vol. 5 No. 5 Octobm 1990
mti
Journal of P&n and SymptomManagement 279
are i
Linda M. Shegda, RN, and Ruth McCorkle, PhD Sc.&od usNursing, University of Pennsylvania, Philadelphia, Pennsylvania
Abstract Early dischargefiom the hospital or home health agency necessitates efictive continuity of care planni?ag in orderto assure that patient-s and-families will have their health care needs met after dkowtinuance qfformal health care services. In this article,we have defined eontinuily qf care from several perspectives, presented kuo theoretical viewpoints on this concept, and, with four models of carp that have actually been implemented, analyzed the commonalities and dijkences amongmodels. In addition, recommendations forfuture research and care delivery for the j’ncrposeof enhancement of continuity of care have been made. J ndn Symptom Manage 1990;5:279-286. Key words Continuity of care, discharge pla.nning, community health care, home health care
duction In the United States, government cost containment efforts and a new era of competition in health care has lead to increased emphasis on continuity of care planning in both acute care institutions and home care settings.**” The prospective payment system recently adopted by the government to func. the public program that pays for inpatient care for, the elderly (Medicare) has lead to shortened hospital stays. s-5 Zarle uotes that, for this reason, a discharge from the hospital has increasingly become a time of crisis for patients. as they may still be acutely ill and feel unready to return to the home setting. Early discbarges also piace an additional burden on the p;ltLrrt’s family, as providing care to an acut5c1yill person car: prove to be both complex and time consuming.‘j Government cost containment efforts have also put pressure on home hea!th agencies to A&f*ess reprintrequeststo: Ruth McCorkle, PhD, School of Nursing, University of Pennsylvania, Philadelphia, PA, 19104-6096. 6 U.S. Cancer Pain Relief Committee, 1990 Published by Elsevier, New York, New York
discharge patients as quickly as possible.’ Funding for home care in the United States has always been profoundly affected by ;;overnment policy.* 1Eligibility and benefit structures established by the major public programs that fund home care, such as Medicare and Medicaid, largely dIetermine who gets services and what types of services are provided.“*rO Current eligibility and. benefit structures are so restrictive that only a narrow range of services are reimbursed, with significant constraints placed on the intensity and duration of care.” Early discharge from the hospital or home health agency necessitates effective continuity of care planning to assure that patients and families C~GWtheir health care needs met after discontinuation of formal he&h ca.re services. The subsequent mental and physicat health of patients is dependent upon the way continuing care planning is carried out.12 In this article, we define continuity of care from several perspectives, presert two theoretical viewpoints on this concept, analyze the commonalities and differences among four models of care that have aceually been implemented, and make recommen-
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Shegda and McCorkle
dations for fumre research and care delivery to enhance continuity.
Iton’s define continuity of care as a %ordinated process of activities that involves the client and heatth care providers working together to facilitate the transition of health cam from one institution, agency or individual to another.” These authors present a systems model of continuity of care that centers ar~nd the components of structure, process, and outcome, The model is presented fern ~~ a rna~~p~~ and rnic~s~~pi~ perspeo tive,
Themacroscopic perspective of the continuing care system pr&des a theoretical view of varying program approaches. The structure component of this perspective contains eiements related to program design. McKeehan and Coulton*s point out that there are two major classifications QTprogram design: inforformal designs. Informal deupon the belief that pinning care is the sensibility of all health care p~fe~inna~s, as it is an inherent aspect of all professional practice. Formal defer to wellsrganized continuity of care ms with specific role designations, proceThe process component of the macroscopic perspective describes the various ways in which ~tinuing care activities are implemented, McKeehan and Coulto# point out that there are two major approaches to program delivery in continuing care. Placed on a continuum, these approaches range from direct service to consultation. IXrect service programs involve specific in~vidu~s* usually referred to as discharge planner, who work with patients and familii to pIat2for cxmtinuingcare. Consultation programs adhere to the principle that all primaryproviders are responsible for integrating continuirlgcare into their practice. Various pr0&onab who are educated and experienced in the use of co~~ul~ty resources are
Journal of Pain and Symptom Management ,-
available to the primary providers as consultants, Some contin~ng care programs combine both direct service and consultation. In such a program, professionals with expertise in continuity of care planning directly assess high-risk patients, but the primary providers are responsible for actually completing the referral forms. The outcome component of the macroscopic perspective focuses on the impact of the continuity of care program on recipients. McKeeban and CZoultotP state that the outcome component involves the evaluation of the extent to which individual patient goals of health have been met with regard to continuity of care.
The microscopic perspective brings the components of structure, process, and outcome closer to the empirical level. The structure component of this perspective resembles a wheel that centers around the patient. The patient and family are viewed as active participants in the ~ntinuity of care planning process. The model depicts the patient as being circumscribed by the element of legislation, which represents the regulations and standards that govern continuity of care programs. The health team members are considered to be the spokes of the stru~tu~1 wheel, and it is their collaborative action with the patient and one another that provides structural support for a program. The process component of the microscopic perspective depicts continuity of care. planning as a decision-making process that focuses on the patient and family. The task of the health professional is to facilitate this d~ision-making process. The outcome component of the microscopic perspective focuses on the patient’s health outcomes. The authors identify three indicators of patient health: function, comfort, and satisfaction. McKeehan and Coulton14 point out that the mzeroscopic perspective of the model describes how the terms structure, process, and outcome fit the realm of continuity of care, while the zlnicroscopic perspective serves to operationaline these terms. The macroscopic and microscopic perspectives are designed to be superimposed on top of one another, thus completing the systems model of continuity of care.
