Table 1 Problem setting before the implementation of case management

1. Enquiries and coordination

All enquiries about admission to the palliative care ward, for the palliative home care service, for advice from the palliative consultation service and for information and advice in general have previously been dealt with by various professional groups such as physicians, nursing staff and the central office. There was no set contact point for external or internal professional groups, or for patients and relatives. This frequently led to misinformation.

2. Communication

Communication was not transparent between different care settings as the method of information transmission was not clearly defined.

3. Care

Palliative patients receive need-orientated care. Because of frequent changes in symptoms and problem settings, a flexible reaction of all palliative care team members is required. Before the implementation of case management, some services like the transfer management or social services were often not included in due time. As a result, continuity of care could not always be guaranteed.

4. Networking

There was insufficient networking between departments in the hospital and between the hospital and other hospitals, general practitioners and specialists, outpatient care services, outpatient hospice services and inpatient hospices.