What Is the Continuum of Care?

April 25, 2023

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A nurse practitioner holding a clipboard reviews medical records with a patient. The term “continuum of care” refers to the practice of providing consistent and coordinated health care for a patient over a period of time and across the spectrum of care. As the largest sector of health care professionals, nurses play an essential role in helping ensure the seamless transition of patients from one type of care to another in this continuum.

A 2021 Journal of Nursing Regulation article reports that there are 4.2 million licensed registered nurses (RN) — of whom 6.6%, or approximately 277,000, are advanced practice registered nurses, such as nurse practitioners (NP). They participate in a wide variety of services that can make up the continuum of care, from preventing disease to managing treatments, making their knowledge of this coordinated and patient-centered approach vital to their success and to their patients’ well-being.

An advanced nursing education, such as Doctor of Nursing Practice (DNP) programs, can help nursing leaders better understand what the continuum of care is and prepare for their important role in coordinating many types of care.

Continuum of Care: What Is It?

Understanding the continuum of care requires taking a big-picture look at medical services. The continuum of care can encompass the changing health care needs throughout a patient’s life, or it can focus on a particular health condition.

The term commonly describes health care that follows patients over a period of time — from preventive care to treatment for medical concerns, rehabilitation, and maintenance. Each type of service complements others throughout the continuum, making treatment more efficient and effective.

Offering this comprehensive care requires all of a patient’s health care providers to understand the treatments and tests that the individual has previously received. This knowledge helps providers to:

Address patient concerns
Build on previous treatments
Avoid redundancies

Continuum of Care Requirements

This unified approach to care can involve various health care professionals, places, and services — all working in concert. Among the parts of the continuum of care are:

Personnel
Facilities
Procedures
Treatments

Because the continuum of care encompasses so many elements and generally occurs across a long time span, everyone involved needs to communicate to keep one another abreast of the patient’s needs and past treatments. This open communication should include everyone from health care providers, such as physicians and nurses, to nonmedical professionals who document and assist with care, focusing on concerns such as:

Care transitions. Providers should have access to a patient’s medical history and know what services they’ve received as they progress through each phase of treatment.
Outside treatments. Providers also need information about past care that a patient received from medical and nonmedical professionals in other facilities or health care networks.
Staff schedules. Physicians, nursing professionals, specialists, and other providers working in an inpatient setting should ensure that the appropriate personnel are available to provide each type of care a patient needs.
Patient billing. Nonmedical professionals need to have clear records of financing and provider networks to ensure accurate billing.

Examples of the Continuum of Care

Examples can help illustrate what the continuum of care is. The continuum of care often refers to care for older adults or those with mental health issues because they typically rely on many types of medical care. Each step in the continuum entails different types of care, sometimes from many different health care professionals.

These patient populations aren’t the only ones who benefit from this coordinated approach to health care, however. Below are examples of how the continuum of care can work.

Elder Care

One example of the continuum of care is the broad spectrum of services available specifically to older adults as their medical needs change, including the following:

Preventive care
Residential living
Memory care
Home care
Rehabilitation
End-of-life/hospice care

For preventive services, for example, elderly patient care typically involves community wellness centers and outpatient therapy. As aging patients sustain injuries or experience illness, their recovery might include treatment at a rehabilitation center. End-of-life care may involve hospice care. In some cases, long-term care facilities offer various resources within the continuum of care, providing older patients a single point of access to services that address their changing needs.

Women’s Health

Another example of how the continuum of care works concerns women’s health. Care for women that begins with pregnancy, for example, could involve any of the following services:

Prenatal care
Obstetrics services
Preventive and ambulatory care
Elder care
End-of-life care

The health care professionals providing services in this continuum could include those specializing in:

Fertility
OB-GYN
Family medicine
General medicine
Acute care
Long-term care
Hospice care

This care might begin in private practices or clinics, progressing through services in hospitals or ambulatory care centers, and then moving to assisted living facilities or in-home care.

