Comprehensive care of the chronically ill cancer patient: an inter-agency model

The article identifies continuity of care between hospital and community as the key element of comprehensive health care for the chronically ill cancer patient. It describes the collaborative effort of the Michigan Cancer Foundation and the Metropolitan Detroit Cancer Control Program to provide this continuity. The structure, process, and outcome of the inter-agency model is presented and illustrated through case example. The authors believe that this model is applicable to treatment of persons with other chronic diseases which require frequent hospitalization.