Supportive Oncology Care at Home Post-Discharge

This study is evaluating if a program that involves remote monitoring and home-based care may improve the post-discharge care of recently hospitalized patients with advanced cancer. The Supportive Oncology Care at Home intervention consists of three key components: 1. Remote patient monitoring (e.g. patient-reported symptoms, home-monitored vital signs and body weight); 2. A Medically Home care model for symptom assessment, evaluation, and management (e.g. triggers for phone calls and visits to patients' homes to address and manage any concerning issues identified); 3. Structured communication with the oncology team to ensure continuity of care.

This is a single-arm pilot study of recently hospitalized patients with advanced cancer to assess the the feasibility of delivering a remote monitoring and home-based program, Supportive Oncology Care at Home, the acceptability and satisfaction with the Supportive Oncology Care at Home program, and changes in the quality of life and symptoms of patients who receive the Supportive Oncology Care at Home program. Oncologists at the MGH Cancer Center developed the Supportive Oncology Care program to address the symptoms and frequent hospital visits that patients face as a result of their cancer and the treatment they receive. The research study procedures include: * Remote monitoring of symptoms, vital signs, and body weight * Questionnaires asking about demographic information (e.g. gender, ethnicity, income) and participant experience with cancer (e.g. your quality of life, your symptoms) * Interviews to assess participant impressions of the program * Caregiver Interviews, Questionnaires and Surveys to assess caregiver impressions of the program and caregiver perceptions of participant symptoms while in the program * Clinician Interviews and Questionnaires to assess impressions of the program * Data collection from participant medical record. Patients will take part in the program for two weeks following hospital discharge. It is expected that between 75 and 110 people will enroll, including up to 30 patients, up to 30 caregivers, and up to 15 clinicians. Medically Home Group, Inc. is supporting this research study by providing funding for this research study.

Inclusion Criteria: Patient Eligibility * Age 18 or older * Diagnosed with advanced cancer (defined as receiving treatment with palliative intent per chemotherapy order entry treatment intent designation and/or trial consent forms OR based on documentation in the oncology clinic notes for those not receiving chemotherapy) * Admitted with an unplanned or non-elective hospitalization at Massachusetts General Hospital (MGH) * Not requiring ICU-level care during their hospitalization * Receiving care at the MGH Cancer Center * Ability to read and respond to question in English * Residing within 50 miles of MGH. Caregiver Eligibility * Relative or friend of eligible patient * Verbally fluent in English * Age 18 or older Clinician Eligibility \-- Outpatient oncology physicians and advanced practice clinicians who care for patients that receive the Supportive Oncology Care at Home intervention Exclusion Criteria: Patient Exclusion * Are admitted to the intensive care unit * Have a high oxygen requirement (FIO2 \> 0.40) * Experience active angina or cardiac arrythmias * Have a planned inpatient surgical or interventional procedure * Have uncontrolled psychiatric illness or impaired cognition interfering with their ability to understand study procedures and provide written informed consent * Are deemed ineligible for home-based care based on the inpatient oncology clinician assessment * Are planning to be discharged to hospice or to any location other than their home Caregiver Exclusion -- Caregivers who are unwilling or unable to participate in the study. Clinician Exclusion \-- Clinicians who are unwilling or unable to participate in the study.