Continuity of care is all about simplicity. It’s about improving patient experience by creating a system in which they get to see the same core team of healthcare providers, who become familiar with the patient’s health history and needs over time.
As far back as 2018, research has demonstrated an association between higher rates of continuity and reduced all-cause mortality (BMJ, BJGP). More recently, a 2023 systematic review of recent research identified a significant association between fragmented care and adverse outcomes of chronic illnesses (Nursing Open).
Continuous care requires a dedicated effort to ensure seamless and coordinated navigation through the intricate network of healthcare, beginning with the initial consultation and extending to subsequent follow-ups. Central to continuity of care is a focus on prioritizing patients’ specific needs, building trust, and nurturing understanding between those receiving treatment and the various health providers they interact with.
Today’s medical systems are complex, yet continuity of care aims to maintain patient safety by offering consistent standards in treatments over time. It represents an assurance to patients that despite potential confusion amidst referrals or changes during their course of treatment, they’ll experience a consistent and coherent approach that guides them toward improved health.
In this article, we’ll discuss the importance of continuity of care towards achieving superior quality in delivering medical services and offer practical perspectives on how to achieve it.
Continuity of care is the consistent and seamless provision of ongoing health care management to a patient over time, ensuring coordinated and high-quality treatment across various providers and settings.
The concept of continuity in care is pivotal to the management of patient health, giving patients a unified and methodical course throughout the complex terrain of medical services. Hand-in-hand with a patient-centered approach to care, establishing continuity is a dedication to enhancing patient treatment across various health settings (including family medicine, nursing, brain health, and more). The approach centers on safeguarding patient welfare while providing cost-efficient healthcare solutions.
Haggerty et al. (BMJ) identified three types of continuity in every discipline:
For these three types of continuity to be achieved, there needs to be an understanding of each patient’s medical history paired with diligent communication efforts within the continuum of healthcare providers. Excellent notes and record-keeping (from both in-person consultations and telehealth services) are also key.
Together, these elements construct a robust framework dedicated to team-based strategies for managing patients’ cases and incorporating social support services into overall wellness plans—all aimed at achieving superior standards in healthcare provision.
Care continuity is particularly important in the settings that nurse practitioners occupy. Nurse practitioners are tasked with understanding their patients' needs and effectively communicating this information to physicians, specialists, and fellow nurses, making them a linchpin in successful continuity of care.
By effectively sharing detailed patient records and fostering an environment of trust, nurse practitioners contribute to several critical aspects, including:
The uninterrupted continuum of management is vital for fostering improved outcomes for those under medical supervision while also enhancing their overall experience with the healthcare system.
When there’s steady interaction with either a single nurse practitioner or provider, it paves the way for better communication channels, which can lessen errors related to medical attention and heighten levels of contentment among those receiving care.
Maintaining continuity of care in the realm of brain health is crucial, as it guarantees that patients with neurocognitive conditions experience consistent and well-integrated health services throughout their rehabilitation process.
Particularly in the context of progressive conditions like dementia, reducing redundancy in care is critical as it can mean more timely care, better patient compliance, and less strain on patients and caregivers.
Neurocognitive conditions often require care from multiple providers like primary care providers, neurologists, therapists, and social workers. For patients dealing with dementia, traumatic brain injury, Parkinson’s disease, or any other neurocognitive condition, continuity of care is essential because it:
For example, in one study following dementia patients, continuity of care was associated with lower rates of hospitalization, emergency department visits, testing, and health care spending (JAMA Intern Med). As another example, supporting patients transitioning from an acute care environment to community-based rehab facilities is an approach that can combat issues such as mobility constraints and helps avert social isolation by providing continual support.
Related: Discussing Cognitive Health: How to Talk About Cognitive Health Care With Patients
In the past 10+ years, emergency mental health visits for young people have more than tripled. But what happens once the patient is discharged? A recent study (Mental Health Research) explored the importance of continuity of care in follow-up appointments for young patients with diagnosed psychiatric conditions. It also touched on the challenges healthcare providers face in delivering that care.
