I recently read a Swedish blogpost with the title “Recovery stops when patients are discharged from healthcare” (in Swedish). Sweden participated in an international evaluation “International Health Policy Survey”, and the results show that Swedish healthcare ranks low on areas regarding continuity of care and coordination. I’m not surprised (and neither is the representative from the board of health and welfare commenting on the results). I have worked within homecare of elderly and stroke patients, and the dominating experience is that as long as the patients are in hospital everything works relatively well, but after discharge chaos sets in. Many different care providers are involved, without proper communication and information sharing tools and patients and their family carers are left to try to navigate the muddy waters of primary care and social services as best they can. As expressed in the article above, the support for patients’ continuous self-management (with the help of family or social services) is also very low.
From a health informatics perspective there remains a lot of work to be done to adapt the monolithic and profession-centered health information systems to a team-based, collaborative healthcare environment where continuity of information can be provided and where all members of the team (including patients and family carers) have adequate support for their activities!