Coordinated care planning

This digital article based on Swedish conditions is computer translated. Hopefully we can inspire people from other countries.

Good planning at discharge from hospital reduces the risk of readmission. A well-coordinated planning of care upon discharge from hospital is an important part of ensuring safe, high-quality care for the patient. It is an example of how the health care system can work more efficiently and more patient-centered to promote health and well-being.

Foto: Mostphotos

Plan care well in connection with discharge from hospital


A hospital stay is often a turning point in people's lives. Illness or disability as a result of illness that occurs or is noticed in connection with hospital care. Here there is an opportunity to gain insight into the individual's needs and the willingness to receive support is greater. Before discharge from hospital, a simple plan is often made so that the individual will return home and receive safe and secure care. It is then desirable that those who are jointly responsible for the care in the home meet and plan the care together with the individual. For those who live in a special accommodation, this often takes place via contact between representatives of the accommodation and inpatient care. At the same time, it is important to state that the person who is to receive help must be motivated to seek help. A well-coordinated planning of care in connection with discharge from hospital is essential to ensure a smooth transition and the best possible quality of care for the patient. There are several benefits to such coordination, which are valuable to both patients and the healthcare system as a whole.

Continuity of care:
A coordinated care plan ensures that the patient's care process is seamless. This means that the medical information and treatment plan are transferred correctly from the hospital to primary care or the next level of care.

Reduced risk of misunderstanding:
Clear communication and documentation in a coordinated plan reduces the risk of misunderstandings between different care providers. All parties involved have access to the same information about the patient's condition and care needs.

Better medical follow-up:
A coordinated plan often includes follow-up appointments and tests that the patient needs to undergo after discharge. This ensures that any changes in health status are identified early and managed effectively.

Reduced risk of need for readmission:
By providing the patient with the right care and support after discharge, the risk of readmissions is reduced. By avoiding unnecessary admissions and readmissions, healthcare resources can be used more efficiently. This benefits both patients and caregivers.

Participation with individually adapted care:
A coordinated planning in which the patient is involved takes into account the individual needs. This means that care becomes more person-centred and tailored for each patient. The patient and his relatives also gain knowledge about the disease and the planned care and can thus become more involved in and motivated for the treatment.

Reduced stress and anxiety:
For patients and their families, hospital stays and discharges can be stressful and worrying. A coordinated plan provides security and increases trust in care.

Enhanced Security:
By minimizing the risk of errors and misunderstandings in care, safety for the patient increases. This is especially important when it comes to medication and treatments.

To distribute responsibility


It happens that benevolent relatives pressure the individual to apply for a nursing home. It rarely turns out well. Most adults want to make decisions about their own care. In the care planning, the individual participates, often relatives and representatives of the care. With cross-professional competence, it is a golden opportunity to make a thorough review of what is required for a safe and secure homecoming.

In the planning, questions are raised that may concern several care providers. There, it can be decided who will do what, how responsibility is distributed between different care providers and when return visits need to be planned.

In advanced care, different specialist doctors may have shared medical responsibility for care interventions for the same patient. In order for the patient and, for example, nurses to know where to turn, it may be necessary to clarify which doctor is responsible for what.

It may also be that the patient needs rehabilitation and medical technical aids before going home. Likewise, the care staff may need training to manage the care of the patient in the right way.

For those who live in a nursing home, changing needs can mean that the support at the nursing home needs to change. Planning can then begin already during the hospital stay, for example if training or newly added medical technology aids are needed.

Coordination with the nursing home doctor


The care of the elderly is becoming increasingly advanced. A functioning collaboration between the resident and the doctor is of great importance for quality. To avoid unnecessary referrals to hospital, a nurse can be available during on-call hours to make on-site assessments.

Collaboration between care staff and licensed staff


Routines need to be in place for how and when employees should contact authorized personnel. The nurse in turn must be able to reach the doctor for assessment.

Information transfer between, for example, the hospital and the nursing home


One difficulty is how the information transfer should take place. Many journal systems have built-in functions for sending messages. But where this is not available, you can be referred to sending a fax. Fax is not secure from a privacy point of view so messages must be de-identified.

Transferring patient information between two common email addresses is not secure from a confidentiality point of view.It is possible to have e-mail contact with the patient if he himself initiated contact via e-mail, but then do not write sensitive information in e-mail. If you fax material, you can delete personal data or save initials and names and then call and hand these over to the recipient. It has happened several times that medical records that were faxed ended up wrong. Some organizations have special confidentiality emails.

Medical care planning


A good friend told me that his father had spent his last years in a nursing home. Not long after moving in, he suffered a stroke. During the last period of his life, the man had to undergo three extensive brain operations. His experience was that his father was subjected to unnecessary suffering. They had not been invited to any medical care planning and, as far as he knew, neither the relatives nor the father had been asked any questions about their attitude to medical measures.

Medical care plans should be made in connection with moving in and then annually or when something else significant occurs. The elderly and any relatives participate in the planning together with the doctor and team, preferably a few weeks after the elderly move in. Then the nurse and the staff have time to get an idea of how the elderly person is doing and what needs the elderly person has. Before the doctor's visit, it is common for a blood sample to be taken if there are no other current test results available. In connection with the planning, a drug review is also carried out. It may then be appropriate to reduce or make changes in the medication.

Many businesses have a routine that precedes planning. This can involve taking samples, assessing symptoms and inviting relatives so that they can participate in the meeting. Assessments that may be relevant are, for example, symptom assessment, pain assessment, dementia assessment and risk assessment regarding falls, pressure ulcers, malnutrition and oral health.

In the event of persistently deteriorating health, a break-point assessment may be needed. This means that the resident, relatives, doctor and nurse agree that the resident should be allowed to fall asleep in peace and not be sent to hospital in case of deterioration.

In a normal-sized nursing home, the doctor often has to manage several care plans each visit. Everyone must go through the annual care planning and those who move in get their review. In addition, a number of residents will have a new plan when their health deteriorates. The nurses must plan the round times and, together with the doctor, create a clear structure for how the medical care planning should be prepared by different professional groups.

Reflection - coordinated care planning
Care staff:
• Do you have clear procedures for how the information transfer should take place when someone goes to or returns home from hospital?
• Do the routines for getting in touch with the nurse work well around the clock?
• Do you get to know what has been agreed in connection with the medical care planning?

Manager, nurse, occupational therapist and physiotherapist:
• Do you have a good dialogue with your doctor in connection with discharges?
• Are there safe routines for information transfer between the different nurses who have 24/7 responsibilities?
• Are there clear rules for what can be delegated?

Resident and next of kin:
• Do you or relatives need support with coordination of care efforts?
• Have you been asked if it is okay to contact you at night and who should be contacted first if something happens?
• Have you been involved in medical care planning at the nursing home?


Erland Olsson
Head nurse
Sofrosyne
Better care every day

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