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Continuity of Care


Debra Bakerjian

, PhD, APRN, University of California Davis

Reviewed/Revised Oct 2022
Topic Resources

Providing medical care to older people can be complicated. People often have many different health care practitioners at different locations. Travel and transportation issues become more difficult as people age. The medications that are covered by the Medicare prescription drug plan vary between insurance companies and change frequently. Assistance by a team of health care practitioners under the leadership of a primary care physician or a doctor who specializes in the care of older people (geriatrician) is the best way to deal with these complexities.

Continuity of care is an ideal in which health care is provided for a person in a coordinated manner and without disruption despite all the complexities of the health care system and the 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

However, 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 of care

Continuity of care is a particular concern for older people. Older people are particularly likely to have several practitioners (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 private practitioner offices, in a hospital, in a rehabilitation facility, and/or in a long-term facility.

Many practitioners

Having several practitioners 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 miscommunicated or misunderstood, particularly when older people have disorders affecting speech, vision, or mental function (cognition) that make it more difficult for them to communicate effectively. Older people 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 medications prescribed. When this information is missing or miscommunicated, the following can result:

  • Diagnostic tests may be needlessly repeated.

  • Inappropriate medications or other treatments may be prescribed.

  • Preventive measures may not be taken because each practitioner assumes someone else has provided them.

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 practitioner about whether surgery is required or about whether the person should go to a nursing home Nursing Homes Nursing homes are for people who need help with health care for chronic conditions but do not need to be hospitalized. The decision to move to a nursing home may be triggered by a change in... read more 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 medications, 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 medications people are taking and thus will not know when a newly prescribed medication might interact negatively with a current one.

Many settings

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 medications may be prescribed in the hospital, and they may duplicate or interact negatively with the person’s other medications. Sometimes medications prescribed previously that are still needed may be unintentionally omitted. Even when changes in people's medications are appropriate, the changes may not be communicated to all involved health care practitioners, such as the primary care practitioner.

To prevent such problems, current regulations in the United States require health care organizations to do medication reconciliation whenever the care setting is changed and whenever new medications are ordered or existing orders are rewritten. Medication reconciliation involves comparing people's medication orders to all the medications they were previously taking and thus making sure no medications are duplicated or omitted. When changing care settings, older people or their caregiver should ask practitioners whether medication reconciliation was done.

If people are not in a health care facility, they and/or their caregivers should do their own medication reconciliation. People should keep a list of their current medications as well as a list of medications they used to take (and why they were stopped). Then, after people see a new practitioner or enter or leave a hospital or other care facility, they should check whether any newly prescribed medications are on these lists. If people see any of the following, they should speak to the practitioner right away:

  • A duplicate prescription for a medication that they are already taking

  • A prescription for a medication that they previously needed to stop taking

  • A missing medication—one that they were taking but that is not on the facility's list of their current medications

Making an appointment with the primary care practitioner soon after discharge from the hospital or other care facility (such as a rehabilitation center or skilled nursing facility) is always a good idea. People should always bring their current list of medications as well as the actual bottles they are in. The practitioner can then review all of the medications and instructions recommended at the time of discharge.

Many rules

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 primary care practitioner, if not on staff at that hospital, may be unable to provide care there. Also, many primary care practitioners no longer provide care in hospitals or rehabilitation centers. As a result, a person in such settings may be cared for by new practitioners who are not familiar with the person's medical history. It is important for the person or the person's caregiver to make sure that all pertinent information is provided to the new practitioner.

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 practitioner's office. They may not see a practitioner because they do not have insurance and cannot afford to pay for health care themselves.

Other problems

People may forget or be unaware that they have an appointment with a health care practitioner.

Not all practitioners participate in all Medicare Managed Care plans. Before seeing a new practitioner, people with Medicare Managed Care plans should check whether that practitioner participates in their plan so that they do not face unexpected costs.

