Coordinating care in an integrated delivery system.

To keep patients from falling through the cracks, each point of service in a healthcare system must understand its role in the patient's overall care and have access to the right information at the right time. Communication and a system's organization play significant roles in making coordinated care work: Some health systems prefer to keep patients with common diagnoses in service lines that take them from preadmission to home care; others set up separate organizational entities to coordinate care for all patients with chronic illness. Regular meetings on patient status, standardized forms and clear job descriptions all help minimize confusion.