Continuity of Care

objectives:

After successful completion of this module, you will be able to:

•Apply principles of community partnerships and collaboration to engage stakeholders in addressing community health needs and improving outcomes.

•Develop and implement comprehensive plans for continuity of care, including effective referral and discharge processes.

•Utilize case management strategies and holistic assessment skills to coordinate services and address the multifaceted needs of clients.

•Integrate informatics and telehealth technologies to enhance continuity of care in community health settings.

•Advocate for the client/community by understanding and influencing health policy to promote equitable access to resources and improve population health.

objectives

2 questions over this knowt

2 questions over this knowt

define continuity of care

providing consistent and coordinated healthcare services to a patient over time, ensuring a smooth transition between different healthcare settings and providers

define informational contonuity

•Knowing past events and personal circumstances to make current care appropriate for client

define management continuity

•Consistent approach to management of health condition that is responsive to changing needs

define relational continuity

Ongoing therapeutic relationship between patient and one or more providers

continuity of care triangle

continuity of care triangle

define (textbook) care management

•Evaluation of healthcare interventions, including need and appropriateness of care, to attain effective and efficient outcomes

•Key to reducing costs and saving time

(case management is a sub portion of this)

define CASE management

•“an integrated collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes” (CMSA)

•Advocacy role

•Case management is a building block of care management

Case Management Continuum of Health Care

Case Management Continuum of Health Care

what is the role of the case manager?

•Advocacy and education

•Clinical care coordination/facilitation

•Continuity/transition management

•Utilization/financial management

•Performance and outcomes management

•Psychosocial management

•Research and practice development

breakdown disease management

•Coordinated healthcare interventions and communications for chronic disease

•Secondary and tertiary prevention 

•Collaborative practice models 

•Moving toward treating comorbidities together

what is the role of case managers when transitioning from acute to outpatient?

•Largest role for case managers

•Increase in prevalence of chronic disease

•More transitions in and out of acute care with increased need for support

what are some examples of referrals?

•Specialists for consultations

•Behavioral health

•Job assistance

•Insurance Medicare Medicaid

•Food banks

•Housing

•Child Care

•Educational programs

•Home Health

•Rehabilitation

•Physical therapy

•Disability services

what is the following:

•EHR and billing

•Telehealth

•Predictive Modeling and Data Analysis

technology used in the continuity of care

who are some stakeholders in community partnerships?

•Families

•Community Agencies

•Schools

•Employers

•Faith based organizations

•Advocating in public spaces and legislative bodies