RESUMO
It is no exaggeration to say that the linkage among the persons in various specialties, medical staff including the home doctors and visiting nurses, and those related to social welfare is essential for supporting and promoting the terminal care at home of the patients heavily dependent on medical care, as well as the patients and their families with problems in the nursing ability. Good understanding of other specialties and compensation for each other are considered to enable effective service to the patients. At our hospital, we have planned and convened case review sessions for the past two years. The sessions were proved to have the following merits that helped creation of teamwork for smoothly promoting medical care at home: 1. Persons in each specialty became able to play respective roles properly; 2. Measures to be taken were revealed, thereby inducing changes in the subsequent care; 3. The efforts made in the community could be understood and the problems to be wrestled within the hospital were suggested; 4. Smooth cooperation with visiting nurses and home doctors was achieved; 5. Nursing from a broader point of view became possible; and 6. A place for identifying problems and tasks under the present situation was provided.
