This book helps you evaluate and improve the linkages among caregivers, patients, and families. You’ll discover what steps are necessary to optimize continuity of care for patients and strengthen care management initiatives. The self-assessment tools in the book encourage you to take a critical look at how patients move through the systems of care in your organization and where improvements are needed. Plus you'll find lots of examples of what health care organizations are doing to improve communication and reduce continuity of care problems.

Table of Contents

Chapter 1: Continuity and Quality of Patient Care

The Patient Care Continuum

Episodic vs. Chronic Care Continuum

Fragmented Care

Manage the Hand-Offs

How this Book will Help You

Chapter 2: Defining the Patient Care Continuum

Meet Patient Needs

Critical Activities

Where Breakdowns Occur

Information Flow

Identify and Remove Barriers

Chapter 3: Plan for Effective Continuity of Care

Scope of Services

Continuity is a Strategic Goal

Chapter 4: Processes that Impact Continuity of Care

Entry to Setting or Service

Conduct an Assessment

Special assessments

Emergency department assessments

Consent and information Sharing

Documentation practices

Determine Appropriate Setting

Admission criteria

Collecting additional information

Develop the Plan of Care

Inform Patients

During Active Care

Provide Services

Documentation practices

Communication during key transitions

Conduct Reassessment

Interdisciplinary process

Follow-up systems

Provide Continuing Services

Before and During Discharge or Release from Services

Develop a Discharge Plan

Transfer Patient

Discharge Patient

Pulling it all Together

Information Integration

Chapter 5: Measuring Continuity of Care

Structure Measures

Process Measures

Outcome Measures

Satisfaction with care

Plan for Data Collection

Continuity Measures

Chapter 6: Identify and Reinforce Weak Links

Assess Linkages

Linkage Assessment Tool

Appendix

Figure A-1: Admission Assessment

Figure A-2: Factors to Consider when Making Specialty Consultation Referrals

Figure A-3 Patient Questionnaire Used to Identify Specialized Needs

Figure A-4: Interdisciplinary Care Planning Tool (clinical path)

Figure A-5: Form to Document Initial Team Evaluation

Figure A-6: Patient Education Tool for Same-Day Surgery

Figure A-7: LSUMC Multidisciplinary Documentation Tool

Figure A-8: Patient Status – Caregiver Communication Tool

Figure A-9: Documentation Tool Used by Home Health Nurses

Figure A-10: Outpatient Cardiopulmonary Rehab Patient Progress Report

Figure A-11: FIM Scoring System Documentation Tool

Figure A-12: Emergency Department Patient Call Back Form

Figure A-13: Discharge Documentation Procedure

Figure A-14: Patient Movement Form

Figure A-15: Patient Transfer Form

Figure A-16: Clinical Summary for Patients

Figure A-17: Plan of Care for Pain Control

Figure A-18: Continuing Care Path Used for Patient Education

Figure A-19: Clinic Patient Call Back Form