unit 12

Communicating for Continuity of Care

Ensuring that patient care is consistent and seamless across different providers, settings, and time frames.

Key Communication Practices

Detailed Handoffs, Electronic Health Records (EHR), Discharge Planning, Care Coordination Meetings.

Detailed Handoffs

Using tools like SBAR or I-PASS for shift changes and transfers.

Electronic Health Records (EHR)

Shared access among all providers.

Discharge Planning

Clear instructions for patients and next care teams.

Care Coordination Meetings

Regular interdisciplinary updates.

Challenges in Continuity of Care

Fragmented care systems, inconsistent documentation, time pressures and heavy workloads.

Relational Continuity

Ongoing therapeutic relationship between a patient and a consistent care provider/team.

Application of Relational Continuity

Assigning primary care providers (PCP) to patients, continuity clinics, building trust and rapport over time.

Informational Continuity

Using accurate and up-to-date information about the patient's history, preferences, and care across encounters.

Application of Informational Continuity

EHR systems with comprehensive patient records, accessible care plans and medical histories, standardized documentation.

Management Continuity

Coordinated and consistent management of a patient's care, especially for chronic or complex conditions.

Application of Management Continuity

Care pathways and protocols, case management programs, regular review of treatment plans.

Comparison of Types of Continuity

Relational: Ongoing relationship with provider/team; Informational: Consistent use of patient info across settings; Management: Consistency in treatment approach across providers.

Example of Relational Continuity

Long-term PCP, consistent home health nurse.

Example of Informational Continuity

EHR access, shared care plans.

Example of Management Continuity

Coordinated chronic disease management.