Mental Health

The continuum of care for mental health services may entail multiple components that take the patient from receiving initial treatment for a mental health concern to incorporating ways to cope into their lives. These steps can include the following:

Diagnosis
Inpatient care
Therapy
Care management

This care might begin at residential treatment centers and progress to outpatient clinics, with the goal of maintaining the continuum through:

Support networks
Counseling
Medication

Rehabilitative Care

When a patient recovers from surgery or an illness — such as a joint replacement or stroke — the continuum of care could take them from diagnosis in a clinic, to treatment in an inpatient medical facility, to rehabilitation in a long-term care center or at home. The medical professionals involved in this continuum may include surgeons and home health aides.

Disease Management

The treatment of chronic diseases, including those that are terminal, can also involve many types of care, medical professionals, and facilities. A cancer patient, for example, could follow a continuum of care that begins at diagnosis and continues through end-of-life services. The following medical and nonmedical professionals are often among those charged with coordinating the treatment and management of chronic diseases over time:

Oncologists
Nurses
Social workers
Psychiatrists
Home health aides

Benefits of the Continuum of Care

An examination of what the continuum of care means to patients and providers should include a look at how it can enhance care, improve relationships, and increase efficiency. Below are some benefits of the continuum of care, both for those receiving care and those providing it.

Benefits to Patients

Focusing on the continuum of care can pay dividends for patients. A 2021 report in the Journal of General Internal Medicine showed that patients who received coordinated care across various procedures, such as cancer screening and arthritis therapy, reported greater satisfaction with the care they received for nine of the 13 types of care reviewed.

Patient health outcomes can also benefit. Rogers Behavioral Health analyzed the progress of more than 70,000 of its patients over a 10-year period, reporting in 2022 that those who followed a continuum of care showed significantly greater levels of improvement during that time. Patients who receive a continuum of care can experience:

Greater convenience. Providing a continuum of care can include offering various services in one location or through a single, easy-to-access network.
Seamless transitions. Offering medical care that adapts to address a patient’s many needs makes it easier to navigate the changes that come with life’s transitions.
Informed decision-making. Sharing information to coordinate care helps providers educate patients about their conditions and the many types of treatment they’re receiving.
Less expense. Keeping abreast of the treatments a patient has received can lead to fewer duplications and unnecessary procedures, reducing patient expenses.
Personalized care. Understanding a patient’s history can help health care professionals tailor care to that patient’s individual concerns.
Enhanced safety. Having an awareness of a patient’s medical background can help providers avoid prescribing medications and treatments that could be dangerous based on preexisting conditions.

Benefits to Providers

Health care providers can also realize a host of benefits from providing a continuum of care. Among the positive outcomes that coordinating care can yield are:

Greater efficiency. Avoiding duplicate procedures and unnecessary hospital readmissions can save time and money, as well as improve patient satisfaction.
Better reputation. Providing care that puts the changing needs of patients first promotes positive experiences and outcomes.
Improved morale. Helping patients achieve positive health outcomes can lead to a more fulfilling experience and greater job satisfaction for medical professionals.
Increased insurance reimbursements. Offering patient-focused care can yield the positive results that are the cornerstone of value-based care models, which reimburse according to patient outcomes.

Continuum of Care Nursing

The nursing workforce represents the largest segment of health care workers in the United States, according to the American Association of Colleges of Nursing (AACN). Globally, the World Health Organization reports that nurses and midwives comprised nearly 50% of the health care workforce in 2022.

Additionally, AACN reports that nurses are the nation’s primary source of hospital and long-term care — not to mention that providing care according to a patient’s individualized and changing needs has long been a fundamental aspect of nursing.

Because of their prominent role in patient care and the profession’s long-standing emphasis on care coordination, nurses are integral to the success of continuum of care services. In fact, the American Nurses Association advocates for spotlighting the important role of nurses in care coordination.

So what does the continuum of care mean in nursing?