Strategies to Improve Continuity of care

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

  • Geriatric care managers

  • Electronic medical records

Interdisciplinary care

Interdisciplinary care is coordinated care provided by many types of practitioners, including doctors Doctors Because they have different needs, people, particularly older people, often need to see several types of health care practitioners whose skills match their needs. This type of care is called... read more , nurses Nurses Because they have different needs, people, particularly older people, often need to see several types of health care practitioners whose skills match their needs. This type of care is called... read more , pharmacists Pharmacists Because they have different needs, people, particularly older people, often need to see several types of health care practitioners whose skills match their needs. This type of care is called... read more , dietitians Dietitians Because they have different needs, people, particularly older people, often need to see several types of health care practitioners whose skills match their needs. This type of care is called... read more , physical therapists Physical Therapy (PT) Physical therapy, a component of rehabilitation, involves exercising and manipulating the body with an emphasis on the back, upper arms, and legs. It can improve joint and muscle function, helping... read more , occupational therapists Occupational Therapy (OT) Occupational therapy, a component of rehabilitation, is intended to enhance a person's ability to do basic self-care activities, useful work, and leisure activities. These activities include... read more , and social workers Social workers Because they have different needs, people, particularly older people, often need to see several types of health care practitioners whose skills match their needs. This type of care is called... read more . These practitioners make a conscious, organized effort to communicate, cooperate, and come to agreement 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 medications.

The practitioners who care for a particular person are called the interdisciplinary team. One practitioner, who may be the person's primary care practitioner or a social worker or care manager, 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 settings 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

Geriatric care managers 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 medications or arrange for transportation to and from the doctor's office. Geriatric care managers may be members of the team in a health care organization such as a clinic. Alternatively, patients and families may be able to hire them at an hourly rate, which is not reimbursed by Medicare.

Electronic medical (health) records (EMRs)

EMRs contain health information about a person in a digital format. Their purpose is to enable all health care practitioners caring for a person to see accurate, up-to-date, legible, and complete information about the person whenever they need to.

EMRs typically contain demographic and personal information (such as age and weight), the medical history (including vital signs, medications being taken, allergies, and immunization status), test results (of laboratory and imaging tests), and billing information.

EMRs can improve care by

  • Enabling practitioners caring for a person to communicate with each other more easily and more quickly

  • Reducing mistakes and omissions made because practitioners lacked needed information

  • Reducing the number of duplicated tests

  • Reducing delays in treatment

  • Enabling people to have access to their medical records and participate more fully in their own health care

However, there are many different EMR systems. Practitioners and hospitals often cannot read records created by practitioners and hospitals that use a different system. Furthermore, the information in EMRs is only as accurate as the data that are entered by previous practitioners, and data entry is often very time-consuming. When possible, people should verify the information contained in their EMR.

People Receiving Care

To help improve the continuity of their care, older people and their caregivers (whether family members, people outside the family, or both) can take an 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 resources (such as care managers or social workers) are available 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 medications are covered by their Medicare prescription drug plan.

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 practitioner, to minimize the problems created by having several health care practitioners. Older people should make sure the primary care practitioner is aware of changes in their condition and their medications, 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 means asking questions about a disorder, treatment, or other aspects of care. It also includes learning how to prevent disorders and taking the appropriate steps to do so.

For people who have a disorder, active participation often involves following a healthy lifestyle. For example, people with high blood pressure can follow a heart-healthy diet and exercise regularly. People can also monitor their condition at home. For example, people with high blood pressure can check their blood pressure, and people with diabetes can measure 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 primary care practitioner. A copy of the medical record is useful as a reference for information about current disorders, medications being taken, treatments and tests done, and payments made. This information can also help people explain a problem to other health care practitioners. File boxes, binders, computer software, and internet programs have been designed for this purpose. Additionally, many doctors' offices provide secure, online portals that people can access to view their laboratory results, prescription information, and summaries of office visits.

When more than one practitioner 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 medications (prescription and nonprescription) they are currently taking, plus the doses and the reason they are taking the medication. 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 medications (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 medications they are taking. They can also ask for containers that are easy to open and labels that are easy to read.

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