A standout outcome from the above-mentioned study was that young people were at least three times more likely to attend the follow-up community appointment if they had already seen the designated clinician before discharge.
The results of this study point to important questions healthcare providers face today about how to address gaps in continuity. Potential solutions include being able to administer regular mental health questionnaires, improve continuity of reporting between care teams, track significant changes, and more.
Continuity of care in mental health could entail:
Within the realm of mental health, maintaining uninterrupted care goes beyond healthcare professionals. It equally highlights services such as community groups, day centers, and other socially oriented organizations that offer consistency outside of a medical setting.
Continuity of care involves all individuals in team-based care—from family physicians to specialists, support staff to caregivers, and beyond. Here are just a few examples of continuity of care practices that clinicians, nurse practitioners, neurologists, and mental health professionals can implement:
Nurse practitioners have an extremely active role in patient care and can enhance continuity of care in many ways, such as:
Interdisciplinary teams comprising neurologists, rehabilitation specialists, and primary care providers embody the principle of continuity of care. If members of the team prioritize continuity of care, patients gain the benefits of collaborative plans, fewer redundant tests, and involvement of the right professionals at the right times.
Continuity of care in mental health services involves tight coordination between psychiatrists, psychologists, and primary care providers to ensure treatment plans remain consistent. It’s imperative that all therapeutic interventions and prescriptions are clearly communicated among various health providers. Those receiving care place high importance on readily available access to these services as well as support after leaving the hospital and from peers—elements deemed essential for sustained continuity (Psychiatric Services).
At a high level, the objective of continuity in care is centered on advancing patients’ health by minimizing unnecessary handoffs between multiple providers—and improving information transfer and collaboration across the care team. Care continuity also encourages patient satisfaction and involvement through an approach where individuals feel attentively looked after.
Below, we’ll explore tactics and expected outcomes that ladder up to better care continuity.
To enhance this aspect of healthcare delivery, strategies should include:
Focusing on these strategic areas can lead to streamlined processes, more integrated care provision, and robust relationships between patients and their healthcare providers—all fundamental components necessary in securing improved outcomes for patients as well as elevating the overall standard of healthcare quality.
Maintaining patient engagement within the healthcare system (for as long as necessary) is fundamental to achieving successful outcomes. Several factors, especially those connected with continuity of care, might cause patients to disengage from their own healthcare journey:
Continuity of care best practices are designed to address and overcome the various challenges that can disrupt seamless healthcare delivery. Effective coordination, proactive management strategies, the integration of telemedicine, and virtual primary care help prevent discontinuities in care or unwarranted visits to emergency departments.
How many touchpoints with a healthcare provider does a patient typically have? Medicare patients have reported receiving care from five or more physicians within the span of a year (Senate Committee of Finance). And for a single medical condition, some patients have as many as “50 interactions in a three-month period (through various modes of communication) between patient, primary care physician, and other physicians” (NEJM). Let’s expand on what this can look like:
Imagine a patient with dementia. They first visit their primary care physician, who refers them to a neurologist. At the neurologist's office, the patient must recount their entire medical history, including symptoms, previous tests, treatments, and medications, despite having already provided this information to their primary care physician. After a few weeks, the patient is referred to a geriatric psychiatrist, where they once again have to repeat their medical history and treatment details.
This repetitive process frustrates the patient and makes them feel that the healthcare system is disjointed and inefficient. They feel like a number rather than a person, and their trust in healthcare providers diminishes. The lack of continuity in care means that each provider works with incomplete information, leading to miscommunication, redundant tests, and delays in receiving appropriate treatment. The overall experience is marred by unnecessary and redundant touchpoints, making the patient feel overwhelmed and undervalued.
