Continuity of care is defined as the sound, timely, smooth, unfragmented and seamless transition of a client from one area within the same healthcare facility, from one level of care to a higher and more intense level of care or to a less intense level of care based on the client’s status and level of acuity, from one healthcare facility to another healthcare facility and also any discharges to the home in the client’s community.
Maintaining the continuity of care requires that the nurse, and other members of the healthcare team, identify current client needs and then move the client to the appropriate clinical area, to the appropriate level of care, and to the appropriate healthcare facility in a timely and effective manner.
The Nurse’s role in Continuity of Care:
Coordinate care with the interprofessional team
Act as a liaison and be a client advocate
Complete admission, transfer, discharge, and post-discharge prescriptions
Initiate, revise, and evaluate the plan of care
Report the client’s status
Coordinate discharge planning
Facilitate referrals and use of community resources
Communication, collaboration and cooperation among and between appropriate healthcare team members and the client are essential components of the continuity of care.
Initial Discussion Assignment:
Part 1: Create a detailed scenario in which a patient with frequent re-admissions for Chronic Obstructive Pulmonary Disease (COPD) is successfully integrated into a care plan that exhibits continuity of care from admission to successful discharge to home with follow-up visits and monitoring. You are not allowed to simply agree or disagree in your responses to the initial postings. All responses must have evidence-based reasons why you agree or disagree and must be supported by research. At least one evidence-based article must be referenced.
Part 2: Your patient has transitioned home; however, during a follow-up visit you notice that the patient is having a mild exacerbation and you need to notify the patients doctor for possible admission. Create a detailed ISBAR report prior to calling the physician.