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Coordination of Care

Rationale

The task of coordinating a patient’s care is central to the general internist’s role and involves communication with the patient and his/her family; colleagues; consultants; nurses; social workers; and community-based agencies. It is essential for the student to learn that the physician’s responsibility toward the patient does not stop at the end of the office visit or hospitalization, but continues in collaboration with other professionals to ensure that the patient receives optimal care.

Prerequisites

None.

Specific Learning Objectives

  1. Knowledge: Each student should be able to describe:
    1. the role of consultants and their limits in the care of a patient.
    2. key personnel and programs in and out of the hospital that may be able to contribute to the ongoing care of an individual patient for whom the student has responsibility.
    3. the role of the primary care physician in coordinating the comprehensive and longitudinal patient care plan, including communicating with the patient and family through telecommunications and evaluating patient well-being through home health and other care providers.
    4. the role of the primary care physician in the coordination of care during key transitions (e.g., outpatient to inpatient, inpatient to hospice, etc.).
  2. Skills: Each student should be able to:
    1. discuss with the patient (and family as appropriate) ongoing health care needs, using appropriate language, avoiding jargon and medical terminology.
    2. participate in requesting a consultation and identifying the specific question(s) to be addressed.
    3. participate in the discussion of the consultant’s recommendations.
    4. participate in developing a coordinated, ongoing care plan in the community.
    5. obtain a social history that identifies potential limitations in the home setting which may require an alteration in the medical care plan to protect the patient’s welfare.
  3. Attitudes: Each student should:
    1. demonstrate teamwork and respect toward all members of the health care team.
    2. demonstrate responsibility for patients’ overall welfare.
    3. participate, whenever possible, in coordination of care and in provision of continuity.