The American Healthcare Enterprise is a complex and complicated system with conflicting demands often placed on healthcare workers and Providers as they navigate toward a positive patient outcome. This all has to be accomplished with patient safety as the ever-present guardrails. Maintaining continuity of care in this complex system is crucial for patient safety as it builds trust, ensures staff and providers are kept aware of patient needs and vulnerabilities, and coordinates treatment, preventing fragmented care, errors, and readmissions, especially for chronic conditions, through strong provider-patient relationships, seamless team communication, and robust information sharing. Ultimately, maintaining continuity of care reduces adverse safety events and improves patient outcomes.
Members of the healthcare team must understand the elements that support the concept of continuity of care, including their role in preserving it to support safe patient care. These elements can be employed in most organizations, regardless of the technology or the level of investment in time, money, or human resources. These include relational continuity practices, care coordination, and patient empowerment.
Healthcare is based on relationships. Effective and safe healthcare is built on strong, consistent relationships. This includes having the same core team (doctors, nurses, techs, etc.) associated with the same patient. This relationship builds trust, improves communication, and helps identify subtle changes in health. Familiarity builds consistency in processes and expectations (especially with emergent situations). Organizations should support maintaining consistent patient assignments. Likewise, when relationships are inconsistent (shifting assignments, contract staff, etc.), there should be greater awareness of potential risks.
If healthcare is built upon relationships, the sharing and flow of information are the lifeblood that sustain it. Optimizing the sharing of patient information, including medical records, and supporting transparency in health status updates between providers and staff ensures everyone is on the same page, preventing duplication or missed care. Ensuring openness with patients and their designated representative is critical in establishing an effective discharge plan. Organizations should review their information streams, especially when addressing adverse or near-patient events, to identify real or potential vulnerabilities in establishing continuity of care through the flow of information in healthcare delivery.
One of the most vulnerable aspects of patient care, associated with poor patient outcomes and safety events, is failing to coordinate effective care. Combining relational continuity with information flow into an effective plan of care that coordinates all members of the healthcare team toward mutually agreed upon goals supports optimal patient outcomes. Lack of coordination of healthcare disciplines results in chaos. Transitions of care are especially vulnerable as they can present a break in care coordination. Seamless transitions between different care settings (hospital to home, primary to specialist, unit to unit, etc.) are vital as the responsibilities of patient care shift. Gaps in information, missing elements of care plans, and environmental changes contribute to incongruities in the plan of care. Leaders must empower the healthcare team and hold them accountable for coordinating care across all disciplines. The use of standardized communication protocols, practices, and check/recheck procedures is critical to ensuring nothing is missed.
Patients are the center of the healthcare team. When patients are included in team discussions, they feel heard and involved and are more likely to adhere to treatment regimes, enhancing safety and positive outcomes of care. Designated patient representatives, often family members, are instrumental in supporting continuity of care, especially with discharge planning. They are vital sources of information and can reinforce treatment plans for their loved ones after discharge. Organizations should ensure they include patients and their representatives in treatment planning. Additionally, documentation of patient/representative discussions, including treatment and discharge planning, is essential to communicate with the healthcare team.
Strengthening the continuity of healthcare delivery supports positive patient outcomes, especially by addressing vulnerabilities in patient safety. Standard work practices and solid communication have demonstrated effects on preventing patient harm in various ways.
When healthcare team efforts are coordinated around clear goals and expectations, the risk of missed steps or conflicting treatments is lower. Consistency in healthcare delivery through standardized procedures, checklists, protocols, and response plans is proven to ensure safety even as patient conditions change. Most reviews of patient safety events show that harm occurs when staff fail to follow policy or established procedures.
Consistent care for chronic illnesses improves long-term health and prevents crises. All team members who understand the patient’s treatment plan goals and how they contribute to achieving them are more likely to recognize variations in the patient’s condition and respond accordingly.
Proactive, continuous management reduces the need for emergency care and readmissions. Patients who understand and follow their treatment plan at home are less likely to be readmitted. This will require detailed education on the treatment plan communicated to the patient and/or their representative.
There are many initiatives organizations can employ to address continuity of care. These include consistencies in staffing, training, structure, and so forth. Our review and experience point to the following as primary initiatives organizations should consider, as they may provide the most benefit.
Organizations should use structured communication during transitions of care (e.g., transfers, shift changes, discharge). As mentioned earlier, these transitions are the most vulnerable time for patient safety events, during which patient risks are not communicated or are missed. Scripted checklists are often helpful in ensuring that important information is not missed.
The use of shared electronic health records (EHRs) for seamless information exchange optimizes the continuity of documentation across Nursing, Physicians, Specialists, and ancillary staff. An integrated EHR provides a centralized repository of patient data, including treatment plans and the patient’s progress toward the plan goals. For organizations that do not have an integrated EHR platform or are entirely hardcopy-based, the challenge is to develop a hub within their platform where information can be shared across all disciplines. The design of this collaborative hub is based on the technology and design of their existing documentation systems, but it is crucial to ensuring that information is shared between disciplines.
Fostering collaboration and understanding of roles within interdisciplinary teams can support continuity in treatment delivery. Maintaining structure, command, control, and consistency is paramount. Ensure that teams meet with all required disciplines to share and receive information on the patient’s progress toward goals. Develop a shared mental model of the care plan so team members can anticipate potential changes in patient condition and report them. Ensure a culture of safety exists that allows all team members to provide input and ask questions when concerns arise freely.
Keeping the patient an integral part of the care team includes providing clear information about their condition and treatment goals. Ensure they and/or their designated representative have accessible contacts for questions or concerns. Be mindful of language and comprehension limitations to avoid misunderstandings. Provide patients with written instructions, guidelines, and resources upon discharge or transfer.
Continuity of care is critical in addressing patient safety risks. As healthcare has become increasingly complex, maintaining consistency across all aspects of healthcare delivery is essential to avoid miscommunication, improve efficiency, and support patient satisfaction. Organizational leaders should support the development of standard practices and workflows, communication pathways, and a culture that maintains the continuity of healthcare practice
For questions or to learn more, contact the C&A team at 704-573-4535 or email us at info@courtemanche-assocs.com.