Vol. 5 No. 5 October 1990
Continuing Care in the CommuniQ
of Care Z&e* defines continuing care as “the coordination of services rendered to patients throughout the three phases of their illness: 1) prehospitalization, 2) hospitalization and 3) posthospitalization.” In this view, the goal of a continuing care program is to assure that patients who enter the acute care institution have a planned program for their continuing care needs when they leave the hospital. The Roy Adaptation Modells serves as the theoretical basis for the continuing care planning model proposed by Zarle.* The model also incorporates the nursing process, which is viewed as a series of actiolrs intended to encompass all of the steps that need to be taken to assure high quality continuity of care. According to this model, providers seek to assess the patient’s behavior and the factors influencing the human adaptation level. Intervention involves the manipulation of the influencing factors or stimuli in order to change the patient’s response. Stimuli are altered so that a positive response is possible. Zarle* points out that the goal of care is to promote adaptation in health and illness. To achieve this goal, the nurse musi assess the patient’s current level of adaptation, plan the care, implement the plan, and evaluate the eff’ectiveness of the process. To this end, data are collected, the problems are defined, and the appropriate approach is selected for the purpose of maintaining continuity of care. Patient and family input is sought in each of these steps, as they are the ultimate decision-makers in the continuity of care planning process. Zarle* proposes an interdisciplinary team approach, with the patient’s primary nurse providing the coordinating link between the various team members, as a means by which to achieve high quality continuity of care. Three multidisciplinary teams are involved in this process. These teams are designated as the primary team, the resource team, and the community team. The primary team is made up of professionals from the acute care institution, such as the nurse, physician, and social worker. This team a!,so includes the patient. The primary team meets weekly in c0ntinuir.g care rounds to discuss btient needs after drscharge 1 The lesourit team mxisisrs frtxn the 11usp:Ll..
281
of persons within the acute care setting who are available to the primary team as consultants, such as the continuing care nurse specialist. The community team is the group of health care providers who, at the point of the patient’s discharge from the hospital, take over the continuing care plan developed by the primary team. Open communication among the three teams is essential for effective continuing care to occur.
dek Patients with chronic illnesses have a need for continuing care and follow-up by consistent and competent professionals. These patients receive care that is organized in many ways. Various systems can facilitate the assessment, monitoring, and management of the patient’s ongoing health problems. Four models that illustrate the provision of continuity of care to patients with chronic illnesses and their families are presented.
Oncology Transition Services is a graduate program developed in 1974 by Drs. Jeanne Quint Benoliel and Ruth McCorkle, in the Department of Community Mealth Care Systems, School of Nursing, University of Washington. The Oncology Transition Services model has been successfully implemented by the Visiting Nurse Service of King County in Seattle.14*15 The VNS program has attained wide acceptance from the community at large, receiving referrals to provide patient care in the home setting from many area hospitals. Transition Services is a model of nursing practice designed to offer home-based, personalized services and continuity of care to patients with cancer and their families throughout the course of the illness. It is defined as “a system of community-based, person-centered nursing services to assist patients with cancer and their families to cope with: 1) the progressive physical and social dependencies imposed by the disease and treatment, and 2) the changing life toward goals *;s@ciat~rl with movement death.“15 In this model, home care IS provided bv cz:ter’s prepared community oncology
282
She& and McCarkk?
nurse specialists tined to give personalized me to patients with advanced cancer and their families. The advanced training background of these nurses includes knowledge of symptom m~~ment, cancer treatments, pain management, physical assessment, psychosocial assessment, grief and mourning theory, communications systems, community resources and agencies, systems analysis, self support, professional role ~veIopm~nt, ~~hophy~olo~ of &ath, and research theory and rneth~ol~~~ The community oncology nurse specialist serves as the patient’s primary nurse and is available to assist the patient and family on a &hr basis, The sp&alist has direct access to the ~tient~s ~tirna~ physiG~n. The s~ci~~is~ provides akilled care, assiststhe patient in making decisions about treatment and source of care, and facilitates smooth transitions through multiple care settings for the patient and family, Nu~~g inte~en~ons include symptom control, monito~ng and coordination of health services, and patient and family counseling and education with a focus on the provision of anticipatory guidance for potential problems. A randomized clinical trial was conducted to assess the efficacy of home c,are plods by the community oncology nurse specialists.*~17 A total of 166 pa:ients with a diagnosis of lung cancer were assigned to either an oncology home care group that received care from a community oncology nurse specialist, a saner home care group that received care from regular home care nurses, or an o&e care group that received whatever care they needed except for home are, Results of the clinical trial indicated that home care ~atment plods by the speciaIized oncology nurses was more intensive, as evidenced by the significantly longer duration of home care services provided to this group. Although subjects in the specialized group received fewer actual home visits on the average than the standard home care group, they received more telephone calls. In addition, patients in the specialized home care group had fewer complications than the other two groups. Although the two groups had a similar number of hospital admissions for active t~a~ent of hmg cancer, subjects receiving speciakd home dare had relatively fewer hospital admissions for symptoms and complications of malignancy. ‘I& specialked home care providers may have been able to prevent certain symptoms and
Journal of Pain and S’mptvm Management
complications or to substitute for some types:of inpatient care in a way that standard care providers could not. Furthermore, patients who received home care remained physi~lly and socially inde~ndent for a longer period of time than patients who did not receive SW+ services,18
AP~-~P~~~ Nzsrse
~~
The Pain Service at the Memorial Sloan-Kettering Cancer Center (MSKCC) in New York City has developed a patient- and family-cectered nu~~oo~in~ted model in order to meet the continuing care needs of its patients.t@~ The goal of this program is to adequately manage pain in the home setting, This goal is achieved in two whys: (a) by providing a vital communication link between MSKCC and the community health portioners, for patients being followed by the Pain Service at MSKCC, and (b) by acting as an expert information resource for community health professionals throughout the country who care for patients in pain. The net result of this program is continuity of care of patients from a wide geo~aphie distribution. Coyle and colleagues*Opoint out that this model utilizes a collaborattve approach among all members of the health care team. Team members include the nurse, physician, social worker, ~ych~t~st, music therapist, and chaplain. The team is based at the cancer center, but is oriented toward the community. Coyle*l notes thar team members work both independently and as a team. This process requires open communication, a common framework, and respect for each other’s expertise. The underlying philosophy of the team states that the patient, family and support system are to be considered as one unit; that unconditional positive regard will be maintained for the patietit and other team members at all times; that patients will not be abandoned when doing well; and tbat all team members share responsibility for patieut well-being. CoyletQ notes that communication among team members occurs on both a formal and an informal basis. Formal team meetings are held on a weekly basis. During these meetings, new patients are reviewed;treatment plans are clarified, reevaluated, changed, or supported: and guidelines are set for drug therapy and other approaches to patient and family care, so that
Vol. 5 No. 5 October 1990
Cuntinuing Care in ths Community
the nurse and other team members h.6ire parameters within which to work. Communication at :,ong team members also occurs on a less formal basis. Members of the team frequently consult with each other in the clinic, hallways, cafeteria, and over the phcze. In this model, the nurse is the team member primarily responsible for the daily management of the patient’s pain and coordination of the patient’s care. The nurse works along with the patient, family, and community professionals in order to provide symptom control and supportive care. Emphasis is placed upon the utilization of community health professionals in working with the patient at home. The expertise of the team’s nurse clinician is available to the patient, family, and community health pro&zional on a 24-hr basis. The nurge clinician follows the patient and family on both an inpatient and outpatient basis by telephone calls, home visits, and clinic visits. Continuity of care is facilitated via the nurses’ ongoing communication with the patient and family throughout the various care settings, and by the nurse’s ability to carry out a liaison coordinating role. The nurse shares information, answers questions, advises regarding symptom control, adjusts medications, interprets information, and guides the patient and family through decision making and through the dying and grieving process.
