Continuity of care is an ideal in which health care is provided for a person in a coordinated manner and without disruption despite involvement of different practitioners in different care settings. Also, all people involved in a person's health care, including the person receiving care, communicate and work with each other to coordinate health care and to set goals for health care.
Continuity of care is not always easy to accomplish, especially in the United States, where the health care system is complicated and fragmented. When continuity of care is missing, people may not adequately understand their health care problems and may not know which practitioner to talk to when they have problems or questions.
Challenges to Continuity
Continuity of care is a particular concern for older people. Older people are particularly likely to have several doctors (each specializing in one organ system or problem) and thus to move from one care setting to another (called transition of care). They may receive care in several doctors' offices, in a hospital, in a rehabilitation facility, or in a long-term facility.
Having many practitioners at many places may disrupt the continuity of an older person's health care. For example, one health care practitioner may not have up-to-date, accurate information about the care provided or recommended by other practitioners. That practitioner may not know the names of the other practitioners involved or may not think to contact them. Information about care may be misremembered, miscommunicated, or misunderstood, particularly when older people have disorders affecting speech, vision, or cognition that make it more difficult for them to communicate effectively. An older person may mention an important detail to one practitioner and forget to mention it to the others.
To ensure that care is continuous (and optimal), all practitioners involved must have complete, up-to-date, and accurate information about what other practitioners have done—particularly about tests done and drugs prescribed. When this information is missing or miscommunicated, the following can result:
Different practitioners may have different opinions about a person's health care. For example, practitioners in a hospital may disagree with a person's primary care doctor about whether surgery is required or about whether the person should go to a nursing home after being discharged. The person and family members may be overwhelmed and confused by differences of opinion among the various practitioners.
People taking many prescription drugs, as is common with older people, may fill their prescriptions at different pharmacies (for example, the one nearest each specialist's office). When different pharmacies are involved, each pharmacist may not know all the drugs people are taking and thus will not know when a newly prescribed drug might interact negatively with a current one.
Moving from one care setting to another (transition of care), such as going from a hospital to a skilled nursing facility, increases the chance that errors in care may occur. New drugs may be prescribed in the hospital, and they may duplicate or interact negatively with the person's other drugs. Sometimes old, needed drugs may be unintentionally omitted. Even when changes in people's drugs are appropriate, the changes may not be communicated to all involved health care practitioners, such as the primary care doctor.
To prevent such problems, current regulations in the United States require health care organizations to do drug reconciliation whenever the care setting is changed and whenever new drugs are ordered or existing orders are rewritten. Drug reconciliation involves comparing people's drug orders to all the drugs they were previously taking and thus make sure no drugs are duplicated or omitted. When changing care settings, older people or their caregiver needs to ask one of the hospital staff members, such as a nurse, doctor, or social worker, whether drug reconciliation was done. People should also be sure to obtain their own copy of the current drug regimen. They should then compare it with the list of drugs that they have been taking and check to make sure that no drugs are duplicated. If they have any questions, they should contact their primary care doctor. Making an appointment with the primary care doctor soon after discharge from the hospital is always a good idea. The doctor can then review all of the drugs and instructions recommended by the hospital.
The health care system has many rules that affect continuity of care. The rules may be made by the government, insurance companies, or professional organizations for health care practitioners. For example, some insurance companies limit which hospital people can go to. The person's doctor, if not on staff at that hospital, may be unable to provide care there. As a result, important information about the person may not be communicated.
Lack of Access to Care:
Continuity of care may be disrupted when people do not have access to health care. For example, older people may miss a follow-up appointment because they do not have transportation to a doctor's office. They may not see a doctor or specialist because they do not have insurance and cannot afford to pay for health care themselves.
Strategies to Improve Continuity
Improving continuity of care requires efforts by the health care system, by the people receiving care, and by family members.
Health Care System
Managed care organizations and some government health care plans coordinate all health care and thus contribute to continuity of care. Also, the health care system has developed several strategies to improve continuity of care. Examples are
Interdisciplinary care is coordinated care provided by many types of practitioners, including doctors, nurses, pharmacists, dietitians, physical and occupational therapists, and social workers. These practitioners make a conscious, organized effort to communicate, cooperate, and agree with each other about a person's care. Interdisciplinary care aims to ensure that people move safely and easily from one care setting to another and from one health care practitioner to another. It also aims to ensure that the most qualified health care practitioner provides care for each problem and that care is not duplicated. Interdisciplinary care is not available everywhere.
