[Patient-oriented quality assurance. Information and cooperation of the health services as a condition for integrated care].

The increasing care needs of the elderly and chronically ill have a growing impact on health care services. With complex needs to meet, the patient's quality of life depends on multiple factors, of which the continuity of care plays an important role. Information on the past and present health state and on self care resources are prerequisites for adequate rehabilitation efforts that are patient-oriented and of high quality. Institutionally induced "cascade episodes of incompetence" (Ulmer & Saller, 1994) have to be avoided. To make sure that interventions promote or stabilize the quality of life, the participation of the client is crucial in all stages of the process of care planning and coordination. Integrated care requires the exchange of information and close coordination on the concept of care between all participants in the care process. Yet, collaborative care is often seriously jeopardized by lack of knowledge about the concepts, scope of action and requests of the involved health professionals and services. At the Agnes Karll Institute of Nursing Research an action research project aiming at cooperative quality assurance was carried out. It became obvious that there is a large amount of intersectoral knowledge necessarily needed by all professionals and services to ensure seamless professional care. But often they have no access to the information needed. Therefore a client's accompanying booklet was developed to pass on basic information. It is kept by the client and shall be used and filled out by them, their relatives and the different health professionals and health care services involved.