of C&nuiy Care for Advanced Cancer Pain Treahnmt
A Model
A continuing care program for cancer patients experiencing pain has been set up at the Pain Clinic of the National Cancer Institute of Milan. According to Ventafridda and colleagues,*’ the objective of this program is to integrate inpatient care with a home care program, Ventafridda and colleagues express the belief that the best environment for terminal patients to live out the remainder of their lives is in the comfort of their own homes, providing that adequate home care is available. Ventafridda and colleagueGl point out that the Continuing Care Unit of the Pain Clinic is composed of two fundamental elements, specialized inpatient wards and a home care program. Inpatient care is available for brief periods before, during, and after special therapy or when a family requires respite care. The home care program extends the expertise and sup-
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port of the Pain Clinic staff into the community setting. Ventafiidda and colleagues*l note that the basis of the condnuing carifr:srogram is the firm conviction that a multidisciplinary approach is an absolute necessity for the care of advanced cancer patients experiencing pain, The continuing care team is composed of physicians, nurses, psychologists, social workers, and a number of volunteers. Team members work both within the hospital and in the home setting, thus enabling members to build strong relationships with patients and families. All team members are required to take part in weekly team meet,ings at which clinical results for each case are updated; psvchoemotional dynamics of the relationship among patients, families and team members are discussed; and team members are familiarized with new develop ments regarding pain control. In this model, the patient and family are viewed as the central focus of the continuing care program. As the team believes thp.t only a well-informed family can collaborate effectively, family members are given information regarding the disease and its progression, the methods and aims of treatment, and the purpose and side effects of drugs administered to the patient. Family members are also frequently included in the weekly team meetings. Team members strive to create a relationship based on trust with both the patient and family. A study was conducted to examine the efficacy of the Pain Clinic’s home care program.** The sample consisted of 50 patients with advanced cancer pain. Thirty-three of the patients were enrolled in the home care program and the remaining 17 patients, who lived outside of the area in which home care services were being provided, were assisted only by constant monitoring of family members. Results indicated a deterioration in quality of life for patients not enrolled in the home care program, whereas quality of life measurements remained stable for the home care patients. Pain decreased for both groups, but a statistically significant difference was noted in favor of the home care group. A C&ir&ng
Medicaland Home Care l&it
The Unit for Continuing Medical and Home care is operated as an accompanying service at the Ichilov Medical Center in Tel Aviv, Israel.
According to Mot- and colleagurs,as the Unit was established in response to the recognition of the need for a connecting link between the hospital and the ~bulato~~ommuni~ me&cal sjqtem in order to assure continuity of care. The go& of the home care unit is to meet the medical, nursing~ and ~ych~~i~ needs of patients during what the authors term the ‘intermediate care? period. This period begins when the patient is discharged home from the hospital turd ends when a stable medical state has been achkwd, Patients receiving services from the Home Cam! Unit are usually elderly, homebound, and M a num~r of ~~rnu~~~~u~health prob hma that require close medical follow-up. Conditions commonly encountered by the unit include m~~ant di~ase, ce~b~va~u~a~ aceidents, and ~~o~ular pt~blems. Mor and ~llea~es,~ point out that the guiding principle of the Home Care Unit is to provide comp~hen~ve patient care. The Unit’s team is multidiscip~ina~, including medical, nursing, and social work personnel. The physician is in charge of the team. Team members are selected frcrm. the hospital’s inhouse staff at the time the patient is admitted to the Home Care Unit’s service. ~~u~utly, the team includes personnel who were involve in caring for the patient while still in the h~~it~l~ thus assuring continuity of care. Team meetings are held on a regular basis to di~u~ various aspects of patient care and reachdecisionsregardingfuture treatment, Liaison nurses responsible for the discharge of patients identify those in need of continuing care, and refer these patients to the Home Care Unit. Whilethe patient is under the care of the unit, all health care and treatment services are pvid& by the Unit’s staff. Upon conciusion Of care, referral is made back to the patient’s family physician, with whom contact has heen maintained. The specific means by which communi~tion took place between the Home Care Unit and the family physician was not identified,
The ma&&y of these models are bqital based and otiented toward the p~vis~~ of continning care after the patient’s discharge from
the acute care institution back into the community. The Transition Services model is the only model that is completely ~mrnuni~ based, designed to provide continuity of care to patients receiving health care services in their homes. Two of the models presented include the home care department as an integral element of the larger acute care institution. In the models described by Mor and colleaguesgg and Ventafridda and colleagues,P1 patients requiring home care services are referred to a depa~ent based within the hospital itself, as opposed to being referred to an outside home care agency not directly associated with the hospital, A rn~ei in which the home care agency is integrated into the hospital may facilitate access to patient information for both the home care and acute care teams, thus enhancing continuity of care.pI*as In hospitals that do not have an integrated home care department, where ready access to patient info~ation for all health care professionals may be a problem, a documentation system that allows for access to relevant information would enhance continuity of care. The ideal d~umen~tion system would enable both acute care and community professionals involved in the patient’s care to have quick and easy access to current data regarding the patient’s status. Among the modets that specify the characteristics of patients served by the continuing care programs, all appear to provide cant prima~ly to patients with progressive, chronic illnesses. Several of the continuity of care programs provide services to cancer patients, and two programs deliver care exclusively to eaneer patients experiencing severe pain. Many chronic illnesses are characterized by exacerbations and remissions. Two of the models presented in this article address the need for maintaining continuity of care once the patient is considered to be clinically stable. Coyle and colleagues~ point out that nona~ndonment of the patient when he/she is doing well is an important aspect of the philosophy of the continuity of care team. The Transition Services Modell*+tsmaint~ns contact with patients with cancer and their families throughout the course of the illness. Continuity of care models that discharge patients once they have become ~ini~ly stable may still take into consideration the benefits of
