What is the Continuum of Care?
The continuum of care is case managing a patient’s care in multiple settings from the beginning of an illness until the patient is no longer ill and no longer under a medical regiment. For patients who are terminal or have chronic illnesses the continuum of care may become a recurring cycle until the end of life.
The case managers, along with the healthcare team, will identify and address medical needs, financial needs, psychological needs, family needs, and resource needs at each level to ensure a smooth transition from one level to the next. The intent is to anticipate the patient’s needs prior to moving him/her to the next level. Through proper set up and family preparation, the necessary resources are in place when the patient is ready to transition from hospital to skilled nursing, skilled rehabilitation, home health, and/or to home.
In case of a patient who is chronically ill, the transition would be from the acute care, to perhaps a skilled setting, and then back home with the community, clinic, doctor’s office, or medical home model to support the patient as needed. The ideal model is to have someone, hopefully a trained case manager, available as a contact for care coordination in the community and at the home to proactively promote compliance with the plan of care which helps prevent unnecessary re-admissions to the hospital.
The current healthcare model supports the case management process in every health care setting. Case managers in the hospitals can coordinate care for the patient and the family prior to discharge by knowing the plan of care and effectively performing discharge planning evaluations.
Case managers can and should communicate with other case managers along the continuum of care to prepare for the patient’s seamless transitions from the hospital to the final discharge disposition.
In the case of a patient who is on palliative care, end of life, and hospice care, the case managers will be the pivotal support for the patient and the family at the end of life process.