Coordinating Care Within and Across Settings

Seriously ill patients often move among many different health care settings where they are cared for by many different physicians, nurses, and other personnel. Coordinating care among various personnel and units within a single setting can be difficult enough. Coordinating care during transitions from one setting to another presents even greater challenges, especially when different organizations and funding sources are involved.

Procedures to Smooth Transitions

Because coordination and continuity of care are well-recognized trouble spots for health care organizations, hospitals, nursing homes, and other institutions, a variety of structures and processes have been created to smooth the transition of patients into and out of their organizations. Such structures and processes usually figure prominently in the requirements of accrediting organizations. They include the development of defined procedures for patient transfers (e.g., defining why, when, where, how), follow-up mechanisms, and standardized interorganizational relationships among hospitals, home care agencies, nursing homes, hospices, and other organizations that are or should be involved. Formally integrated health care systems, as described earlier, attempt to provide even stronger mechanisms for coordination, including designated primary care providers and integrated patient information systems. The various structures and processes for coordinating care may or may not be organized with particular attention to the needs of dying patients and their families, and this committee was not able to assess their strengths and limitations in this area.

Broader and more intensive community education may help patients, families, and providers become more aware of the range of health care and other resources available to patients approaching death, including those for whom hospital care is not appropriate but who do not qualify for hospice care. These resources may not be narrowly focused on such patients but nonetheless may be valuable, especially if their potential is more explicitly understood and the ways of integrating them into the care processes and transitions are identified. Thus, community groups might develop inventories of resources available to dying patients not only from health care institutions but also from churches, other charitable organizations, support groups, and agencies serving special populations, such as older individuals, children, or people with disabilities.

For example, a statewide task force in Oregon has developed a booklet listing for every county those resources that may be helpful to dying patients and their families (see Appendix C). This initiative has also included intensive efforts to make advance care planning in nursing homes more

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