Nurses and the Continuum of Care

In the continuum of care, nursing can serve various roles. Because of their many opportunities to interact with both patients and other medical professionals, nurses can facilitate the continuum of care through actions such as:

Building relationships with patients and families, discussing their changing needs and concerns with them
Advocating for patients to encourage treatments and procedures that align with their unique needs
Educating individuals about the next phase of their care as they prepare for discharge from the hospital
Ensuring that other health care professionals involved in a patient’s care are aware of treatments required and those already performed
Developing care plans to help patients with multiple chronic conditions manage them simultaneously
Submitting patient referrals for additional types of care, such as specialist services or long-term care facilities

Nurse Practitioners and the Continuum of Care

As advanced nursing professionals focused on holistic care, nurse practitioners are uniquely positioned to provide services that support the continuum of care. Below are some reasons why NPs are particularly important in the continuum of care.

Care for the Whole Person

NPs focus not only on addressing medical issues but also on health promotion, education, and counseling. Whole-person care can help patients address a broad range of health needs that they may have throughout their lives.

Options for Specialization

NPs can select a population or condition on which to focus their work, from family care to adult gerontology practice. These specialization areas present opportunities for NPs to address a host of care changes and transitions for a specific group.

For example, NPs who specialize in adult gerontology primary care might treat patients who are managing chronic illness, and may be integral in a continuum of care that takes these patients through multiple phases, such as changing medication and treatment and making end-of-life decisions.

Similarly, NPs who focus on psychiatric mental health can help patients through the changing phases of treatment throughout their lives, from prescribing medication to coordinating therapeutic support.

Emphasis on Primary Care

Although they may focus on certain populations as their specialty, most NPs provide some type of primary care. The American Association of Nurse Practitioners reports that 88% of NPs hold a certification in some type of primary care, and 70% deliver primary care. Primary care providers can facilitate a broad variety of treatments and procedures in a patient’s health care journey.

Continuum of Care Best Practices

Nurses and other medical professionals, as well as the health systems they work for, can help guide a smooth continuum of care by following some key steps. These efforts center on effective data sharing, coordinated scheduling, and clear communication.

The success of the continuum of care is what’s at the heart of best practices such as the following:

Collecting Data

In a 2022 report from the American Hospital Association (AHA), medical administrators suggested collecting various types of data from patients at every step of the continuum of care to help providers stay abreast of patients’ changing needs and concerns. This collection should include qualitative and quantitative data not only during inpatient and outpatient care but also in home and community care settings.

Standardizing Records

The AHA report also recommended standardizing data collection throughout medical systems during the continuum of care. Making data collection uniform makes it easier to compare and review, which can aid in identifying care gaps for specific populations or at certain facilities and improve care across the life span of all patients.

Strengthening Communication

Coordinating care requires open communication between medical providers. This communication should include access to patient records and data, to help providers from different facilities and systems stay up to date on a patient’s medical history.

Establishing Success Metrics

Health care providers should establish how they’ll determine success in the services they offer throughout the continuum of care. These success metrics should inform goal setting to help health systems and hospitals determine the effectiveness of care initiatives and the work that supports them.

Lead the Way to Coordinated Health Care

Providing a continuum of care means ensuring consistent and coordinated health care, and the practice holds many benefits for patients and medical professionals alike. As the profession representing the largest sector in the health care field, nursing plays a key role in providing an effective continuum of care for patients.

An advanced nursing education can provide the knowledge and skills to help nurses lead the way to coordinated care. If you’re interested in learning more about how you can facilitate the continuum of care while taking the next step in your nursing career, explore the online BSN to DNP program.

Through doctoral-level training focused on improving patient outcomes in a changing health care landscape, you’ll learn the latest in effective strategies and policies. You’ll also learn research methods that can help you uncover new trends and best practices.

Discover how the Regis online BSN to DNP program can help you make the most of your patients’ health care journey — and your career aspirations.