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Hospital and Hospice Partnerships

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Post Continuity of Care
Author: rhpallsw
Date: Nov 3, 2011 2:50 pm
Our program is looking to improve our continuity of care upon discharge from our consultation service in the hospital. We wanted to see if other programs had standard tools used to help with this? We are thinking about possibly creating a standard tool that we send to patients' primary care mds, snf, etc.. We are open to ideas and suggestions.

Thanks.
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Re:Continuity of Care (by SharolHerr on 11/03/2011)
Continuity is a hallmark of quality palliative care but accomplishing this in a standardized, routine way is easier said than done. Most hospital systems have a Continuity of Care and discharge process that is in place and this usually includes medication reconciliation and patient and family teaching and receiving written instructions. As much as you can you will want to organize your tools around this system that is in place. For information transfer to the physician we recommend copying or faxing the Dictated consult to the outpatient facility or physician along with discharge instructions. Our PC team members often make phone contact with the receiving facilty and physicians especially if there are special concerns or exceptions to usual care. I'm not aware of a specific tool for communicating with physicians but believe consultation and COC documents would be very valuable. Sharol Herr, RN, BSN, MSEd; Palliative Clinical Manager; Mount Carmel Health Palliative Care Leadership Center; Columbus, Ohio.

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