03.07 Continuity of Care

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We will discuss the factors contributing to continuity of care in the community and why continuity is important.

Nursing Points


  1. Continuity of care
    1. Ongoing health care
    2. Consistent quality care
      1. From hospital to community
    3. Provides stability
      1. Decreases errors
      2. Increases compliance
    4. Requires good communication 
      1. Between patient and care team 
      2. Between care teams 
    5. Nurse Role
      1. Liaison
  2. Discharge planning
    1. Information should be passed on 
      1. To outpatient providers
      2. To caregivers
      3. To family members
    2. Proper education for patient
      1. Follow up care
      2. Medications
  3. Noncompliance vs. Health Literacy 
    1. Noncompliance
      1. Not following through with direction
        1. Follow ups
        2. Medication management
      2. Factors 
        1. Refusal 
        2. Health literacy
    2. Health literacy
      1. Capacity to understand health information 
      2. Essential to making health decisions
      3. Barrier to compliance
      4. Risk factors
        1. Age
        2. Education 
        3. Language/Cultural background
    3. Interventions
      1. Simplify teaching
      2. Provide demonstration/teach back 
      3. Use pictures if available 
      4. Encourage questions 
  4. Referrals and resources
    1. Referrals
      1. Request for needs assessment 
        1. For community based assistance 
          1. Member of community 
          2. Caregiver
        2. From 
          1. Family member/caregiver
          2. Community member
          3. Physician/facility
        3. Services 
          1. Assistance with ADL/iADLs
          2. Companionship
          3. Assistance with connecting to other services
            1. Legal services
            2. Home repairs/modifications
            3. Support groups 
            4. Adult day care
          4. Respite for caregivers
          5. Home delivered meals 
    2. Resources 
      1. Anything used to provide care 
        1. Financial 
        2. Equipment and supplies
        3. Skill set 
        4. Appropriate staff
        5. Information/Education 
        6. Technology
  5. Partnerships in the community 
    1. Collaboration 
      1. Multiple agencies work together
        1. Private
        2. Nonprofit
        3. Government
      2. Mulitple units in same agency work together
        1. Facility
        2. Primary care
        3. Home care
        4. Pharmacy
    2. Provides holistic approach to healthcare
    3. Successful partnerships 
      1. Same goals in mind 
        1. Healthy community/individual
      2. Engaged in community
      3. Have ability to make changes
  6. Role of case managers
    1. Assess client needs
    2. Plan care
      1. Provide resources
      2. Collaborate
      3. Coordinate care
    3. Monitor client progress
      1. Use of services and resources
    4. Advocate for client and family
      1. Ensure all needs are met
      2. Ensure continuity of care is maintained



Hi guys! Welcome to the continuity of care lesson. In this lesson, we’re going to talk about how important a piece the community nurse is to providing consistent quality care. We’ll tie together some of those concepts we’ve been talking about throughout this course as well so if it sounds familiar, it probably is! Let’s get started! 

What is continuity of care? It’s ongoing, quality health care for our clients. The goal is to seamlessly follow a patient from hospital back to community to ensure they remain compliant with their treatment. This will limit hospitalizations and decrease errors in care as well. There’s nothing worse than going for a follow-up visit and finding out your information didn’t make it there before you did and the doctor you’re seeing hasn’t seen any information as to why you are there except, you were supposed to be there. Now you’re sitting and waiting. These are blatant breaks in the chain and with all the technology we have these days it shouldn’t happen but even technology glitches from time to time.  We don’t like them and we don’t want them so facility and community nurses act as liaisons in the process to try to minimize those breaks.

Continuity of care begins with discharge plans at the hospital. For this to work the way it’s supposed to, information should be passed from the hospital to any outpatient providers, family members and caregivers. Also, prior to discharge patients and family members require the proper education for any follow up care and new prescriptions the patient may have.

There’s an entire lesson on discharge planning in the Fundamentals course so please feel free to check it out.

An important thing to note when we’re talking about proper education and continuity of care is the difference between noncompliance and health literacy. There are lots of people in the community who are noncompliant with treatment once they are at home. This simply means they aren’t following up with their care, managing their medications correctly if at all, or it could be a combination of both. This can either be because they refuse or because they don’t get it.  Health literacy can be a barrier to compliance. It’s the patient’s capacity to understand the information they’re given. How many of you know someone that gets frustrated when they don’t understand instructions and give up trying? It’s easy to brush off what you don’t understand. We see it a lot in the elderly especially when it’s a change to their routine. Cultural background and language barriers play a big role here too. Sound familiar?

