Establishing interfaces between community- and hospital-based service systems for the elderly.

The gerontological service delivery system often fails to integrate the different types of services needed at different times by older clients. Social workers need to address the urgent and increasing need for communication among acute care hospitals that are diversifying into areas previously the domain of community-based providers of services for the aged. Coordinated care case management programs were developed in seven hospitals to determine whether hospitals could serve as a logical entry point of frail elderly persons into the system. Examination of the experiences of these hospitals illustrated the need for models of service integration and resulted in several approaches to comprehensive service delivery and coordination. Social work professionals in both acute and long-term care settings need to understand all aspects of the service delivery system to ensure that elderly clients receive appropriate levels and continuity of care in a complex and constantly changing system.