Long-Term Care Service Demands for Cancer Patients: A Machine Learning Approach. Cancers (Basel). 2023;15(18):4598.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTsui J, Hudson SV, Rubinstein EB, Howard J, Hicks E, Kieber-Emmons A, Bator A, Lee HS, Ferrante J, Crabtree BF. A mixed-methods analysis of the capacity of the Patient-Centered Medical Home to implement care coordination services for cancer survivors. Transl Behav Med. 2018;8(3):319\u0026ndash;327.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLin WC, Tsao CJ. Information needs of family caregivers of terminal cancer patients in Taiwan. Am J Hosp Palliat Care. 2004 Nov-Dec;21(6):438\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKadambi S, Loh KP, Dunne R, Magnuson A, Maggiore R, Zittel J, Flannery M, Inglis J, Gilmore N, Mohamed M, Ramsdale E, Mohile S. Older adults with cancer and their caregivers - current landscape and future directions for clinical care. Nat Rev Clin Oncol. 2020;17(12):742\u0026ndash;755.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYoo BK, Bhattacharya J, McDonald KM, Garber AM. Impacts of informal caregiver availability on long-term care expenditures in OECD countries. Health Serv Res. 2004;39(6 Pt 2):1971\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhou M, Zha F, Liu F, Zhou J, Liu X, Li J, Yang Q, Zhang Z, Xiong F, Hou D, Weng H, Wang Y. Long-term care status for the elderly with different levels of physical ability: a cross-sectional survey in first-tier cities of China. BMC Health Serv Res. 2023;23(1):953.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDulko D, Pace CM, Dittus KL, Sprague BL, Pollack LA, Hawkins NA, Geller BM. Barriers and facilitators to implementing cancer survivorship care plans. Oncol Nurs Forum. 2013;40(6):575\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu D. Addressing healthcare disparities in long-term care: challenges and strategies. Managing Quality and Safety in Long-Term Care. 2024.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cancer, Long-Term Care, Discharge Planning, Case-Mix System (CMS), Disability Levels, Caregiver Burden","lastPublishedDoi":"10.21203/rs.3.rs-7325521/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7325521/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eAdvancements in cancer diagnosis, screening, and treatment have transformed cancer into a chronic condition, resulting in a growing population of survivors with long-term healthcare needs.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis retrospective descriptive study evaluated the discharge planning outcomes of cancer patients managed by discharge-planning nurses in 2024, with a focus on their long-term care (LTC) requirements using the Case-Mix System (CMS).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAmong 207 cancer patients analyzed, discharge outcomes included returning home (68.1%), transfer to LTC facilities (12.6%), transfer to another hospital (0.5%), and death (18.8%). Of the 167 patients who returned home or were transferred to care facilities, 75 (44.9%) applied for government-funded LTC services. Non-application reasons included full independence in activities of daily living (26.1%), ineligibility based on criteria (17.4%), and reliance on family or privately hired caregivers (56.5%). Based on CMS classification, LTC applicants were categorized as having mild (25.3%), moderate (48.0%), or severe disability (26.7%). Mildly disabled patients primarily required home-care support, while those with moderate disabilities had higher needs for combined home-care and respite services. Severely disabled patients showed the greatest reliance on respite care, reflecting substantial caregiver burden.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThese findings underscore the heterogeneous LTC needs among discharged cancer patients and support the utility of the CMS as a comprehensive tool for guiding resource allocation, caregiver support, and policy planning.\u003c/p\u003e","manuscriptTitle":"Evaluating Long-Term Care Needs in Cancer Survivors: A Case-Mix System-Based Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-10 14:59:52","doi":"10.21203/rs.3.rs-7325521/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8d476102-0706-4521-bac5-7031579f2d91","owner":[],"postedDate":"October 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-21T00:38:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-10 14:59:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7325521","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7325521","identity":"rs-7325521","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}