Moreover, their caregiver, who often accompanies the patient to these appointments, experiences significant frustration as well. They must repeatedly explain the patient's condition and history to different providers, which can be emotionally exhausting and time-consuming. The caregiver's stress levels increase as they navigate the fragmented healthcare system, feeling as though they must constantly advocate for the patient to ensure they receive the necessary care.
By ensuring continuity of care through the use of electronic health records (EHRs) and coordinated communication among providers, these unnecessary touchpoints can be minimized. This would lead to a more streamlined and patient-centered experience, where the patient feels heard, respected, and efficiently cared for, and the caregiver experiences less stress and frustration.
Continuity of care best practices are essential for speeding up the time to symptom improvement. By ensuring a unified and steady regimen, healthcare providers can create a seamless treatment experience that places the patient at the center. This approach fosters quicker relief from symptoms and improved overall health outcomes.
Research has shown that patients who experience continuous care are more likely to adhere to treatment plans and follow medical advice, leading to faster recovery times.
For example, one study (BMC Psychiatry) focused on the treatment of psychiatric disorders found that higher continuity of care significantly reduced symptom severity and significantly increased social functioning.
Another study (The British Journal of Psychiatry) looked at the long-term efficacy of a continuity-of-care treatment model for patients who transition from inpatient to outpatient services, resulting in significantly reduced admission time. In other words, patients were able to return to their everyday lives faster.
The results of this study underscored the effectiveness of a continuity-of-care model, which revolved around an integrated ‘continuity team’ led by senior psychiatrists and comprises paramedical personnel, including occupational therapists, psychologists, and expressive art therapists.
Continuity of care is associated with improved health outcomes. Patients receiving consistent and cohesive medical services tend to follow through with medical recommendations, engage more in preventative healthcare measures, and have reduced instances of hospital admissions and emergencies.
Numerous studies have highlighted the positive impact of continuity of care on health outcomes. For example, a study published in BMC Psychiatry indicated that higher relational continuity of care for patients with serious mental illness may:
Implementing best practices such as interdisciplinary collaboration, effective communication, and personalized care plans ensures that patients receive consistent and cohesive treatment. This is particularly vital for individuals with complex health needs, as it allows for the integration of efforts across various healthcare providers, significantly accelerating the healing process.
Active patient engagement and involvement in their care journey further enhance the effectiveness of continuity of care. Patients who are well-informed and actively participate in their treatment plans are more likely to experience prompt symptom relief and better long-term health outcomes.
Improving both the satisfaction and active involvement of patients is at the heart of care continuity (JECP), which offers significant benefits such as:
With digital engagement technologies (like cognitive testing) and resources enhancing continuity in healthcare, not only are health outcomes improved, but also the overall experience of receiving medical attention. This transforms recipients into engaged partners in managing their own healthcare paths.
A Continuity of Care Document (CCD) is a standardized electronic document designed to facilitate the exchange of patient information across different healthcare settings. The CCD is formatted in a standardized manner and contains critical aspects of an individual’s medical history, which allows for fluid exchange of information among various medical professionals.
This record ensures that every provider possesses the requisite knowledge to uphold the caliber and consistency of treatment provided, independent of their history with the patient or case. The primary goals of the CCD are to ensure continuity of care and improve patient outcomes by providing a comprehensive and up-to-date summary of a patient's health information.
A continuity of care document thoroughly details a wide range of information, covering:
The CCD incorporates detailed care plans that reflect the entirety of a patient’s health journey, helping to ensure that:
The CCD also helps mitigate some of the common challenges to providing continuity of care, such as:
These factors may complicate the evolving narrative of a patient’s medical experiences and pose difficulties in achieving steady provision of healthcare services but a CCD can help smooth those transitions.
Continuity of care is about connecting the dots in a patient’s healthcare journey, reducing complexities, and fostering a cohesive healthcare environment. By embracing the strategies and innovations discussed, healthcare providers can overcome challenges and improve patient outcomes.