Vol. 5 No. 5 October 1990
Continuing Care in the Community
continuing care beyond the acute period. The anticipatory guidance that may be offered during the time in which the patient is relatively well may prevent or delay costly inpatient care, in addition to providing the patient and family with much needed support, as found in the study conducted by McCorkle and colleagues. I7 Continuity of care might be maintained during the nonacute phases of illness simply through regular telephone contact between the patient and selected members of the health care team.*” The majority of models presented note the vital importance of including the patient and family in the continuing care planning process. Many of the authors point out that active patient and family participation in the continuing care process increases its ehectiveness in meeting identified patient needs. Many models specify the need for a multidisciplinary team approach to continuity of care planning. Patients frequently manifest multiple physical, psychological, and social problems, which are best resolved through a collaborative, multidisciplinary team effort. The most commonly identified team members include the nurse, the physician, and the social worker. The necessity of communication among continuing care team members is noted by the majority of authors. Most of the models describe formal and/or informal mechanisms for communication among team members. Several of the models identify specific professionals primarily responsible for the coordination of the continuity of care process. Coyle and colleagues*O and Saunders and McCorkle14 assign the responsibility of coordination of care to a clinical nurse specialist. Zarle* describes the coordination of continuity of care as the role of the patient’s primary nurse, as it is believed that this individual is most familiar with the patient’s health care needs. Mor and colleaguefs place the physician in charge of the continuing care team. In conclusion, there are various models of continuity of care. Notable similarities and differences among models have been discussed, along with suggestions for future development. Inclusion of the patient and family in the planning process, a multidisciplinary team approach, the designation of a specific professional to coordinate services, easy access to current information for all professionals involved in a patient’s care, and maintenance of patient con-
285
tact beyond the period of acute illness appear to emerge as elements of effective continuity of care. Two models have undergone systematic evaluation with regard to level of family satisfactionlg and attainment of goals of patient care.*s Oncology Transition Services and the Home Care Program of the Pain Clinic at the National Cancer Institute of Milan have demonstrated the efficacy of their respective approaches in studies using a control group. Purther research of this type is required for the purpose of definitive identification of the elements essential to effective continuity of care.
eferences 1. McCarthy SA. Ths PWC~SS of discharge planning. In: O’Hare P, Terry M, eds. Discharge planning: strategies for assuring continuity of care. Rockvllle, MD: Aspen, 1988: f O’L 128. 2. Zarle N. Contbting care: the process and practice of discharge plannmg. Rockville, MD: Aspen, 1987. 3. Coleman JR, Smith DS. DRG’s and the growth of home health care. Nurs Econ 1984;2:391-395 and 408. 4. O’Hare P. An overview of discharge planning. In: O’Hare P, Terry M, eds. Discharge planning: strategies for assuring continuity of care. Rockville, MD: Aspen, 1988:5- 18. 5. Ramage N. In-home healtlr care services: a policy perspective. Fam Community Health 1985;8(2,: 1 I 21. 6. Stetz KM. Caregiving demands during advanced needs. Cancer Nurs the spouse’s cancer: 1987;10:260-263. 7. Coleman S. Discharge planning from the home health agency. In: O’Hare P, Terry, eds. Discharge planning: strategies for assuring continuity of care. Rockville, MD: Aspen, 1988:175- 180. 8. Mundiger M. Home care controversy: too little, too late, too costly. Rokville, MD: Aspen, 1983. 9. Cowart ME. Policy issues: financial reimbursement for home care. Fam Community Health 1985;8(2): l10. 10. Pasquale DK. Characteristics of Medicare-eligible home care clients. Public Health Nurs 1988;5:129134. l l. Reif L. The real victims of the crisis in home care: patients and their families. Home Health Care Serv Q l987;8: l-4. 12. McKeehan KM, Coulton CJ. A systems approach to program development for continuity of care in hospitals. In: McClelland E, Kelly K, Buckwalter KG eds. Continuity of care: advancing the concept of dis-
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charge planning, Orlando, FL: Grune and Stratton, 1985:79-92. 19. Roy C. Adaptation: a basis for nursing practice. Nurs Outlook 1971;19:25?-26% 14. Saunders JM, McCorkle R. Models of care for persons with progressive cancer. Nurs Clin North Am 1985;20:365-977. 15. Tomberg M, McGrathBB, BenolielJQ. Oncology transitionservices:partnershipof nursesand families. CancerNurs 1~,7:lSl-187. 16. McCorkleR, Benoliel JQ, Georgiadou F. The effects of home care on patiant’ssymptoms,hospitalizations, and complications. In: Funk S, Tornquist EM, Champagne MT, Copp LA, Wiese RA, eds. Key aspects ofcomfort:management of pain, fatigue, and aunt New York:Springer, 1~~~98-3 12, 17. boric R, Benoliel JQ, ~naf~n G, Georgiadou F, Moinpour C, Goode11B, A randomized clinical trial of home nursing care for lung cancer patients. Cancer 1989#4:199-206. 18. McCorkle R, Benoliel JQ. The importance of ftm&nal status in prong nursing care. In: Funk S, Tornquist EM, Champagne MT, Copp LA, Weise RA,eds. Key aspects of comfort. New York:Springer, 1990 (in ptess)* 19. Coyle N. A model of continuity of care for cancer
Journal of Pain and Symptm Mana ment
patients with chronic pain. Med Clin North Am 1987;71:259-270. 20. Coyle N, Monzillo E, Loscalzo M, Farkas C, Massie MJ, Foley KM. A model of contin~ty of care for cancer patients with pain and neu~n~lo~c complications. Cancer Nurs 1985;8: 111- 119. 21. Ventafridda V, Selmi S, DiMoIa G, Tamburi M, Deconno F. A new model of continuing care for advanced cancer pain treatment. Nospice J 1987;3:8589. 22. Ventafridda V, T~bu~ M, Selmi S, VaCeraL, DeConno F. The importance of a home care program for patients with advanced cancer pain. Tumori 1985;71:449-454. 23. Mor G, Joshpeh RS, Brayer M. Evaluation of the annual activity of a continuing medical and home care unit. Sot Sci Med 1987;2~~7-972. 24. Frasca C. Christy MW. Assuring continuity of care through a hospital-based home care agency. Quality Rev Bull 1986;12:167- 171. 25. Padilla GV. Grant proposah Improving cancer patients hospital-home transition. Grant NR01498. National Center for Nursing Research, NIH, 1987. 26. Nail LM, Greene D, Jones Is, Flannery M. Nursing care by telephone: describing practice in an ambulatory oncology center. Oncol Nurs Forum 1989;16:$87-395.
