Bridging the information gap between hospitals and home care services: experience with a patient admission and discharge form.

Hospital care and ambulatory care are institutionally and financially so deeply separated in Germany that discontinuity of individual treatment and, hence, losses in both the quality and efficiency of care are all too often the consequences of this widely deplored systemic defect. In order to improve the communication between home care services and hospitals during admission or discharge of patients in need of long-term nursing care, the research project 'aski' has developed an innovative instrument and procedure for the reciprocal transfer of information between these institutions. After successful testing, the Patient Accompanying Form was offered for public use. Two years later, a written and telephone survey was conducted among the somewhat disappointingly small number of its users. Based on their experience, issues surrounding the implementation of such instruments in the health care system are discussed as well as the chances of enhancing integrative care by promoting coordinated communication between the providers.