Patients hospitalized in the Hadassah University hospital, who were residents of a Jerusalem neighborhood, were followed for six weeks and one year after discharge from hospital in order to assess their progress and need for further medical care. One year after hospital discharge, 601 patients were found (representing 90 per cent of known survivors). Sixty-one per cent were assessed to be in need of further medical care for the condition for which they were originally hospitalized. While the majority of those in need were receiving medical care by a physician, a considerably smaller number were receiving nursing care. The fact that a proportion of patients in need were not receiving medical care is considered to be due to the prevailing system, where there are inadequate administrative arrangements for ensuring continuity of care of post-hospitalized patients. The initiation of a coordinated care program for such patients is reported. The community nurse, as a member of the program team, is regarded as the key professional worker in ensuring that continuity of care by hospital and community doctors and the recommended care program are, in fact, taking place.
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