mti
Journal of P&n and SymptomManagement 279
are i
Linda M. Shegda, RN, and Ruth McCorkle, PhD Sc.&od usNursing, University of Pennsylvania, Philadelphia, Pennsylvania
Abstract Early dischargefiom the hospital or home health agency necessitates efictive continuity of care planni?ag in orderto assure that patient-s and-families will have their health care needs met after dkowtinuance qfformal health care services. In this article,we have defined eontinuily qf care from several perspectives, presented kuo theoretical viewpoints on this concept, and, with four models of carp that have actually been implemented, analyzed the commonalities and dijkences amongmodels. In addition, recommendations forfuture research and care delivery for the j’ncrposeof enhancement of continuity of care have been made. J ndn Symptom Manage 1990;5:279-286. Key words Continuity of care, discharge pla.nning, community health care, home health care
duction In the United States, government cost containment efforts and a new era of competition in health care has lead to increased emphasis on continuity of care planning in both acute care institutions and home care settings.**” The prospective payment system recently adopted by the government to func. the public program that pays for inpatient care for, the elderly (Medicare) has lead to shortened hospital stays. s-5 Zarle uotes that, for this reason, a discharge from the hospital has increasingly become a time of crisis for patients. as they may still be acutely ill and feel unready to return to the home setting. Early discbarges also piace an additional burden on the p;ltLrrt’s family, as providing care to an acut5c1yill person car: prove to be both complex and time consuming.‘j Government cost containment efforts have also put pressure on home hea!th agencies to A&f*ess reprintrequeststo: Ruth McCorkle, PhD, School of Nursing, University of Pennsylvania, Philadelphia, PA, 19104-6096. 6 U.S. Cancer Pain Relief Committee, 1990 Published by Elsevier, New York, New York
discharge patients as quickly as possible.’ Funding for home care in the United States has always been profoundly affected by ;;overnment policy.* 1Eligibility and benefit structures established by the major public programs that fund home care, such as Medicare and Medicaid, largely dIetermine who gets services and what types of services are provided.“*rO Current eligibility and. benefit structures are so restrictive that only a narrow range of services are reimbursed, with significant constraints placed on the intensity and duration of care.” Early discharge from the hospital or home health agency necessitates effective continuity of care planning to assure that patients and families C~GWtheir health care needs met after discontinuation of formal he&h ca.re services. The subsequent mental and physicat health of patients is dependent upon the way continuing care planning is carried out.12 In this article, we define continuity of care from several perspectives, presert two theoretical viewpoints on this concept, analyze the commonalities and differences among four models of care that have aceually been implemented, and make recommen-
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Shegda and McCorkle
dations for fumre research and care delivery to enhance continuity.
Iton’s define continuity of care as a %ordinated process of activities that involves the client and heatth care providers working together to facilitate the transition of health cam from one institution, agency or individual to another.” These authors present a systems model of continuity of care that centers ar~nd the components of structure, process, and outcome, The model is presented fern ~~ a rna~~p~~ and rnic~s~~pi~ perspeo tive,
Themacroscopic perspective of the continuing care system pr&des a theoretical view of varying program approaches. The structure component of this perspective contains eiements related to program design. McKeehan and Coulton*s point out that there are two major classifications QTprogram design: inforformal designs. Informal deupon the belief that pinning care is the sensibility of all health care p~fe~inna~s, as it is an inherent aspect of all professional practice. Formal defer to wellsrganized continuity of care ms with specific role designations, proceThe process component of the macroscopic perspective describes the various ways in which ~tinuing care activities are implemented, McKeehan and Coulto# point out that there are two major approaches to program delivery in continuing care. Placed on a continuum, these approaches range from direct service to consultation. IXrect service programs involve specific in~vidu~s* usually referred to as discharge planner, who work with patients and familii to pIat2for cxmtinuingcare. Consultation programs adhere to the principle that all primaryproviders are responsible for integrating continuirlgcare into their practice. Various pr0&onab who are educated and experienced in the use of co~~ul~ty resources are
Journal of Pain and Symptom Management ,-
available to the primary providers as consultants, Some contin~ng care programs combine both direct service and consultation. In such a program, professionals with expertise in continuity of care planning directly assess high-risk patients, but the primary providers are responsible for actually completing the referral forms. The outcome component of the macroscopic perspective focuses on the impact of the continuity of care program on recipients. McKeeban and CZoultotP state that the outcome component involves the evaluation of the extent to which individual patient goals of health have been met with regard to continuity of care.
The microscopic perspective brings the components of structure, process, and outcome closer to the empirical level. The structure component of this perspective resembles a wheel that centers around the patient. The patient and family are viewed as active participants in the ~ntinuity of care planning process. The model depicts the patient as being circumscribed by the element of legislation, which represents the regulations and standards that govern continuity of care programs. The health team members are considered to be the spokes of the stru~tu~1 wheel, and it is their collaborative action with the patient and one another that provides structural support for a program. The process component of the microscopic perspective depicts continuity of care. planning as a decision-making process that focuses on the patient and family. The task of the health professional is to facilitate this d~ision-making process. The outcome component of the microscopic perspective focuses on the patient’s health outcomes. The authors identify three indicators of patient health: function, comfort, and satisfaction. McKeehan and Coulton14 point out that the mzeroscopic perspective of the model describes how the terms structure, process, and outcome fit the realm of continuity of care, while the zlnicroscopic perspective serves to operationaline these terms. The macroscopic and microscopic perspectives are designed to be superimposed on top of one another, thus completing the systems model of continuity of care.
Vol. 5 No. 5 October 1990
Continuing Care in the CommuniQ
of Care Z&e* defines continuing care as “the coordination of services rendered to patients throughout the three phases of their illness: 1) prehospitalization, 2) hospitalization and 3) posthospitalization.” In this view, the goal of a continuing care program is to assure that patients who enter the acute care institution have a planned program for their continuing care needs when they leave the hospital. The Roy Adaptation Modells serves as the theoretical basis for the continuing care planning model proposed by Zarle.* The model also incorporates the nursing process, which is viewed as a series of actiolrs intended to encompass all of the steps that need to be taken to assure high quality continuity of care. According to this model, providers seek to assess the patient’s behavior and the factors influencing the human adaptation level. Intervention involves the manipulation of the influencing factors or stimuli in order to change the patient’s response. Stimuli are altered so that a positive response is possible. Zarle* points out that the goal of care is to promote adaptation in health and illness. To achieve this goal, the nurse musi assess the patient’s current level of adaptation, plan the care, implement the plan, and evaluate the eff’ectiveness of the process. To this end, data are collected, the problems are defined, and the appropriate approach is selected for the purpose of maintaining continuity of care. Patient and family input is sought in each of these steps, as they are the ultimate decision-makers in the continuity of care planning process. Zarle* proposes an interdisciplinary team approach, with the patient’s primary nurse providing the coordinating link between the various team members, as a means by which to achieve high quality continuity of care. Three multidisciplinary teams are involved in this process. These teams are designated as the primary team, the resource team, and the community team. The primary team is made up of professionals from the acute care institution, such as the nurse, physician, and social worker. This team a!,so includes the patient. The primary team meets weekly in c0ntinuir.g care rounds to discuss btient needs after drscharge 1 The lesourit team mxisisrs frtxn the 11usp:Ll..