We know why someone wouldn’t follow instructions, now what do we do to increase the chances that they do? We simplify the education we’re giving. We should be providing client education on a 3rd-5th grade reading level. Using medical terminology and big technical words can turn someone off if they lack that health literacy we were talking about. We can also demonstrate instructions when teaching. Some people learn by watching and imitating. We’ve talked about this before. So if you’re able to, demonstrate the task and ask the client or family member, caregiver, whoever to show you what they saw. It’s a great way to determine if they get it. Use pictures. Again, some are visual. We see pictures all over doctor offices that describe different things. It’s helpful to see things color-coded or labeled. And finally we want to make sure we provide an opportunity for questions for clarity. We haven’t done the job if there are questions left on the table.

How do community nurses become involved here? We get referrals! Someone from the community, maybe a neighbor, family member, caregiver, or a doctor or hospital want someone assessed for services in the home. Remember we talked about home care in the practice settings lesson. We’re not going door to door looking for people to care for. Referrals make our world go round.

What kind of services can community members be assessed for? Maybe they need assistance with ADLs or iADLs. Maybe the elderly client can use a companion. We also help connect clients to other services like legal services or maybe they need a stair climber or ramp installed at home, maybe they lost a loved one and need help getting through the grieving process. Or maybe no one is home during the day to take care of grandma and she can’t be home alone. Respite for caregivers helps minimize caregiver burnout. It’s not surprising how many adult children care for their elderly parent and it consumes their entire life. Everyone needs a break sometimes. There’s also home delivered meal programs like Meals on Wheels for those who aren’t able to cook any longer.

We need a way to be able to provide all those services. That’s where resources come in. Resources are things used to provide care to a client. So this can include financial resources, equipment and supplies needed for care, a specific skill set may be required. We definitely need to have the appropriate staff to meet the client’s needs. The right information and education on available services from what organizations, and we also need the right technology.

We talked a few lessons back about planning programs and creating policies. This doesn’t happen in the community without strong community partnerships. This is a collaboration between multiple agencies from private, nonprofit and government sectors or it can be between different units in the same agency like the facility, primary care, home care and pharmacy can be from the same place. These collaborations give us a more holistic approach to community healthcare. So I mentioned strong partnerships a second ago. For a partnership to be strong and successful, everyone involved has to be on the same page. They need to have the same goals in mind along with the same understanding of the problems they’re looking to solve and what community health actually means. They have to agree that the cause is a healthy community or individual. They need to be engaged in the community because that’s how we ensure goals are met. Most importantly they have to have the ability to make the necessary changes. How effective is it if everyone sits at the table, sets a goal and no one has a way to reach it? It’s not.

Partnerships don’t always have to be so official sounding. I said that different parts of an agency can work together just as well and when they do, it becomes multidisciplinary in nature. Case managers fall under that umbrella. Why am I talking about case managers? What if I told you that nurses act as case managers too? Not a practice setting, but more of an additional role for community nurses. So what does that role entail? We got the referral so now we have to figure out what the client needs. We plan their care by finding and providing resources, collaborating with those resources and other agencies and we coordinate the care to be provided. We also monitor the client’s progress or decline and watch their usage of the available services and resources. Do they need more or less or do they stay the same? We look at this frequently to make sure we are meeting the client’s needs. Advocating for the client and family members is also a case manager’s role to ensure continuity of care is maintained. This should all sound super similar to the nurse’s role and you can see how we slip into these roles so easily.

Some key points. Continuity of care helps to increase treatment compliance. We can’t expect someone to follow through with treatments and instructions if we as healthcare professionals are not onboard with adequate communication among ourselves. There’s a few reasons for noncompliance but it is a result of low health literacy. We can’t assume everyone has the same learning style or mental capability so we have to make sure we are using appropriate language and techniques to successfully educate. Partnerships are a collaborative effort to maintain continuity of care. Creating a strong partnership requires everyone to have the same goals in mind for a community or individual.

That’s all for the Continuity of care lesson. Make sure you check out all the resources attached to this lesson. Now go out and be your best selves today. And, as always, Happy Nursing!