Sourcebook : Improving Care for the End of Life : 7.4 Coordinate Patient Care across and within All Operating Units

Continuity of care requires an integrated approach to care. Professionals and health care institutions accept the ongoing responsibility of caring for dying patients. The health care aide who visits a patient on Monday also visits the patient on Wednesday. The treatment plan used at home is followed in the hospital. A patient being cared for in an integrated system does not have to explain to ER staff that she is enrolled in hospice. No one has to search for a DNAR order - and one order is honored everywhere. The system operates cohesively and coherently, and patients and families trust providers - and the health care system - depending on it for care best suited to their disease and circumstance. In this system, all members share a commitment to key elements of care, such as pain relief or bereavement support.

Some Elements of Coordinated Care

Defined procedures for patient transfers
Regularly used follow-up mechanisms
Designated primary care providers
Integrated patient information systems
Medications travel with patients
Follow-up calls and contacts are made
Standardized relationships among different healthcare systems

(Source Institute of Medicine, 1997)

7.4.1 Case Study - EverCare Program, United HealthCare Corporation
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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.

For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].