281
of persons within the acute care setting who are available to the primary team as consultants, such as the continuing care nurse specialist. The community team is the group of health care providers who, at the point of the patient’s discharge from the hospital, take over the continuing care plan developed by the primary team. Open communication among the three teams is essential for effective continuing care to occur.
dek Patients with chronic illnesses have a need for continuing care and follow-up by consistent and competent professionals. These patients receive care that is organized in many ways. Various systems can facilitate the assessment, monitoring, and management of the patient’s ongoing health problems. Four models that illustrate the provision of continuity of care to patients with chronic illnesses and their families are presented.
Oncology Transition Services is a graduate program developed in 1974 by Drs. Jeanne Quint Benoliel and Ruth McCorkle, in the Department of Community Mealth Care Systems, School of Nursing, University of Washington. The Oncology Transition Services model has been successfully implemented by the Visiting Nurse Service of King County in Seattle.14*15 The VNS program has attained wide acceptance from the community at large, receiving referrals to provide patient care in the home setting from many area hospitals. Transition Services is a model of nursing practice designed to offer home-based, personalized services and continuity of care to patients with cancer and their families throughout the course of the illness. It is defined as “a system of community-based, person-centered nursing services to assist patients with cancer and their families to cope with: 1) the progressive physical and social dependencies imposed by the disease and treatment, and 2) the changing life toward goals *;s@ciat~rl with movement death.“15 In this model, home care IS provided bv cz:ter’s prepared community oncology
282
She& and McCarkk?
nurse specialists tined to give personalized me to patients with advanced cancer and their families. The advanced training background of these nurses includes knowledge of symptom m~~ment, cancer treatments, pain management, physical assessment, psychosocial assessment, grief and mourning theory, communications systems, community resources and agencies, systems analysis, self support, professional role ~veIopm~nt, ~~hophy~olo~ of &ath, and research theory and rneth~ol~~~ The community oncology nurse specialist serves as the patient’s primary nurse and is available to assist the patient and family on a &hr basis, The sp&alist has direct access to the ~tient~s ~tirna~ physiG~n. The s~ci~~is~ provides akilled care, assiststhe patient in making decisions about treatment and source of care, and facilitates smooth transitions through multiple care settings for the patient and family, Nu~~g inte~en~ons include symptom control, monito~ng and coordination of health services, and patient and family counseling and education with a focus on the provision of anticipatory guidance for potential problems. A randomized clinical trial was conducted to assess the efficacy of home c,are plods by the community oncology nurse specialists.*~17 A total of 166 pa:ients with a diagnosis of lung cancer were assigned to either an oncology home care group that received care from a community oncology nurse specialist, a saner home care group that received care from regular home care nurses, or an o&e care group that received whatever care they needed except for home are, Results of the clinical trial indicated that home care ~atment plods by the speciaIized oncology nurses was more intensive, as evidenced by the significantly longer duration of home care services provided to this group. Although subjects in the specialized group received fewer actual home visits on the average than the standard home care group, they received more telephone calls. In addition, patients in the specialized home care group had fewer complications than the other two groups. Although the two groups had a similar number of hospital admissions for active t~a~ent of hmg cancer, subjects receiving speciakd home dare had relatively fewer hospital admissions for symptoms and complications of malignancy. ‘I& specialked home care providers may have been able to prevent certain symptoms and
Journal of Pain and S’mptvm Management
complications or to substitute for some types:of inpatient care in a way that standard care providers could not. Furthermore, patients who received home care remained physi~lly and socially inde~ndent for a longer period of time than patients who did not receive SW+ services,18
AP~-~P~~~ Nzsrse
~~
The Pain Service at the Memorial Sloan-Kettering Cancer Center (MSKCC) in New York City has developed a patient- and family-cectered nu~~oo~in~ted model in order to meet the continuing care needs of its patients.t@~ The goal of this program is to adequately manage pain in the home setting, This goal is achieved in two whys: (a) by providing a vital communication link between MSKCC and the community health portioners, for patients being followed by the Pain Service at MSKCC, and (b) by acting as an expert information resource for community health professionals throughout the country who care for patients in pain. The net result of this program is continuity of care of patients from a wide geo~aphie distribution. Coyle and colleagues*Opoint out that this model utilizes a collaborattve approach among all members of the health care team. Team members include the nurse, physician, social worker, ~ych~t~st, music therapist, and chaplain. The team is based at the cancer center, but is oriented toward the community. Coyle*l notes thar team members work both independently and as a team. This process requires open communication, a common framework, and respect for each other’s expertise. The underlying philosophy of the team states that the patient, family and support system are to be considered as one unit; that unconditional positive regard will be maintained for the patietit and other team members at all times; that patients will not be abandoned when doing well; and tbat all team members share responsibility for patieut well-being. CoyletQ notes that communication among team members occurs on both a formal and an informal basis. Formal team meetings are held on a weekly basis. During these meetings, new patients are reviewed;treatment plans are clarified, reevaluated, changed, or supported: and guidelines are set for drug therapy and other approaches to patient and family care, so that
Vol. 5 No. 5 October 1990
Cuntinuing Care in ths Community
the nurse and other team members h.6ire parameters within which to work. Communication at :,ong team members also occurs on a less formal basis. Members of the team frequently consult with each other in the clinic, hallways, cafeteria, and over the phcze. In this model, the nurse is the team member primarily responsible for the daily management of the patient’s pain and coordination of the patient’s care. The nurse works along with the patient, family, and community professionals in order to provide symptom control and supportive care. Emphasis is placed upon the utilization of community health professionals in working with the patient at home. The expertise of the team’s nurse clinician is available to the patient, family, and community health pro&zional on a 24-hr basis. The nurge clinician follows the patient and family on both an inpatient and outpatient basis by telephone calls, home visits, and clinic visits. Continuity of care is facilitated via the nurses’ ongoing communication with the patient and family throughout the various care settings, and by the nurse’s ability to carry out a liaison coordinating role. The nurse shares information, answers questions, advises regarding symptom control, adjusts medications, interprets information, and guides the patient and family through decision making and through the dying and grieving process.
