Creating Continuum Care

The expressions “the right hand didn’t know what the left hand was doing” and “it takes a village” best illustrate exactly what continuum care is and how it works.

Continuum care is the safety net built to ensure that miscommunication never happens to your loved one when multiple doctors or levels of care are involved in their treatment plan. Continuum care focuses on the plan and responsibility of everyone for total patient care and opens communication between caregivers. Sometimes caregivers are medical professionals and sometimes they are the loved ones at home supporting continued care. There can be reasons for long-term and situational continuum care for a patient. Whether short or long, there should be no gaps in care that can jeopardize a patient’s health with the appropriate continuum care plan.

Recipe for Successful Continuum Care

  • Team-based care with all caregivers represented.
  • Focused on the positive impact on patient care or possible recovery.
  • Communication and connectivity between members.

Examples of Continuum Care

  • A patient has had surgery and the surgical team will inform the primary care physician (PCP) and any at-home caregivers of the appropriate steps of care. This could include administering medication, wound checking or re-dressing, or making follow-up appointments. The PCP will stay in contact with the at-home care provider and update the surgical team with any questions or concerns.
  • A patient needs to move from one place of care to another that offers more specialized or intensive treatment. The previous care provider and the new treatment center need to stay connected on patient’s history. Both also need to stay connected to their family or support team to understand concerns and hear any additional information the patient is unable to give.
  • Managing a long-term disease or illness can involve multiple specialists or hospitals or extended periods as the situation changes and different levels of care are required. Remote or telehealth options can be a great part of continuum care in this situation if the patient needs to be in and out of nursing care homes.

Mindfulness, heightened communication, and patient security provide the most profound reasons for continuum care and having all caregivers connected are important. Remember the expression, “it takes a village”? Our village is ready and looking forward to caring for your loved one when it is time. Get in touch with us about the steps we have in place for continuum care here at Conroe Health Care Center, or best practices for the care already taking place.

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