Interdisciplinary care is particularly important when treatment is complex or when it involves movement from one care setting to another. People who are most likely to benefit include those who are very frail, those who have many disorders, those who need to see several different types of health care practitioners, and those who have side effects from drugs.
The practitioners who care for a particular person are called the interdisciplinary team. One practitioner, often the person's primary care doctor, coordinates care.
Sometimes the health care practitioners on an interdisciplinary team do not work together on a regular basis (an ad hoc team). They come together to meet a particular person's needs. In other situations, there is an established team with the same members who usually work together and who care for many people. Some nursing homes, hospitals, and hospice organizations have established teams.
Team members discuss plans for treatment and inform each other about changes in the person's health, changes in treatment, and results of examinations and tests. They make sure that the person's records are up-to-date and that the records accompany the person through the health care system. Such efforts help make changes in care setting or in health care practitioners smoother and less traumatic. Also, tests are less likely to be repeated unnecessarily, and mistakes or omissions in treatment are less likely.
The interdisciplinary team also includes the older person being cared for and family members or other caregivers. For effective interdisciplinary care, these people must actively participate in care and must communicate with the health care practitioners on the team.
Geriatric Care Managers:
These people are specialists who make sure that an older person receives all the help and care needed. Most geriatric care managers are social workers or nurses. They may be members of an interdisciplinary team. Geriatric care managers can make arrangements for the services needed and supervise these arrangements. For example, care managers may arrange for a home nurse to visit or for an aide to help with housecleaning and preparation of meals. They may locate a pharmacy that delivers drugs or arrange for transportation to and from the doctor's office. Geriatric care managers are relatively uncommon.
People Receiving Care
To help improve the continuity of their care, older people or their caregivers can take a more active part in their care. For example, they can learn more about what can interfere with continuity, how the health care system works, and what tools are available (such as care managers or social workers) to improve continuity of care. Being familiar with their disorders and the details of their health insurance plan can also help.
Active participation begins with communication—giving and getting information. When older people have special health care needs or questions, they or their family members should tell their health care practitioners. For example, older people often need help determining which drugs are covered by their Medicare prescription drug plan.
When an interdisciplinary team or geriatric care manager is unavailable, people who are receiving care or their family members need to become proactive in care. For example, older people or their caregivers need to establish an ongoing relationship with at least one health care practitioner, usually the primary care doctor, to minimize the problems created by having several health care practitioners. Older people should make sure the primary doctor is aware of changes in their condition and their drugs, especially when a specialist has made a new diagnosis or changed a treatment regimen. They may need to ask one health care practitioner to call and talk with another to make sure that information is communicated clearly and that treatment is appropriate.
Active participation also includes seeing a health care practitioner (usually the primary care doctor) regularly and following the instructions of health care practitioners. It means asking questions about a disorder, treatment, or other aspect of care. It includes learning how to prevent disorders and taking the appropriate steps to do so.
For people who have a disorder, active participation may involve self-monitoring. For example, people with high blood pressure can regularly monitor their blood pressure. People with diabetes can regularly check the level of sugar in their blood.
Keeping a copy of their medical record can help people participate in their health care. They can often obtain a copy from their doctor. A copy of the medical record is useful as a reference for information about disorders present, drugs being taken, treatments and tests done, and payments made. This information can also help people explain a problem to a health care practitioner. File boxes, binders, computer software, and Internet programs have been designed for this purpose. When more than one doctor is involved, people can keep their own records of their care, including the type and date of examinations and procedures and a list of their diagnoses. At a minimum, people should keep a record of all drugs (prescription and nonprescription) they are currently taking, plus the doses and the reason they are taking the drug. They should bring this record with them each time they visit a doctor.
When people go to a hospital or to a new health care practitioner, they should check with someone at the new location to make sure that their medical record has been received.
Buying all drugs (prescription and nonprescription) at one pharmacy or through one mail order service and getting to know a pharmacist there are also important. Older people can ask their pharmacist questions about the drugs they are taking. They can also ask for containers that are easy to open and labels that are easy to read.
Last full review/revision January 2009 by Mary Ann Anderson, PhD, RN