of C&nuiy Care for Advanced Cancer Pain Treahnmt
A Model
A continuing care program for cancer patients experiencing pain has been set up at the Pain Clinic of the National Cancer Institute of Milan. According to Ventafridda and colleagues,*’ the objective of this program is to integrate inpatient care with a home care program, Ventafridda and colleagues express the belief that the best environment for terminal patients to live out the remainder of their lives is in the comfort of their own homes, providing that adequate home care is available. Ventafridda and colleagueGl point out that the Continuing Care Unit of the Pain Clinic is composed of two fundamental elements, specialized inpatient wards and a home care program. Inpatient care is available for brief periods before, during, and after special therapy or when a family requires respite care. The home care program extends the expertise and sup-
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port of the Pain Clinic staff into the community setting. Ventafiidda and colleagues*l note that the basis of the condnuing carifr:srogram is the firm conviction that a multidisciplinary approach is an absolute necessity for the care of advanced cancer patients experiencing pain, The continuing care team is composed of physicians, nurses, psychologists, social workers, and a number of volunteers. Team members work both within the hospital and in the home setting, thus enabling members to build strong relationships with patients and families. All team members are required to take part in weekly team meet,ings at which clinical results for each case are updated; psvchoemotional dynamics of the relationship among patients, families and team members are discussed; and team members are familiarized with new develop ments regarding pain control. In this model, the patient and family are viewed as the central focus of the continuing care program. As the team believes thp.t only a well-informed family can collaborate effectively, family members are given information regarding the disease and its progression, the methods and aims of treatment, and the purpose and side effects of drugs administered to the patient. Family members are also frequently included in the weekly team meetings. Team members strive to create a relationship based on trust with both the patient and family. A study was conducted to examine the efficacy of the Pain Clinic’s home care program.** The sample consisted of 50 patients with advanced cancer pain. Thirty-three of the patients were enrolled in the home care program and the remaining 17 patients, who lived outside of the area in which home care services were being provided, were assisted only by constant monitoring of family members. Results indicated a deterioration in quality of life for patients not enrolled in the home care program, whereas quality of life measurements remained stable for the home care patients. Pain decreased for both groups, but a statistically significant difference was noted in favor of the home care group. A C&ir&ng
Medicaland Home Care l&it
The Unit for Continuing Medical and Home care is operated as an accompanying service at the Ichilov Medical Center in Tel Aviv, Israel.
According to Mot- and colleagurs,as the Unit was established in response to the recognition of the need for a connecting link between the hospital and the ~bulato~~ommuni~ me&cal sjqtem in order to assure continuity of care. The go& of the home care unit is to meet the medical, nursing~ and ~ych~~i~ needs of patients during what the authors term the ‘intermediate care? period. This period begins when the patient is discharged home from the hospital turd ends when a stable medical state has been achkwd, Patients receiving services from the Home Cam! Unit are usually elderly, homebound, and M a num~r of ~~rnu~~~~u~health prob hma that require close medical follow-up. Conditions commonly encountered by the unit include m~~ant di~ase, ce~b~va~u~a~ aceidents, and ~~o~ular pt~blems. Mor and ~llea~es,~ point out that the guiding principle of the Home Care Unit is to provide comp~hen~ve patient care. The Unit’s team is multidiscip~ina~, including medical, nursing, and social work personnel. The physician is in charge of the team. Team members are selected frcrm. the hospital’s inhouse staff at the time the patient is admitted to the Home Care Unit’s service. ~~u~utly, the team includes personnel who were involve in caring for the patient while still in the h~~it~l~ thus assuring continuity of care. Team meetings are held on a regular basis to di~u~ various aspects of patient care and reachdecisionsregardingfuture treatment, Liaison nurses responsible for the discharge of patients identify those in need of continuing care, and refer these patients to the Home Care Unit. Whilethe patient is under the care of the unit, all health care and treatment services are pvid& by the Unit’s staff. Upon conciusion Of care, referral is made back to the patient’s family physician, with whom contact has heen maintained. The specific means by which communi~tion took place between the Home Care Unit and the family physician was not identified,
The ma&&y of these models are bqital based and otiented toward the p~vis~~ of continning care after the patient’s discharge from
the acute care institution back into the community. The Transition Services model is the only model that is completely ~mrnuni~ based, designed to provide continuity of care to patients receiving health care services in their homes. Two of the models presented include the home care department as an integral element of the larger acute care institution. In the models described by Mor and colleaguesgg and Ventafridda and colleagues,P1 patients requiring home care services are referred to a depa~ent based within the hospital itself, as opposed to being referred to an outside home care agency not directly associated with the hospital, A rn~ei in which the home care agency is integrated into the hospital may facilitate access to patient information for both the home care and acute care teams, thus enhancing continuity of care.pI*as In hospitals that do not have an integrated home care department, where ready access to patient info~ation for all health care professionals may be a problem, a documentation system that allows for access to relevant information would enhance continuity of care. The ideal d~umen~tion system would enable both acute care and community professionals involved in the patient’s care to have quick and easy access to current data regarding the patient’s status. Among the modets that specify the characteristics of patients served by the continuing care programs, all appear to provide cant prima~ly to patients with progressive, chronic illnesses. Several of the continuity of care programs provide services to cancer patients, and two programs deliver care exclusively to eaneer patients experiencing severe pain. Many chronic illnesses are characterized by exacerbations and remissions. Two of the models presented in this article address the need for maintaining continuity of care once the patient is considered to be clinically stable. Coyle and colleagues~ point out that nona~ndonment of the patient when he/she is doing well is an important aspect of the philosophy of the continuity of care team. The Transition Services Modell*+tsmaint~ns contact with patients with cancer and their families throughout the course of the illness. Continuity of care models that discharge patients once they have become ~ini~ly stable may still take into consideration the benefits of
Vol. 5 No. 5 October 1990
Continuing Care in the Community
continuing care beyond the acute period. The anticipatory guidance that may be offered during the time in which the patient is relatively well may prevent or delay costly inpatient care, in addition to providing the patient and family with much needed support, as found in the study conducted by McCorkle and colleagues. I7 Continuity of care might be maintained during the nonacute phases of illness simply through regular telephone contact between the patient and selected members of the health care team.*” The majority of models presented note the vital importance of including the patient and family in the continuing care planning process. Many of the authors point out that active patient and family participation in the continuing care process increases its ehectiveness in meeting identified patient needs. Many models specify the need for a multidisciplinary team approach to continuity of care planning. Patients frequently manifest multiple physical, psychological, and social problems, which are best resolved through a collaborative, multidisciplinary team effort. The most commonly identified team members include the nurse, the physician, and the social worker. The necessity of communication among continuing care team members is noted by the majority of authors. Most of the models describe formal and/or informal mechanisms for communication among team members. Several of the models identify specific professionals primarily responsible for the coordination of the continuity of care process. Coyle and colleagues*O and Saunders and McCorkle14 assign the responsibility of coordination of care to a clinical nurse specialist. Zarle* describes the coordination of continuity of care as the role of the patient’s primary nurse, as it is believed that this individual is most familiar with the patient’s health care needs. Mor and colleaguefs place the physician in charge of the continuing care team. In conclusion, there are various models of continuity of care. Notable similarities and differences among models have been discussed, along with suggestions for future development. Inclusion of the patient and family in the planning process, a multidisciplinary team approach, the designation of a specific professional to coordinate services, easy access to current information for all professionals involved in a patient’s care, and maintenance of patient con-
285
tact beyond the period of acute illness appear to emerge as elements of effective continuity of care. Two models have undergone systematic evaluation with regard to level of family satisfactionlg and attainment of goals of patient care.*s Oncology Transition Services and the Home Care Program of the Pain Clinic at the National Cancer Institute of Milan have demonstrated the efficacy of their respective approaches in studies using a control group. Purther research of this type is required for the purpose of definitive identification of the elements essential to effective continuity of care.
eferences 1. McCarthy SA. Ths PWC~SS of discharge planning. In: O’Hare P, Terry M, eds. Discharge planning: strategies for assuring continuity of care. Rockvllle, MD: Aspen, 1988: f O’L 128. 2. Zarle N. Contbting care: the process and practice of discharge plannmg. Rockville, MD: Aspen, 1987. 3. Coleman JR, Smith DS. DRG’s and the growth of home health care. Nurs Econ 1984;2:391-395 and 408. 4. O’Hare P. An overview of discharge planning. In: O’Hare P, Terry M, eds. Discharge planning: strategies for assuring continuity of care. Rockville, MD: Aspen, 1988:5- 18. 5. Ramage N. In-home healtlr care services: a policy perspective. Fam Community Health 1985;8(2,: 1 I 21. 6. Stetz KM. Caregiving demands during advanced needs. Cancer Nurs the spouse’s cancer: 1987;10:260-263. 7. Coleman S. Discharge planning from the home health agency. In: O’Hare P, Terry, eds. Discharge planning: strategies for assuring continuity of care. Rockville, MD: Aspen, 1988:175- 180. 8. Mundiger M. Home care controversy: too little, too late, too costly. Rokville, MD: Aspen, 1983. 9. Cowart ME. Policy issues: financial reimbursement for home care. Fam Community Health 1985;8(2): l10. 10. Pasquale DK. Characteristics of Medicare-eligible home care clients. Public Health Nurs 1988;5:129134. l l. Reif L. The real victims of the crisis in home care: patients and their families. Home Health Care Serv Q l987;8: l-4. 12. McKeehan KM, Coulton CJ. A systems approach to program development for continuity of care in hospitals. In: McClelland E, Kelly K, Buckwalter KG eds. Continuity of care: advancing the concept of dis-
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charge planning, Orlando, FL: Grune and Stratton, 1985:79-92. 19. Roy C. Adaptation: a basis for nursing practice. Nurs Outlook 1971;19:25?-26% 14. Saunders JM, McCorkle R. Models of care for persons with progressive cancer. Nurs Clin North Am 1985;20:365-977. 15. Tomberg M, McGrathBB, BenolielJQ. Oncology transitionservices:partnershipof nursesand families. CancerNurs 1~,7:lSl-187. 16. McCorkleR, Benoliel JQ, Georgiadou F. The effects of home care on patiant’ssymptoms,hospitalizations, and complications. In: Funk S, Tornquist EM, Champagne MT, Copp LA, Wiese RA, eds. Key aspects ofcomfort:management of pain, fatigue, and aunt New York:Springer, 1~~~98-3 12, 17. boric R, Benoliel JQ, ~naf~n G, Georgiadou F, Moinpour C, Goode11B, A randomized clinical trial of home nursing care for lung cancer patients. Cancer 1989#4:199-206. 18. McCorkle R, Benoliel JQ. The importance of ftm&nal status in prong nursing care. In: Funk S, Tornquist EM, Champagne MT, Copp LA, Weise RA,eds. Key aspects of comfort. New York:Springer, 1990 (in ptess)* 19. Coyle N. A model of continuity of care for cancer
Journal of Pain and Symptm Mana ment
patients with chronic pain. Med Clin North Am 1987;71:259-270. 20. Coyle N, Monzillo E, Loscalzo M, Farkas C, Massie MJ, Foley KM. A model of contin~ty of care for cancer patients with pain and neu~n~lo~c complications. Cancer Nurs 1985;8: 111- 119. 21. Ventafridda V, Selmi S, DiMoIa G, Tamburi M, Deconno F. A new model of continuing care for advanced cancer pain treatment. Nospice J 1987;3:8589. 22. Ventafridda V, T~bu~ M, Selmi S, VaCeraL, DeConno F. The importance of a home care program for patients with advanced cancer pain. Tumori 1985;71:449-454. 23. Mor G, Joshpeh RS, Brayer M. Evaluation of the annual activity of a continuing medical and home care unit. Sot Sci Med 1987;2~~7-972. 24. Frasca C. Christy MW. Assuring continuity of care through a hospital-based home care agency. Quality Rev Bull 1986;12:167- 171. 25. Padilla GV. Grant proposah Improving cancer patients hospital-home transition. Grant NR01498. National Center for Nursing Research, NIH, 1987. 26. Nail LM, Greene D, Jones Is, Flannery M. Nursing care by telephone: describing practice in an ambulatory oncology center. Oncol Nurs Forum 1989;16:$87-395.
